1,721,114 research outputs found
Pathophysiologic and clinical correlates of hypophosphatemia and the relationship with sepsis and outcome in postoperative patients after hepatectomy
No full textHypophosphatemia in critically ill and postoperative (p.o.) patients is a multifactorial event, and is also related to severity of illness. This study was conducted to assess pathophysiologic correlates of hypophosphatemia and the simultaneous relationship with clinical events after hepatectomy. A total of 333 measurements were obtained in 59 patients: these were performed preoperatively and at p.o. days 1, 3, and 7 in all patients, and subsequently, until recovery or death, only in those with complications. Measurements included plasma phosphate together with a large number of additional blood chemistries, taking into account primary and associated diseases, events associated with the operation, doses of parenteral substrates, occurrence of sepsis or other p.o. complications, outcome, and a consistent set of complementary variables. Plasma phosphate decreased at p.o. days 1 and 3 (P < 0.001) and returned to a level close to baseline at p.o. day 7. Regression analysis showed that phosphate was related simultaneously to patient age (inversely), levels of creatinine and potassium (directly), and dose of parenteral amino acids (inversely; P < 0.001 for all). Independently of covariation with these variables, there was a decrement in phosphate at p.o. days 1 and 3 that was related specifically to p.o. condition; this decrement had a general component common to all patients, an additional component related to duration of previous hepatic ischemia at surgery, and a further component predictive of the subsequent development of complications (in most cases, sepsis). Plasma phosphate at p.o. day 1 was related inversely to APACHE II score (r(2) = 0.4, P < 0.001), and levels lower than 1.5 mg/dL were associated with an almost 4-fold increase in the rate of complications compared with cases with higher phosphate (P < 0.001). The best single variable bridging early evidence of hypophosphatemia to subsequent development of complications was plasma cholesterol, which fell significantly from p.o. day 3 onward in patients with complications compared with those recovering normally (P < 0.01), and in nonsurvivors compared with survivors (P < 0.01). Hypophosphatemia may anticipate clinical evidence of complications by reflecting an early stronger acute-phase response, with shift of phosphate from intra- to extravascular space, or true phosphorus deficiency, which may favor development of complications by impairing high-energy substrate availability for host defense and other cell functions
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
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
Plasma cholesterol level after hepatopancreatobiliary surgery provides information on the postoperative clinical course
No full textNo Abstract - The article, in the form of an Editorial, explains the practical implications of postoperative hypocholesterolemia in surgical and critically ill patients
Laparoscopic management of cholecystogastric fistula
No full textSummary. Description of a case with lithiasis of the gallbladder and a colecystogastric fistula. Both cholecystectomy and closure of the fistula were performed in laparoscopy
Total Vascular Exclusion: indications, techniques and results
No full textThe book chapter describes the indications, technical modalities and multiple issues related to the performance of total vascular exclusion during liver resection
Tumori maligni primitivi e secondari del fegato
No full textIl capitolo descrive vari aspetti di rilevanza chirurgica relativi ai tumori epatici primitivi ed alle metastasi epatiche
Influence of surgical margins on outcome in patients with intrahepatic cholangiocarcinoma: a multicenter study by the AFC-IHCC-2009 study group
No full textOBJECTIVE: Define the optimal surgical margin in patients undergoing surgery for intrahepatic cholangiocarcinoma (IHCC).
BACKGROUND DATA: Surgery is the most effective treatment for IHCC. However, the influence of R1 resection on outcome is controversial and that of margin width has not been evaluated.
METHODS: We studied 212 patients undergoing curative resection of mass-forming-type IHCC. The respective influences on survival of resection status (R0 vs R1), surgical margin width, pTNM stage, and the latter's components were evaluated.
RESULTS: Incidence of R1 resection was 24%. Overall, R1 resection was not an independent predictor of survival [odds ratio (OR) 1.2 (0.7-2.1)] in contrast to the pTNM stage [OR 2.10 (1.2-3.5)]. In the 78 pN+ patients, survival was similar after R0 and R1 resections (median: 18 vs 13 months, respectively, P = 0.1). In the 134 pN0 patients, R1 resection was an independent predictor of poor survival [OR 9.6 (4.5-20.4)], as was the presence of satellite nodules [OR 1.9 (1.1-3.2)]. In the 116 pN0 patients with R0 resections, median survival was correlated with margin width (≤1 mm: 15 months; 2-4 mm: 36 months; 5-9 mm: 57 month; ≥10 mm: 64 month, P 5 mm was an independent predictor of survival [OR 2.22 (1.59-3.09)].
CONCLUSION: Patients undergoing surgery for IHCC are at high risk of R1 resections. In pN0 patients, R1 resection is the strongest independent predictor of poor outcome and a margin of at least 5 mm should be created. The survival benefits of resection in pN+ patients and R1 resection in general are very low
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