1,721,367 research outputs found
Open technique during laparoscopic operations (Reply to Letter)
No full textNo abstract - The publication replies to issues raised by other surgeons regarding the use of the open technique in laparoscopic operations
Minimally invasive liver surgery in a hepato-biliary unit: learning curve and indications
No full textOperative indications and type of resection represent a crucial issue of minimally invasive liver surgery (MILS), and they should not be modified by the increased experience of laparoscopic liver surgeons. The aim of this study was to define the indications for MILS and the learning curve in a high-volume hepatobiliary surgery Unit. Between 2009 and 2014, 993 liver resections were performed in our unit, and MILS was performed in 81 of these (8.2 %). The proportion of MILS significantly increased over the study period of time and was significantly higher during the last 2 years than during the first 2 years (10.8 vs. 6.4 %; p = 0.042). Rate of liver resections for benign disease between the first 2 years and the last 2 years of the study period was not significantly different (14.7 vs. 10.5 %; p = 0.098). Rate of MILS for malignant disease significantly increased from the first 2 years to the last 2 years: 3.2 vs. 7.5 % (p < 0.001). Indication for left lateral sectionectomy in the whole series was rare. It was performed in 37 cases as the only liver surgical procedure, on 993 liver resections (3.7 %). In 25 (67.6 %) of these, a minimally invasive approach was used. Rate of left lateral sectionectomies between the first 2 years and the last 2 years of the study period was not significantly different: 4.5 vs. 3.8 % (p = 0.645). This study shows that the proportion of MILS significantly increased over the study period of time in our high-volume hepatobiliary surgery Unit without changing surgical indications for benign disease and type of resections
Indications for Surgery in Cirrhotic Patients
Full text linkLiver resection (LR) still remains one of the main curative options for hepatocellular carcinoma (HCC). When HCC is diagnosed in the cirrhotic liver, the indication for LR should be carefully established. The assessment of such patients should not consider only tumor burden, but must also necessarily include an accurate evaluation of the preoperative liver function to reduce the risk of the most feared complication following LR, that is, post-hepatectomy liver failure (PHLF). PHLF represents the most important cause of postoperative 90-day mortality and is the most commonly used measure to assess the early postoperative outcome. The evaluation of liver function includes assessment of functional reserve of the cirrhotic liver, presence of portal hypertension, extent of LR, volume of functional remnant liver (FRLV), patient performance status and comorbidities. Furthermore, LR should be carefully evaluated against liver transplantation, when this can be a chance of cure, and other potentially curative therapies such as ablation
Incidence, diagnosis, and treatment of enteric and colorectal fistulae in patients with Crohn's disease
No full textOBJECTIVE:
The authors review their experience, evaluating the incidence and examining the various modalities employed in the diagnosis and treatment of patients with Crohn's disease complicated by fistulae.
SUMMARY BACKGROUND DATA:
Although common, internal and external fistulae in Crohn's disease may pose challenging problems to the surgeon.
METHODS:
Of 639 patients who underwent surgical treatment at the University of Chicago between 1970 and 1988 for complications of Crohn's disease, 222 patients (34.7%) were found to have 290 intra-abdominal fistulae.
RESULTS:
A fistula was diagnosed preoperatively in 154 patients (69.4%), intraoperatively in 60 (27%), and only after examination of the specimen in 8 (3.6%). The fistula represented the primary or single indication for surgical treatment in 14 patients (6.3%) and one of several indications in the remaining patients. Of 165 patients with an abdominal mass or abscess, 69 (41.8%) had a fistula. All patients underwent resection of the diseased intestinal segment; 160 (73.1%) with primary anastomosis and the remaining 62 with a temporary or permanent stoma. The fistula was directly responsible for a stoma in only 16 patients (7.2%) and was never responsible for a permanent stoma. Resection of the diseased bowel achieved en bloc removal of the fistula in 145 cases. Removal of 93 additional fistulae required resection of the diseased bowel segment along with closure of a fistulous opening on the stomach or duodenum (n = 14), bladder (n = 35), or rectosigmoid (n = 44). When the fistula drained through a vaginal cuff (n = 4), the opening was left to close by secondary intention; when the fistula opened through the abdominal wall (n = 46), the fistulous tract was debrided. In the remaining two entero-salpingeal fistulae, en bloc resection of the involved salpinx accomplished complete removal of the fistula. There was a dehiscence of one duodenal and one bladder repair; 14 patients (6%) experienced postoperative septic complications and one patient died.
CONCLUSIONS:
Fistulae are diagnosed preoperatively in 69% of cases and can be suspected in as many as 42% of patients with an abdominal mass. Fistulae are the primary or single indication for surgical treatment and are directly responsible for a stoma only in a few patients. Treatment, based on resection of the diseased bowel and extirpation of the fistula, can be accomplished with minimal morbidity and mortality
Timing of repair of bile duct injuries associated with laparoscopic cholecystectomy (Letter)
No full textNo Abstract (Letter). The topic is the repair of iatrogenic biliary stenoses withouth overimposed sepsis within approximately two weeks from surgery
Le risque de plaies biliaires au cours de la cholécystectomie par laparoscopie
No full textThe incidence of iatrogenic injuries of the bile ducts has increased significantly since laparascopic cholecystectomy became the "gold standard" in the treatment of cholelithiasis. The incidence of major biliary ductal injury ranges from 0.25% to 0.74%, and of minor injury from 0.28% to 1.7%. The cause of the injury is not always clearly identifiable. In more than half the cases, the injury occurs during maneuvers to isolate the cystic duct or to free the gallbladder from the common bile duct. These maneuvers may be more difficult and consequently more dangerous when there is significant inflammation as may be seen in acute cholecystitis, or in case of obesity, cirrhosis with portal hypertension, previous surgery with peritoneal adhesions, or anatomic variations of the hepatic pedicle. Pre-operative evaluation of clinical risk factors should be coupled with intra-operative caution and instrumental evaluation. The increase in frequency of iatrogenic biliary injuries can not be attributed simply to the inexperience of the surgeon or the learning curve as was initially suggested. Many injuries are due, rather, to the surgeon's failure to respect basic technical rules, long established for open cholecystectomy and which should not be modified for the laparoscopic technique. While routine cholangiography does not offer complete protection from iatrogenic ductal injuries, it is essential to visualize the biliary tract whenever a lesion of the ductal system is clearly identified or even suspected. In such cases, facility with the technique of intraoperative cholangiography and a knowledge of the radiological anatomy of the biliary tree are essential for an accurate and complete intraoperative evaluation of the biliary injury. Finally, in the presence of acute or chronic inflammation or other factors for technical difficulty (obesity, cirrhosis, previous surgery, anatomic variations, intraoperative bleeding), the surgeon must not hesitate to consider conversion to an open surgical approach. In such complicated cases, even the open approach is not a guarantee against biliary injury; there is no substitute for experience and caution in biliary surgery
The impact of intraoperative ultrasonography on the management of disappearing colorectal liver metastases
No full textHepatic resection for colorectal liver metastases (CRLM) is currently the only treatment option that can offer a chance of long-term survival, with 5-year survival rates of 40% [1–3], and exceeding 50% in selected patients [4–6]. However, resectability is the limiting factor; indeed, only 10–25% of patients with CRLM are candidates for surgical resection at the time of presentation [7].
More recently, the introduction of new and more effective chemotherapy regimens combined with targeted agents have improved the response rate over that of standard chemotherapy alone, from 30 to 60% [8–10]. For this reason preoperative chemotherapy for CRLM has been widely used and an increasing number of patients receive chemotherapy prior to liver resection, either as neoadjuvant strategy for initially resectable CRLM [11], or as conversion chemotherapy in patients with initially unresectable CRLM in attempt to convert them into surgical candidates [12,13].
The extensive use of chemotherapy may cause the shrinkage of CRLM and sometimes makes such lesions impossible to identify in radiological imaging studies. These lesions are called ‘missing’ or ‘disappearing’ CRLM [14]. Disappearing liver metastases (DLM) are defined as a disappearance of liver metastases on cross-sectional imaging after administration of preoperative chemotherapy, which means a complete radiological response or complete clinical response (CCR). This phenomenon has been reported by several centers and can occur in 5–25% of patients who undergo preoperative systemic chemotherapy [15–21]. Patients with multiple CRLM, with size <1 cm and those undergoing prolonged preoperative chemotherapy, presented significantly higher risk of developing DLM [18]. Different reported rates of DLM may depend on the quality and type of cross-sectional imaging [22]. Indeed preoperative chemotherapy can induce parenchymal changes to the liver by increasing fatty content, defined as steatosis or steatohepatitis. In that setting the background liver appears less dense, with lower contrast between the parenchyma and the hypovascular metastases, hindering their detection [14,22]. Compared with computed tomography (CT), magnetic resonance imaging (MRI) with liver-specific contrast agents, presents higher sensitivity and better specificity to detect and differentiate CRLM, and can be considered as the best modality to image CRLM missing on CT scan, especially in case of chemotherapy-induced steatosis or steatohepatitis [14,22,23]
Hepatolithiasis-associated cholangiocarcinoma: results from a multi-institutional national database on a case series of 23 patients
No full textAims: Few papers focused on association between hepatolithiasis (HL) and cholangiocarcinoma (CCC) in Western countries. The aims of
this paper are to describe the clinical presentation, treatment, and postoperative outcomes of CCC with HL in a cohort of Western patients
and to compare the surgical outcomes of these patients with patients with CCC without HL.
Materials and methods: Among 161 patients with HL from five Italian tertiary hepato-biliary centers, 23 (14.3%) patients with concomitant
CCC were analyzed. The results of surgery in these patients were compared with patients with CCC without HL.
Results: The 60.9% of patients with HL received the diagnosis of CCC intra- or postoperatively, with a resectability rate of 91.3%. The postoperative
morbidity was 61.6%. The 1- and 3-year survival rates were 78.6% and 21.0%, respectively. The recurrence rate was 44.4% and the 3-
year disease-free survival rates were 18.8%. The comparison with patients with CCC without HL showed a higher resectability rate ( p 1⁄40.02)
and a higher frequency of earlier stage ( p 1⁄4 0.04) in CCC with HL. Biliary leakage was more frequent in CCC with HL group ( p 1⁄4 0.01)
compared to CCC without HL group. We found no differences in overall and disease-free survival between the two groups.
Conclusions: Patients with HL and CCC showed a high resectability rate but a higher morbidity. Nevertheless, overall and disease-free
survival of patients with CCC and HL showed no differences compared to those of patients with CCC without HL. Also in Western countries,
HL needs a careful management for the possible presence of CCC
ALPPS Versus Conventional Two-stage Hepatectomy in Patients With Advanced Colorectal Liver Metastases
No full textN
- …
