1,721,038 research outputs found
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
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
Rischio operatorio della colecistectomia laparoscopica
No full textLaparoscopic cholecystectomy has become the treatment of choice for gallbladder stones. As a matter of fact, the advantages related to the significant reduction of postoperative pain and the early mobilization of the patient, with a decrease of general surgical risk, have been well demonstrated. Also the complications of the surgical wound have been drastically reduced. On the contrary, iatrogenic trocar-related injuries represent specific complications of laparoscopic technique. However, the incidence of these complications, mostly the more severe ones, may be significantly reduced with routine use of the "open" technique. The increased incidence of common bile duct (CBD) injuries in laparoscopic cholecystectomy compared with the conventional technique may be partly explained with the learning curve related to the rapid diffusion of this new approach. An appropriate training, a meticulous operative technique and an early conversion to open procedure in case of intraoperative difficulties may reduce the risk of a CBD injury. In this work the authors' experience of 400 laparoscopic cholecystectomies without CBD injury and major complications is presented. Conversion rate was 5.2% in patients with simple symptomatic cholelithiasis and 37.5% in patients with acute or subacute cholecystitis
The relationship between plasma albumin, other proteins and variables, and age in the acute phase response after hepatectomy in man
No full textLiver resections for hilar cholangiocarcinoma
No full textHilar cholangiocarcinoma (HC) is a rare tumor which has to be distinguished by intrahepatic cholagiocarcinoma invading hepatic hilum because the former has better prognosis then the latter. Patients with HC are difficult to manage because many challenging issues remain in the treatment of this tumour regarding correct diagnosis and therapeutic strategy. HC is resectable in about 30% of cases, but operative risk is highly influenced by septic complications of preoperative biliary drainage and by the need of major liver resection associated with biliary resection. We report the results of 43 resected patients (28 M/15 F; mean age 60 years, range 33-78), accounting for 29% of 149 patients with HC. Symptomless jaundice was the most common clinical presentation (87%; 130 patients). Biliary stricture was classified according to the Bismuth-Corlette classification as type 1 in 3 patients (7%); type 2 in 12 patients (28%); type 3 in 28 patients (65%). Ten patients underwent preoperative right portal vein embolization. Main biliary confluence excision associated with major hepatectomy was performed in 40 patients (93%), with R0 resection rate by 77%. Postoperative mortality rate was 6.9% (3 patients). Morbidity rate was 52.5% (21 patients), being biliary fistula (38%) and liver failure (19%) the most frequent complications. Five-year overall and disease-free survival rate were 36.1% and 28.2, respectively.
Surgical resection remains the only chance of cure for patients with HC. However, due to the complexity of surgery immediate results remain unsatisfactory with morbidity and mortality rates higher than those reported after liver resection for other malignancies. This is mainly related to septic complications, strictly linked to complications of preoperative biliary drainage. Selective biliary drainage, careful management of biliary drains, drainage of excluded ducts in case of cholangitis, bile culture guided antibiotic use and preoperative portal vein embolizationln are important factors to reduce the risk of cholangitis and of postoperative complications. Because of the significant perioperative risk, the demanding operative management and the rarity of this tumor, patients with HC should be referred to tertiary surgical centers
Author's reply (lettera all'editore su: Hypocholesterolemia in critically ill surgical patients)
No full textNo Abstrac
Routine use of open technique in laparoscopic operations
No full textBACKGROUND: The "blind" insertion of the Veress needle for insufflation of the peritoneal cavity with subsequent closed placement of the first trocar during laparoscopic abdominal procedures can result in severe major vascular and visceral injuries. An open technique was proposed as an alternative method for insufflation in patients with abdominal scars to reduce the possibility of such complications. The aim of this article is to report the results of our experience with the routine use of open technique in laparoscopic surgery.
STUDY DESIGN: Open technique was routinely used and prospectively evaluated in 330 patients who underwent laparoscopic procedures.
RESULTS: Laparoscopic conversion was necessary in 25 out of 330 cases (7.6 percent): in 20 cases for unclear biliary anatomy during laparoscopic cholecystectomy, and in 5 cases for minor hemorrhage that could not be managed by laparoscopy. In the 305 procedures completed by laparoscopy, 11 patients (3.6 percent) had 13 postoperative complications. These complications were all of minor importance and were always unrelated to trocar insertion; in particular, no major vascular or visceral injuries were observed.
CONCLUSIONS: Routine use of open technique for pneumoperitoneum represents the best prevention of most of the severe trocar-related complications that are potentially avoidable
L’esclusione vascolare nella chirurgia resettiva del fegato
No full textThe demonstration that the liver can tolerate prolonged periods of normothermic ischaemia represents one of the most significant developments in liver resection surgery. It has permitted the application of techniques involving the temporary interruption of blood flow to the liver, with the aim of reducing bleeding during resection. This has led to a widening of the range of indications for the excision of lesions with a high risk of bleeding, and a reduction in the number of blood transfusions. This study analysed the results of 125 liver resections, 19 of which involved cirrhotic liver, carried out under conditions of normothermic ischaemia obtained by complete clamping of the hepatic pedicle either alone (112 patients) or together with caval clamping (13 patients). The mean duration of the ischaemia was 39 minutes (7-107). Eighty-two resections (65.6%) were carried out without transfusions; the mean number of units transfused in the other 43 cases (34.4%) was 2.1 +/- 1.3. The postoperative mortality rate was 0.9%; twenty-six patients (20.8%) developed postoperative complications and the incidence of liver failure was 5.6%. Postoperative disturbances of liver function tests were transitory and, in most cases, rapidly resolving
Risk for laparoscopic fenestration of liver cysts
No full textBackground: Laparoscopic fenestration is considered the best treatment for symptomatic simple liver cysts.
Conversely, the laparoscopic approach for the management
of hydatid simple liver cysts is not widely accepted because of the risk for severe complications.
Despite improvement in imaging techniques, the probability
of preoperatively mistaking a hydatid liver cyst for a simple liver cyst remains about 5%. Therefore,
laparoscopic fenestration, planned for a liver cyst could be performed unintentionally for an undiagnosed hydatid liver cyst.
Methods: From January 2000 to January 2001, 15 patients
with a diagnosis of liver cyst underwent laparoscopy
for fenestration. In all cases preoperative serologic
and imaging assessment had excluded hydatid liver cyst.
To further exclude hydatid liver cyst, preliminary aspiration of the cyst with assessment of cystic fluid characteristics was performed.
Results: In two patients with presumedly simple liver
cyst, hydatid liver cyst was diagnosed instead at laparoscopy
by aspiration of cystic fluid. The procedure was converted to laparotomy with subtotal pericystectomy.
Conclusions: The risk of misdiagnosing a hydatid liver cyst for a simple liver cyst, especially in the presence of a
solitary cyst, should be considered before laparoscopic
fenestration is performed. Intraoperative aspiration of
cyst fluid before fenestration can minimize this risk, thus
avoiding severe intraoperative and late complications
Modulation of plasma fibrinogen levels in acute phase response after hepatectomy
No full textIn acutephase response, the use of amino acids is redirected to supporting the synthesis of proteins for host defence and tissue repair. Fibrinogen is one of these proteins, and its plasma levels commonly increase in acutephase conditions. After hepatectomy, this pattern may be modified by the variable impact of postoperative liver dysfunction. Our study was performed to specifically assess and quantify this aspect. Data were collected prospectively on 82 hepatectomized patients; 62 recovered normally, 20 had major complications (most commonly sepsis). Plasma fibrinogen and a large series of complementary variables were determined preoperatively and at postoperative days 1, 3 and 7 in all patients and until recovery, or death in those with complications. Multiple regression analysis showed that postoperative changes in fibrinogen (DeltaFIB, mumol/l) were simultaneously related to the number of resected liver segments (NSEG), total bilirubin (BIL, mumol/l), aspartate aminotransferase (AST, U/l, n.v. 545), albumin (ALB, g/l), prothrombin activity (PA, % of standard reference), age (AGE, years) and basal preoperative fibrinogen (PFIB, mumol/l): DeltaFIB= -0.51 (NSEG) -0.71 (Log(n)BIL) -0.74(Log(n)AST)+0.11(ALB) +0.09(PA) -0.06 (AGE) -0.55(PFIB)+7.74 (n=362, r(2)=0.68, p<0.001). In addition, an early postoperative tendency for low fibrinogen was associated with the subsequent development of complications or death. Our study quantifies the impact of size of hepatectomy and dysfunction of residual liver in modulating postoperative fibrinogen level and suggests that failure of fibrinogen to increase may signal an unfavorable condition limiting upregulation of acutephase response and increasing liability to complications
- …
