Postoperative Hemorrhages
Hemorrhages following biliary tract/liver procedures can have various causes. It is important to differentiate between early and late postoperative bleeding, as well as between intra-abdominal and gastrointestinal/endoluminal bleeding.
Early intra-abdominal hemorrhages are the most common. They usually occur within the first 24 hours post-surgery and are often caused by inadequate hemostasis at the resection sites and anastomoses or by insufficient vascular ligatures.
Coagulation disorders, such as reduced coagulability due to high intraoperative blood loss or hyperbilirubinemia, can also be responsible for diffuse postoperative bleeding.
Early intra-abdominal hemorrhages are diagnosed by blood loss through the inserted target drain, changes in vital signs, and postoperative hemoglobin checks. Depending on severity and dynamics, initial treatment involves procoagulant medication therapy, possibly combined with a transfusion. The indication for surgical revision should be made early if there is no success.
Early endoluminal hemorrhages present with coffee-ground vomiting/melena combined with a drop in hemoglobin, and in cases of severe bleeding, hemodynamic instability. Endoscopy is the first measure; however, the afferent loop (biliodigestive anastomoses) is usually not accessible, making revision surgery unavoidable if severe bleeding is suspected. Most hemorrhages can be directly sutured after enterotomy of the jejunal loop carrying the anastomosis.
Late postoperative hemorrhages occur between the 7th and 80th postoperative day, are associated with high mortality, and are usually the result of septic erosion bleeding of larger vessels due to infectious complications in the surgical area. The hepatic artery or its branches are most commonly affected.
The best therapy for the dreaded erosion bleeding is prophylaxis: anastomotic insufficiencies must be detected early, drained, and abscesses relieved.
In stable circulatory conditions, angiography and interventional hemostasis are preferable to emergency surgery.
Subcapsular Hematoma
Small hematomas are usually resorbed.
Larger ones can rupture in two stages and may require surgical intervention if circulatory instability occurs.
Bile Leakage/Bilioma
Due to the complexity of biliary reconstruction and the great variability of bile ducts, bile leaks are a common problem.
Definition according to ISGLS: If on or after the 3rd postoperative day the bilirubin concentration in the drainage fluid is more than three times the blood concentration, or if there is a need for interventional drainage or surgical therapy due to bile accumulation or biliary peritonitis.
Classification is according to the consensus definition of the ISGLS (International Study Group of Liver Surgery) with a three-stage grading from A to C according to their clinical relevance.
The grading corresponds to the clinical presentation and the resulting necessary measures.
Grade A: no clinical impairment, leakage well drained by existing drainage, uncomplicated bile fistula, can be treated by extended drainage duration without further measures ("Wait-and-see"): leave target drainage in place, monitor output, spontaneous cessation is not uncommon.
Grade B: leakage persists for more than a week, clinical symptoms (pain, fever, signs of inflammation, fluid retention).
For these complicated fistulas, in addition to ensuring adequate secretion drainage (possibly by percutaneous drainage insertion) and antibiotic treatment, interventional measures are often required.
For further localization diagnostics of the leakage and pressure reduction in the bile duct system, PTCD (percutaneous transhepatic cholangiography drainage) is usually required.
PTCD and interventional closure of the leakage (by coils or biological adhesives) or stenting of a stenosis.
A bile leak should always be consistently drained -> leave prophylactically inserted drains, insert a target drain under ultrasound or CT guidance.
If a leakage cannot be demonstrated, an isolated liver segment should be considered. Here, the peripheral bile ducts do not communicate with the main bile duct. Further diagnostics are then recommended with MRCP.
Grade C: surgery, sepsis, severe impairment of the patient with potentially life-threatening course.
In cases of severe and prolonged septic course or failure of interventional therapy with biliary peritonitis, surgical sanitation is indicated: lavage, focus sanitation, biliary tract revision.
Early surgical revision with correction of the anastomosis(es) by oversewing or re-creation is the first measure in the immediate postoperative course. A transhepatic drain for internal splinting/relief is strongly recommended to have direct access in case of persistent problems.
Arterial and portal venous stenoses/thromboses
Depending on the time of diagnosis, surgical, interventional, or conservative treatment.
- Sudden postoperative increase in transaminases.
Doppler ultrasound examination
Delayed Gastric Emptying
Functional gastric emptying disorder between the 2nd and 9th postoperative day, typically after major upper abdominal surgeries with usually multifactorial genesis.
Prokinetic measures: Erythromycin (3-4 x 100-200 mg) for no longer than 3 days due to the development of tachyphylaxis, the risk of resistance development, and cardiac side effects (QT interval prolongation). Metoclopramide (risk of neurological side effects).
Relief by placing a nasogastric tube
Ensuring adequate calorie and fluid intake
Prolonged Postoperative Ileus
Correction of electrolyte imbalances and fluid losses.
Review of postoperative pain management with reduction of opioid administration by using non-opioid analgesics and neuraxial analgesia techniques.
Parenteral calorie intake
Prokinetics such as Neostigmine, selective gastrointestinal opioid antagonists (with unreliable data)
Postoperative Cholangitis
In the recurrent form, occurrence after biliodigestive anastomoses in 6-15%.
Acute postoperative cholangitis with fever, upper abdominal pain, jaundice, hypotension, and confusion. Intravenous antibiotic treatment is sufficient in the majority of cases. Blood cultures and intraoperative swabs provide valuable clues for antibiogram-based treatment.
If there is suspicion of bile flow obstruction, relief via ERC (usually not possible) or PTCD.
Pleural Effusion
Initially negative balance, depending on the extent possibly thoracic drainage placement
Pneumonia
- Postoperative pulmonary infections are not uncommon, especially if postoperative breathing exercises are not performed with the required consistency.
Prophylaxis: rapid postoperative mobilization, Bird ventilation, Triflow, CPAP masks, physiotherapy/breathing exercises
Liver Failure
Insufficiency of the remaining liver, which, without treatment, leads to a fatal outcome.
Postoperative liver failure is rather rare but represents the most important cause of perioperative mortality after liver resection. Since therapeutic options for postoperative (residual) liver insufficiency are very limited, preoperative risk evaluation is of crucial importance.
If fulminant liver failure occurs, rescue is only possible through transplantation.
Bile Duct Stenosis
In the medium to long term, presents as an increase in cholestasis values +/- jaundice possibly as cholangitis with fever, formation of intrahepatic abscesses in recurrent and prolonged courses.
Diagnostic confirmation via MRCP.
