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EXTENDED LEFT LOBECTOMY WITH PRESERVATION OF THE INFERIOR RIGHT HEPATIC VEIN FOR A CHOLANGIOCARCINOMA INVOLVING THE HEPATOCAVAL CONFLUENCE
No full textAfter an extended hemihepatectomy adequate venous drainage of the remaining liver is required in order to preserve hepatic function. Most liver tumours involving the confluence of the hepatic veins are considered unresectable because hepatic venous outflow after resection would be compromised. In 10-25% of people, the inferior right hepatic vein presents large calibre. Thus the superior hepatic veins may be sacrified and hepatic function preserved if a large inferior right hepatic vein is present. The video describes a case of cholangiocarcinoma involving the dome of the liver, all the three hepatic veins and the portal pedicle to the VIII segment. The patient was a 78 old years woman in good general conditions and liver function. At the CT scan she had a large inferior right hepatic vein draining the posterior liver sector. The patient was treated by an extended left hepatic lobectomy with resection of the main right, left and middle hepatic vein and preservation of the inferior right hepatic vein. The video also shows the technical solution (an omental flap like an hammock fixed to the diaphragm) adopted to preserve a good venous drainage of the residual posterior sector hampered by the kinking of the inferior hepatic vein. The patient is still alive after 18 months of follow-up but a recent CT scan showed three distant liver metastasis actually treated with chemotherapy. This case confirms that a hepatic lesion involving the dome of the liver, apparently unresectable can turn resectable if an alternative venous drainage is present. In these cases a pre-operative search for an inferior right hepatic vein is mandatory and is easily accomplished by ultrasound and computerized tomography
THE EFFICACY OF ONDASENTRON IN PREVENTING POSTOPERATIVE NAUSEA AND VOMITING AFTER LAPAROSCOPIC CHOLECYSTECTOMY
No full textTWO LAYER OPEN PANCREATOGASTROSTOMY. TOWARD AN EASY AND SAFE ANASTOMOSIS? PRELIMINARY EXPERIENCE.
No full textIntroduction: Pancreatic fi stula (PF) is the main cause of
morbidity and mortality after pancreaticoduodenectomy
(PD). It mostly occurs when anastomosis is performed in soft
pancreatic tissue. Pancreaticogastrostomy (PG) seems actually
to be preferred to Pancreaticojejunostomy (PJ) in presence
of soft residual parenchyma. The aim of the study is to
compare the PG and PJ in a consecutive series of patients
submitted to PD.
Methods: From January 2009 to September 2011 61 patients
were submitted to two different surgical reconstructive technique,
PG and PJ. 31 patients received PJ (duct to mucosa
pancreaticojejunostomy) and 30 PG (two layer open pancreaticogastrostomy).
All the procedures were performed by the
same surgeon. PF was defi ned in according to the International
Study Group on Pancreatic Fistula Classifi cation. 53 patients
underwent a Whipple procedure whereas 7 patients were
submitted to a pylorus-preserving operation.
Results: In the PJ group (18 male/13 female, average age
69 years) we observed 5 PF (16.1%), 3 grade A, 1 grade B
and 1 grade C. This latter case required a relaparotomy for
completion pancreatectomy. In all these 5 PF the residual
parenchyma was soft. In the PG group (14 male/16 female,
average age 68 years) we registered 4 grade A PF (13.3%)
all in presence of soft pancreatic tissue. In this group of
patients we observed also 1 bleeding from the pancreatic
anastomosis and 1 postoperative pancreatitis with a minimal
leak of the gastrojejuneal anastomosis. All complications
were treated conservatively. In the two groups mortality were
0%. The mean hospitalization time was 15.6 days in PJ group
and 12.2 days in PG group. Histological examination led to
the diagnosis of 36 ductal adenocarcinomas, 15 carcinomas
of the papilla, 6 duodenal carcinoma, 3 chronic pancreatitis
and 1 duodenal polyposis (Spigelmann stage IV).
Conclusion: In our experience the incidence of PF seems to
be lower in the PG group especially in presence of soft pancreatic
tissue. The anterior gastrotomy makes easier the anastomosis
whereas the two layer technique increases its safety.
These initial results appear encouraging but must be confi
rmed in a larger group of patients
VALUTAZIONE DEL DECORSO POST-OPERATORIO DOPO COLECISTECTOMIA LAPAROSCOPICA.ESPERIENZA PERSONALE NEI PRIMI 40 CASI
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