One discussion this week involved air cholangiograms.

Reference: Zimmitti G, et al. Systematic use of an intraoperative air leak test at the time of major liver resection reduces the rate of postoperative biliary complications. Journal of the American College of Surgeons. 2013 Dec;217(6):1028-1037. doi: 10.1016/j.jamcollsurg.2013.07.392.

Summary: Advances in surgical technique and better understanding of liver anatomy and physiology have facilitated a decrease in postoperative hepatic insufficiency rates and in perioperative blood transfusion needs. However, these improvements have not been paralleled by a decrease in the rate of postoperative bile leak, which remains the Achilles’ heel of liver resection. While in many cases a postoperative bile leak can be managed successfully with drainage and antibiotics, it almost always entails longer length of stay and increased hospital costs.

In some cases, post-hepatectomy bile leak can lead to a cascade of systemic morbidity stemming from intra-abdominal sepsis. Documented secondary complications associated with bile leak include venous thromboembolism, further invasive procedures including re-laparotomy, and increased risk of mortality.

This study sought to determine if systematic utilization of a refined intraoperative “Air Leak Test” (ALT) could: 1) improve the detection and repair of intraoperative open bile ducts, and 2) reduce the rate of postoperative bile leak.

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.

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)
• not performing ALT (p = 0.002)