Alberto M. Isla

Is radical hepatic surgery safe

BACKGROUND A prospective review of 200 consecutive liver resections performed for benign and malignant disease, between 1989 and 1995 at the Hammersmith Hospital, was undertaken to evaluate the safety of radical hepatic resection. METHODS The indications for operation were: hepatocellular carcinoma (n = 39), cholangiocarcinoma (n = 21), gall bladder carcinoma (n = 8), colorectal secondaries (n = 75), noncolorectal secondaries (n = 35), and benign disease (n = 26). Twenty patients were cirrhotic and 36 were jaundiced. Major resections were performed in 74% of cases and included 63 extended hepatectomies, 17 repeated resections for recurrent colorectal metastases, and 17 resections combined with vascular reconstruction. Total vascular exclusion of the liver was used in the majority of cases. RESULTS The overall mortality rate was 5%. Thirty-day mortality was 2.5%. Sepsis and not hemorrhage was the most common cause of death. There were 101 complications that occurred in 37% of the patients. The main complications were subphrenic abscess and biliary leak. The extent of liver resection (major versus minor) significantly increased the risk of morbidity (46% versus 16%). Blood loss greater than 100 mL increased the risk of morbidity from 12% to 25%. CONCLUSIONS Major hepatic resection can be achieved with acceptable mortality but high morbidity rates.

A Continuing Role for Surgical Bypass in the Palliative Treatment of Pancreatic Carcinoma

Background: The use of palliative surgery for irresectable pancreatic cancer has been challenged by the advent of non-operative stenting, but it may still be appropriate for selected patients. Methods: Single-loop biliary and gastric bypass was carried out in 56 patients (mean age 60 years) with carcinomas of the pancreatic head that were irresectable because of vascular invasion or distant spread. In 42 patients without a preoperative tissue diagnosis, ductal carcinoma was confirmed by biopsy of the primary (n = 20) or secondary (n = 22) tumour. Preoperative biliary decompression in 31 patients led to positive bile cultures in 22 of 24 patients sampled. Results: There were no deaths in hospital or within 30 days. Complications in 20 patients (35%) included three biliary leaks, two of which required temporary percutaneous stents. The median postoperative hospital stay was 14 days. No re-operations were required before death, though 2 patients required percutaneous stenting of the biliary anastomosis for recurrent jaundice, 1 of whom had a radiation-induced stricture. The median survival was 6 (range 2–21) months. Conclusion: Combined biliary and gastric bypass can be carried out with reasonable safety and remains a useful option for patients with potentially resectable tumours and an anticipated life expectancy of at least 6 months.

Liver resection using total vascular exclusion, scalpel division of the parenchyma, and a simple compression technique for hemostatis and biliary control

Recent improvements in perioperative morbidity and long-term outcome following liver surgery have led surgeons to attempt larger and more technically challenging liver resections. Total vascular exclusion (TVE) of the liver during resection has been proposed as a technique that will facilitate these difficult resections while minimizing blood loss. Total vascular exclusion is performed by obtaining complete isolation of the vascular pedicle of the liver. Once the hepatic vein is clamped, rapid resections may be performed with a loss of only the blood volume contained within the liver itself. Safe performance of total vascular exclusion of the liver requires a thorough understanding of hepatic anatomy, patient selection criteria, and the physiologic changes incurred by hepatic exclusion and subsequent ischemia and reperfusion. The following report discusses these issues, gives a detailed description of the steps involved in obtaining safe total vascular exclusion, and presents a technique using rapid parenchymal excision with a scalpel and capsular compression to obtain hemostasis and prevent bile leaks. We briefly discuss our experience with 144 consecutive resections in which this technique was used.

A technique for safe placement of a biliary endoprosthesis after laparoscopic choledochotomy.

BACKGROUND Biliary endoprosthesis has been proposed as an alternative to T-tube placement after laparoscopic choledochotomy in an attempt to eliminate the complications associated with T-tubes. Biliary endoprostheses have been, until now, placed under fluoroscopic guidance. We present a modification of Gersins method for endoprosthesis placement under direct vision. PATIENTS AND METHODS As of July 2001, seven patients who fulfilled the criteria for common bile duct (CBD) exploration through a choledochotomy, a biliary endoprosthesis was inserted under direct vision at the end of the procedure with primary closure of the CBD above it. In all cases, plastic biliary stents 10F in diameter were used ranging from 5 to 10 cm in length. We describe in detail the technique of CBD stent placement using the choledochoscope as the advancing device. We also propose the use of intraoperative cholangiography instead of on-table endoscopy to check the final correct position of the stent. RESULTS The median postoperative hospital stay was 2 days. Two patients developed transient hyperamylasemia in the immediate postoperative period. None of the patients developed short-term complications (<30 days), namely bile leak, CBD erosion, stent occlusion, or stent migration. The long-term results revealed early return to full daily activities and normal liver function tests. Stents were removed endoscopically 4 weeks after the initial procedure except in two patients who spontaneously passed them. CONCLUSION We propose a 10F 10-cm biliary endoprosthesis placed under direct vision as a safe, effective, time-sparing, and cost-effective adjunct to CBD exploration through a choledochotomy. Placement of the endoprosthesis is associated with low morbidity and eliminates the complications related to T-tubes.

Pancreaticoduodenectomy for periampullary malignancies: the effect of bile colonization on the postoperative outcome

ObjectivesThe presence of bacteria in the bile of patients undergoing biliary tract surgery has been proposed as associated to an increased incidence of postoperative complications. The present study was designed to determine whether colonization of the bile has an adverse effect in terms of postoperative infectious or noninfectious complications and mortality in a homogenous population of patients suffering from periampullary region malignancies, who all underwent resectional (curative) procedures.Materials and methodsBetween January 1997 and December 2002, 115 patients (n = 115) suffering from periampullary region malignancies underwent resectional procedures. Fifty-two of the above patients were referred having undergone preoperative internal biliary drainage. During the operation, bile was routinely isolated from the common bile duct and was sent for culture and sensitivity. Based on the bile culture results, the patients were divided in sterile and colonized group and were retrospectively compared in terms of postoperative outcome and mortality.ResultsOf the 115 bile cultures, 67 were colonized with bacteria and 48 were sterile. Postoperatively, 40 patients developed 35 noninfectious and 21 infectious complications. Univariate analysis did not disclose statistically significant differences in overall, noninfectious or infectious morbidity and mortality between the two groups of patients. Although not statistically significant, a higher incidence (22 vs 10%) of postoperative leaks in the colonized group of patients was noticed. Multiple regression analysis disclosed that colonized bile was independently related to the advanced age, preoperative biliary drainage presence, elevated preoperative serum bilirubin levels and low preoperative serum albumin levels but did not predispose to an increased postoperative morbidity, mortality, or reoperation rate.ConclusionThe present study did not conclude in any statistically significant differences in the postoperative infectious and noninfectious morbidity as well as mortality, between colonized and sterile groups of patients who underwent resectional procedures for malignancies of the periampullary region. Although internal biliary drainage introduces microorganisms into the biliary tree, this colonization does not increase the risk of either infectious or noninfectious complications or postoperative death. Thus, the likelihood of bacterobilia should not contraindicate the procedure in selected cases.

Two cases of ectopic liver attached to the gallbladder wall

BACKGROUND Ectopic liver tissue is occasionally found either attached to the gallbladder or elsewhere in the upper abdomen. CASE OUTLINES A 49-year-old man and a 39-year-old woman were found to have a tongue of liver tissue attached to the serosa of the gallbladder (but separate from the liver) during laparoscopic cholecystectomy for gallstones. The ectopic liver was removed with the gallbladder and was histologically normal in each case. DISCUSSION Several embryological hypotheses have been advanced to explain the development of ectopic liver. The anomaly is usually discovered incidentally at operation. Although the tissue is histologically normal.it can develop the same conditions as orthotopic liver.

Bariatric surgery and nonalcoholic fatty liver disease.

The rising prevalence of nonalcoholic fatty liver disease (NAFLD) is associated with the increasing global pandemic of obesity. These conditions cluster with type II diabetes mellitus and the metabolic syndrome to result in obesity-associated liver disease. The benefits of bariatric procedures on diabetes and the metabolic syndrome have been recognized for some time, and there is now mounting evidence to suggest that bariatric procedures improve liver histology and contribute to the beneficial resolution of NAFLD in obese patients. These beneficial effects derive from a number of weight-dependent and weight-independent mechanisms including surgical BRAVE actions (bile flow changes, restriction of stomach size, anatomical gastrointestinal rearrangement, vagal manipulation, enteric hormonal modulation) and subsequent effects such as reduced lipid intake, adipocytokine secretion, modulation of gut flora, improvements in insulin resistance and reduced inflammation. Here, we review the clinical investigations on bariatric procedures for NAFLD, in addition to the mounting mechanistic data supporting these findings. Elucidating the mechanisms by which bariatric procedures may resolve NAFLD can help enhance surgical approaches for metabolic hepatic dysfunction and also contribute toward developing the next generation of therapies aimed at reducing the burden of obesity-associated liver disease.

Laparoscopic gastric surgery for cancer: Where do we stand?

Gastric cancer poses a significant public health problem, especially in the Far East, due to its high incidence in these areas. Surgical treatment and guidelines have been markedly different in the West, but nowadays this debate is apparently coming to an end. Laparoscopic surgery has been employed in the surgical treatment of gastric cancer for two decades now, but with controversies about the extent of resection and lymphadenectomy. Despite these difficulties, the apparent advantages of the laparoscopic approach helped its implementation in early stage and distal gastric cancer, with an increase on the uptake for distal gastrectomy for more advanced disease and total gastrectomy. Nevertheless, there is no conclusive evidence about the laparoscopic approach yet. In this review article we present and analyse the current status of laparoscopic surgery in the treatment of gastric cancer.

Exploración laparoscópica de la vía biliar. Experiencia de una unidad especializada

Resumen Introduccion En la actualidad no esta claro cual es el mejor abordaje para la coledocolitiasis con vesicula in situ. Recientemente en algunos centros se ha adoptado la exploracion laparoscopica de la via biliar (ELVB) como tecnica de eleccion. Material y metodos Presentamos la experiencia de ELVB en una unidad con especial interes en cirugia laparoscopica. Durante 30 meses 44 pacientes con una edad mediana de 65 anos y sospecha de litiasis de la via biliar principal fueron intervenidos por laparoscopia. Resultados En mas del 90% se completo la extraccion de calculos laparoscopicamente y solo un paciente requirio conversion a cirugia abierta. Un 18% presento complicaciones y hubo un fallecimiento en un paciente de 75 anos debido a una complicacion con el tubo en “T”. Conclusiones Consideramos que, en manos entrenadas, el abordaje laparoscopico de la via biliar tiene al menos los mismos resultados que el abordaje tradicional (colangiopancreatografia retrograda endoscopica [CPRE]) con menos ingresos y probablemente inferior mortalidad en el grupo de enfermos jovenes.

Thoracoscopic Esophageal Repair of a Spontaneous Barrett's Ulcer Perforation

Spontaneous esophageal perforation of a Barretts ulcer is a rare condition that is associated with high morbidity and mortality. It occurs as a result of a missed diagnosis of underlying Barretts esophagus or because of unresponsiveness to medical management. Owing to the life-threatening nature of this disease, emergency surgical intervention is indicated. Here, we report the first case of spontaneous Barretts esophageal perforation that has been managed using a thoracoscopic approach. This case highlights the feasibility of minimally invasive methodology for emergent esophageal disorders. It also demonstrates the altered esophageal wall properties of Barretts esophagus through musculofibrous thickening and muscularis mucosae duplication that may contribute to the technical outcomes of esophageal surgical management.