Systematic use of an intraoperative air leak test at the time of major liver resection reduces the rate of postoperative biliary complications.
BACKGROUND
After hepatectomy, bile leaks remain a major cause of morbidity, cost, and disability. This study was designed to determine if a novel intraoperative air leak test (ALT) would reduce the incidence of post-hepatectomy biliary complications.


METHODS
Rates of postoperative biliary complications were compared among 103 patients who underwent ALT and 120 matched patients operated on before ALT was used. All study patients underwent major hepatectomy without bile duct resection at 3 high-volume hepatobiliary centers between 2008 and 2012. The ALT was performed by placement of a transcystic cholangiogram catheter to inject air into the biliary tree, the upper abdomen was filled with saline, and the distal common bile duct was manually occluded. Uncontrolled bile ducts were identified by localization of air bubbles at the transection surface and were directly repaired.


RESULTS
The 2 groups were similar in diagnosis, chemotherapy use, tumor number and size, resection extent, surgery duration, and blood loss (all, p > 0.05). Single or multiple uncontrolled bile ducts were intraoperatively detected and repaired in 62.1% of ALT vs 8.3% of non-ALT patients (p < 0.001). This resulted in a lower rate of postoperative bile leaks in ALT (1.9%) vs non-ALT patients (10.8%; p = 0.008). Independent risk factors for postoperative bile leaks included extended hepatectomy (p = 0.031), caudate resection (p = 0.02), and not performing ALT (p = 0.002) (odds ratio = 3.8; 95% CI, 1.3-11.8; odds ratio = 4.0; 95% CI, 1.1-14.3; and odds ratio = 11.8; 95% CI, 2.4-58.8, respectively).


CONCLUSIONS
The ALT is an easily reproducible test that is highly effective for intraoperative detection and repair of open bile ducts, reducing the rate of postoperative bile leaks.
Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
Giuseppe
G
Zimmitti
Jean-Nicolas
JN
Vauthey
Junichi
J
Shindoh
Ching-Wei D
CW
Tzeng
Robert E
RE
Roses
Dario
D
Ribero
Lorenzo
L
Capussotti
Felice
F
Giuliante
Gennaro
G
Nuzzo
Thomas A
TA
Aloia
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001646:Bile; D001649:Bile Duct Diseases / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D001652:Bile Ducts / Q000293:injuries* / Q000601:surgery; D002648:Child; D005260:Female; D006498:Hepatectomy / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D015994:Incidence; D007431:Intraoperative Complications / Q000175:diagnosis* / Q000601:surgery; D007432:Intraoperative Period; D008113:Liver Neoplasms / Q000601:surgery*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000453:epidemiology / Q000517:prevention & control*; D012307:Risk Factors; D013536:Suture Techniques; D055815:Young Adult