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Original Article |

The White Test A New Dye Test for Intraoperative Detection of Bile Leakage During Major Liver Resection FREE

Silvio Nadalin, MD; Jun Li, MD; Hauke Lang, MD, MA; Georgios C. Sotiropoulos, MD; Randolph Schaffer, MD; Arnold Radtke, MD; Fuat Saner, MD; Christoph E. Broelsch, MD; Massimo Malagó, MD
[+] Author Affiliations

Author Affiliations: Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany.


Arch Surg. 2008;143(4):402-404. doi:10.1001/archsurg.143.4.402.
Text Size: A A A
Published online

Objective  To describe a new intraoperative bile leakage test in patients undergoing a major liver resection aimed to combine the advantages of each of the other standard bile leakage tests (accurate visualization of leaks, reproducibility, and ease of use) without their disadvantages.

Methods  At the end of the major hepatic resection, 10 to 30 mL of sterile fat emulsion, 5%, is injected via an olive-tip cannula through the cystic duct while manually occluding the distal common bile duct. As the biliary tree fills with fat emulsion solution, leakage of the white fluid is visualized on the raw surface of the liver resection margin. The detected leakages are closed by means of single stitches. Afterwards, the residual fat emulsion on the resection surface is washed off with saline and the White test is repeated to detect and/or exclude additional bile leakages. At the end, residual fat emulsion is washed out from the biliary tract by a low-pressure infusion of saline solution.

Results  Intraoperatively, additional potential bile leakages (not seen using a conventional saline bile leakage test) were identified in 74% of our patients. Postoperative bile leakages (within 30 days) occurred in only 5.1% of patients when the White test was used. No adverse effects related to this technique were observed.

Conclusions  The White test has clear advantages in comparison with other bile leakage tests: it precisely detects bile leakages, regardless of size; it does not stain the resection surface, allowing it to be washed off and repeated ad infinitum; and it is safe, quick, and inexpensive.

Figures in this Article

Bile leakage is the primary complication occurring after liver surgery and directly affects the quality of the postoperative course of patients, influencing both morbidity and mortality rates.1,2 Despite a significant decrease in the overall surgical complication rate in hepatic resections, the rate of postoperative bile leakage has not changed. Many large series have recently reported an incidence ranging from 3.6% to 33%.19 A reliable method for detecting and localizing sites of bile leakage intraoperatively, therefore, is of paramount importance. To this end, several different intraoperative bile leakage tests have been proposed, but despite their routine use, they still have significant inadequacies (Table) and are associated with a relative high incidence of bile leakage.

Table Graphic Jump LocationTable. Standardized Intraoperative Bile Leakage Tests and Their Advantages and Disadvantages 

Therefore, we have developed the White test, a new intraoperative bile leakage test for patients undergoing a major liver resection aimed to combine the advantages of each of the other standard bile leakage tests (accurate visualization of leakages, reproducibility, and ease of use) without the disadvantages associated with those same tests. This new localization technique of bile leakage uses fat emulsion (normally used for parenteral nutrition), which is easily recognized, innocuous to the tissues, and can be easily removed without misleading tissue staining, as previously reported by McFadden et al,13 who used a similar technique for intraoperative localization of urinary leakage.

At the end of the major hepatic resection (done using the standard clamp transection technique14), 10 to 30 mL of sterile fat emulsion, 5%, is injected by means of an olive-tip cannula through the cystic duct while manually occluding the distal common bile duct. As the biliary tree fills with fat emulsion solution, leakage of the white fluid is visualized on the raw surface of the liver resection margin (Figure). The detected leakages are closed by means of single interrupted sutures (5-0 or 6-0 polydioxanone sutures). After closing the leakage site, the residual fat emulsion on the resection surface (potentially masking other bile leakages) is washed off with saline and the White test is repeated to detect additional bile leakages. At the end of the White test, residual fat emulsion is washed out from the biliary tract by a low-pressure infusion of 20 to 50 mL of saline solution.

Place holder to copy figure label and caption
Figure.

The White test. Transductal injection of fat emulsion, 5%. Note the 2 detected bile leakages on the resection surface.

Graphic Jump Location

As noted, fat emulsion solution is usually injected via the cystic duct (which is intentionally left long during cholecystectomy), but alternatively, the injection can be performed through a Kehr tube (which we place in patients with impaired underlying liver parenchyma), through the main bile duct stump in cases of resection of the main duct or bile duct bifurcation, or through a transanatomotic stent when a hepaticojejunostomy is performed.

Fibrin sealant is routinely applied in most cases to the raw cut surface of the liver to promote hemostasis and to prevent minor occult bile leakage. Drainage of the operative field is usually performed by using 2 Penrose drains, which are removed when the drainage is serous and not bile stained (usually around the fifth postoperative day).

Since we began using the White test, we have intraoperatively identified additional potential bile leakages (not seen using a conventional saline bile leakage test) in 74% of our patients (mean, 1.5 [range, 1-6] leakages per patient). Postoperative bile leakage (within 30 days) occurred in only 5.1% of patients when the White test was used. This potentially represents a significant reduction in our incidence of bile leakage (previously 8% in nearly 1600 major hepatic resections). No adverse effects related to transductal injection of fat emulsion (eg, cholestasis) were observed.

Postoperative bile leakages still represent a challenge in liver surgery and especially in major liver resection in which it is associated with serious complications, such as sepsis and liver failure.3 Unfortunately, the traditional bile leakage tests have significant inadequacies (Table). Therefore, we developed the White test as a new alternative to the traditional tests.

Regrettably, the main disadvantage of the White test as well as all other bile leakage tests is their inability to detect bile leakages that originate from a separate bile duct not communicating with the main biliary tree. However, in our experience, the White test has clear advantages compared with other bile leakage tests. The fat emulsion allows for precise detection of bile leakages, regardless of size; it does not stain the resection surface, allowing it to be washed off and repeated ad infinitum; it has no collateral effects on bile ducts or surrounding tissues; and it is quick and inexpensive.

Additional comparative trials of the White test to other bile leakage tests are warranted to confirm that the White test significantly reduces the risk of bile leakage in patients undergoing major hepatic resection. Additionally, another application of the White test being considered includes its use in segmental liver transplantation (ie, split liver transplantation and living donor liver transplantation, in situ or on the back table) whose high incidence of biliary complications (mainly bile leakage) still represents the Achilles' heel of the procedure.11

Correspondence: Silvio Nadalin, MD, Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany (silvio.nadalin@uni-due.de).

Submitted for Publication: October 26, 2006; final revision received January 5, 2007; accepted January 5, 2007.

Financial Disclosure: None reported.

Lo  CMFan  STLiu  CLLai  ECWong  J Biliary complications after hepatic resection: risk factors, management, and outcome. Arch Surg 1998;133 (2) 156- 161
PubMed Link to Article
Yamashita  YHamatsu  TRikimaru  T  et al.  Bile leakage after hepatic resection. Ann Surg 2001;233 (1) 45- 50
PubMed Link to Article
Nagano  YTogo  STanaka  K  et al.  Risk factors and management of bile leakage after hepatic resection. World J Surg 2003;27 (6) 695- 698
PubMed Link to Article
Terajima  HIkai  IHatano  E  et al.  Effectiveness of endoscopic nasobiliary drainage for postoperative bile leakage after hepatic resection. World J Surg 2004;28 (8) 782- 786
PubMed Link to Article
Ijichi  MTakayama  TToyoda  HSano  KKubota  KMakuuchi  M Randomized trial of the usefulness of a bile leakage test during hepatic resection. Arch Surg 2000;135 (12) 1395- 1400
PubMed Link to Article
Rudow  DLBrown  RS  JrEmond  JCMarratta  DBellemare  SKinkhabwala  M One-year morbidity after donor right hepatectomy. Liver Transpl 2004;10 (11) 1428- 1431
PubMed Link to Article
Tanaka  SHirohashi  KTanaka  H  et al.  Incidence and management of bile leakage after hepatic resection for malignant hepatic tumors. J Am Coll Surg 2002;195 (4) 484- 489
PubMed Link to Article
Nakayama  HMasuda  HShibata  MAmano  SFukuzawa  M Incidence of bile leakage after three types of hepatic parenchymal transection. Hepatogastroenterology 2003;50 (53) 1517- 1520
PubMed
Capussotti  LFerrero  AVigano  LSgotto  EMuratore  APolastri  R Bile leakage and liver resection: where is the risk? Arch Surg 2006;141 (7) 690- 695
PubMed Link to Article
Lam  CMLo  CMLiu  CLFan  ST Biliary complications during liver resection. World J Surg 2001;25 (10) 1273- 1276
PubMed Link to Article
Suehiro  TShimada  MKishikawa  K  et al.  In situ dye injection bile leakage test of the graft in living donor liver transplantation. Transplantation 2005;80 (10) 1398- 1401
PubMed Link to Article
Kubo  SSakai  KKinoshita  HHirohashi  K Intraoperative cholangiography using a balloon catheter in liver surgery. World J Surg 1986;10 (5) 844- 850
PubMed Link to Article
McFadden  DWButler  CAPennington  LR Technique for intraoperative localization of urinary leakage. Am J Surg 1987;154 (3) 313- 314
PubMed Link to Article
Takayama  TMakuuchi  MKubota  K  et al.  Randomized comparison of ultrasonic vs clamp transection of the liver. Arch Surg 2001;136 (8) 922- 928
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure.

The White test. Transductal injection of fat emulsion, 5%. Note the 2 detected bile leakages on the resection surface.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable. Standardized Intraoperative Bile Leakage Tests and Their Advantages and Disadvantages 

References

Lo  CMFan  STLiu  CLLai  ECWong  J Biliary complications after hepatic resection: risk factors, management, and outcome. Arch Surg 1998;133 (2) 156- 161
PubMed Link to Article
Yamashita  YHamatsu  TRikimaru  T  et al.  Bile leakage after hepatic resection. Ann Surg 2001;233 (1) 45- 50
PubMed Link to Article
Nagano  YTogo  STanaka  K  et al.  Risk factors and management of bile leakage after hepatic resection. World J Surg 2003;27 (6) 695- 698
PubMed Link to Article
Terajima  HIkai  IHatano  E  et al.  Effectiveness of endoscopic nasobiliary drainage for postoperative bile leakage after hepatic resection. World J Surg 2004;28 (8) 782- 786
PubMed Link to Article
Ijichi  MTakayama  TToyoda  HSano  KKubota  KMakuuchi  M Randomized trial of the usefulness of a bile leakage test during hepatic resection. Arch Surg 2000;135 (12) 1395- 1400
PubMed Link to Article
Rudow  DLBrown  RS  JrEmond  JCMarratta  DBellemare  SKinkhabwala  M One-year morbidity after donor right hepatectomy. Liver Transpl 2004;10 (11) 1428- 1431
PubMed Link to Article
Tanaka  SHirohashi  KTanaka  H  et al.  Incidence and management of bile leakage after hepatic resection for malignant hepatic tumors. J Am Coll Surg 2002;195 (4) 484- 489
PubMed Link to Article
Nakayama  HMasuda  HShibata  MAmano  SFukuzawa  M Incidence of bile leakage after three types of hepatic parenchymal transection. Hepatogastroenterology 2003;50 (53) 1517- 1520
PubMed
Capussotti  LFerrero  AVigano  LSgotto  EMuratore  APolastri  R Bile leakage and liver resection: where is the risk? Arch Surg 2006;141 (7) 690- 695
PubMed Link to Article
Lam  CMLo  CMLiu  CLFan  ST Biliary complications during liver resection. World J Surg 2001;25 (10) 1273- 1276
PubMed Link to Article
Suehiro  TShimada  MKishikawa  K  et al.  In situ dye injection bile leakage test of the graft in living donor liver transplantation. Transplantation 2005;80 (10) 1398- 1401
PubMed Link to Article
Kubo  SSakai  KKinoshita  HHirohashi  K Intraoperative cholangiography using a balloon catheter in liver surgery. World J Surg 1986;10 (5) 844- 850
PubMed Link to Article
McFadden  DWButler  CAPennington  LR Technique for intraoperative localization of urinary leakage. Am J Surg 1987;154 (3) 313- 314
PubMed Link to Article
Takayama  TMakuuchi  MKubota  K  et al.  Randomized comparison of ultrasonic vs clamp transection of the liver. Arch Surg 2001;136 (8) 922- 928
PubMed Link to Article

Correspondence

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