Complications - Endocystectomy for Echinococcus granulosus infection of the liver

Anaphylactic Reaction

• Circulatory stabilization
• Pharmacological therapy with vasoactive substances, antihistamines, and glucocorticoids

Bleeding

• From small vessels: Electrocoagulation or clips
• Arterial vessel leaks: Direct suture with Prolene® 5-0 or 6-0
• Due to the risk of injury to bile duct structures and further vascular injuries, bleeding in the hepatic hilum should not be blindly punctured, instead successive dissection and targeted management.

 Transection of the proper hepatic artery or one of its main branches

• Consequences are unpredictable and can range up to lobe necrosis.
• Therefore, reconstruction of the main artery is mandatory, possibly as a saphenous vein interposition.

Injury to the major hepatic veins and/or the vena cava

• Can lead to air embolism or massive bleeding!
• Tangential clamping with oversewing
• In severe cases, manual compression and temporary occlusion of the inferior vena cava caudal and possibly also cranial to the liver after opening the diaphragm (suprahepatic clamping).

Prophylaxis of intraoperative bleeding

• Adequate access with sufficient exposure
• Generous mobilization of the liver
• Possibly intraoperative ultrasound with visualization of vascular structures
• Avoidance of overfilling the venous system (low CVP)

 Bile leaks

• Management with clips or suture

Transection/Injury of the common bile duct

• Direct anastomosis possibly over T-drainage or creation of a biliodigestive anastomosis

Air embolism

• Is favored by a low or even negative CVP.
• Avoid further air entry by detecting, clamping, or oversewing the entry site, immediate PEEP ventilation.

Pneumothorax

• Can occur with findings near the diaphragm → intraoperative thoracic drainage.

 Hollow organ injuries

• In previously operated patients, especially after cholecystectomy/procedures on the stomach, or due to massive adhesions in the pericystic area, adhesiolysis is necessary. Hollow organs may be injured in the process and must be appropriately managed/oversewn.

Postoperative Hemorrhage

• Postoperative hemorrhage in liver surgeries can be due to inadequate intraoperative hemostasis, but in many cases, it is attributed to coagulation and fibrinolysis system disorders, which must be considered when deciding on surgical revision.
• Detection of the cause via Angio-CT, possibly selective arterial embolization, depending on the extent and circulatory situation, indication for relaparotomy.
• Development of subphrenic or subhepatic abscesses is possible.

Subcapsular Hematoma

• Small hematomas are generally resorbed.
• Larger ones may rupture in two stages and may require surgical intervention in case of circulatory instability.

Bile Fistula

• Stable patient without signs of peritonitis: Leave target drainage in place, monitor output, spontaneous cessation is not uncommon.
• ERCP with stent placement to reduce pressure in the bile duct system.

Portal Vein Thrombosis

• Sudden postoperative increase in transaminases
• Doppler ultrasound examination
• Anticoagulation

Liver Perfusion Disorder

• Due to portal venous and possibly additional arterial vessel stenoses or occlusions.
• No therapy is required for mild cases.
• For severe cases, depending on the cause, interventional or surgical revascularization, focus control in case of infected necroses.

Pleural Effusion

• Respiratory insufficiency
• Chest X-ray, ultrasound
• 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 necessary consistency.
• Prophylaxis: Rapid postoperative mobilization, Bird ventilation, Triflow, CPAP masks, physiotherapy/breathing exercises

Secondary Echinococcosis/Recurrence

• It is recommended to make every effort to avoid contamination of the abdominal cavity with cyst contents, including protecting peritoneal tissue and organs with surgical drapes soaked in protoscolicidal agents.