Georgi L. Kobakov

Six rare biliary tract anatomic variations: implications for liver surgery.

OBJECTIVE The variations in the anatomy of the biliary tract need to be recognized in modern liver surgery. The purpose of this clinical and anatomical study is to describe several novel biliary tract variations and to outline their practical importance for liver resections and transplantations. MATERIALS AND METHODS Over the previous 10 years, the anatomic variations of the bile ducts were examined during 600 intraoperative cholangiographies, 104 segmentectomies and 54 hemihepatectomies in patients with liver diseases. The intraoperative anatomies of the right and left hepatic ducts and the common hepatic duct confluence were analyzed. RESULTS Twenty-two variations occurred in 59.5% of the patients. Six variations were described for the first time: an accessory right hepatic duct in which a cystic duct drained; a tetrafurcation from the right anterior hepatic duct, right posterior hepatic duct and bile ducts for Segments 2 and 3 with aberrant bile drainage from Segment 4 into the bile duct for Segment 8; an aberrant bile drainage from Segments 6 and 7 into the common hepatic duct; an accessory bile duct for Segment 6 that drained into the bile duct for Segment 3; a tetrafurcation from the right anterior hepatic duct and the bile ducts for Segments 6, 3 and 2 with bile from Segment 7 draining into the bile duct for Segment 2; and an accessory bile duct for the left hemiliver that drained bile from the Type 4 small accessory hepatic lobe (according to Caygill & Gatenby) into the common hepatic duct. CONCLUSION These newly described biliary tract variations should be recognized by liver surgeons to avoid unwanted postoperative complications.

Gastrointestinal stromal tumour of the gallbladder

A lesion identified preoperatively in the gallbladder (Fig. 1) in a 41-year-old woman was treated successfully by cholecystectomy, wedge resection of the gallbladder bed, excision of the extrahepatic biliary tree, lymphadenectomy and retrocolic Roux-en-Y hepaticojejunostomy. Final pathology revealed a malignant gastrointestinal stromal tumour (GIST) (Fig. 2), positive for CD117 but negative for CD34 and platelet-derived growth factor receptor-α (Fig. 3). Only five malignant and three benign gallbladder GISTs have been reported.1 Figure 1 Computed tomography of a gallbladder gastrointestinal stromal tumour Figure 2 Gastrointestinal stromal tumour originating from the gallbladder wall Figure 3 Positive cytoplasmic immunoreactivity for CD117 (c-KIT) (Immunohistochemical stain for CD117; original magnification x 200)

Smooth muscle sphincteroplasty in colostomy

Purpose: The present work elaborated on Schmidt’s idea of an effective smooth muscle sphincteroplasty. The aim of the study was to analyze the effects on the patients with a lower quadrant colostomy constructed after abdominoperineal extirpation of a modified smooth muscle sphincteroplasty combined with colon irrigations. Methods: Seventy-two rectal cancer patients (39 men and 33 women, median age, 54.5 years) with smooth muscle sphincteroplasty and 20 controls with conventional colostomy using colon irrigations (11 men and 9 women, median age, 63.2 years) were examined. A modified smooth muscle wrap of the colostomy with a free graft of a 4-cm-long colon segment without mucosa was applied. In this precolostomy segment a high intraluminal pressure was achieved. The functional capacity and anatomic integrity of the transplanted smooth muscle graft were examined manometrically, electromyo-graphically, and histomorphologically. The functional activity of the colostomy was assessed by periodic recording of the number of “spontaneous” and “directed” defecations. Results: In the patients with smooth muscle sphincteroplasty, the basal intraluminal pressure of the precolostomy segment two years after operation measured 29.7 mmHg. After dilatation of the transplant, these pressures reached up to 43 mmHg (P < 0.001). The weekly “spontaneous” stools were 3 to 5 times less frequent than in the controls (P < 0.001). Conclusions: The modified smooth muscle sphincteroplasty offers operative-technical opportunities for increasing intraluminal pressure in the precolostomy colon segment. Its combination with colonic irrigations facilitates control of the evacuatory rhythm and “spontaneous” stools in colostomy patients, thus improving their quality of life.

Resection for Colorectal Liver Metastases

Colorectal cancer is the third most frequent cancer in the Western world. About half of the patients develop synchronous or metachronous metastases. The liver is the most common site of such metastases and thus hepatic metastatic disease is a significant socio-medical problem. If it is not treated, the median patient survival is only some months. Surgical resection is the treatment of choice for patients with isolated colorectal liver metastases when feasible. For patients with four or fewer isolated hepatic lesions, five year relapse-free survival rates range from 24 to 58 percent and ten year survival rates vary between 17 and 33 percent. There is a convincing socio-epidemiological evidence of the dramatic unfavourable influence on population wealth of untimely diagnosis and inadequate treatment of the patients with advanced and metastatic colorectal cancer worldwide (Hata et al., 2010; Kostov & Kobakov, 2006a; Stillwell et al., 2011; Tsoulfas et al., 2011).

Accessory right hepatic duct in which a cystic duct drains

There exist numerous anatomic bile duct variations1,2 and an aberrant right hepatic duct which drains the right hepatic lobe directly into the extrahepatic bliary tree occurs in 3.2–18.0% of patients.3 The rare anatomical variation of an accessory right hepatic duct into which a cystic duct drains (Fig. 1) was encountered during surgery for obstructive jaundice as a result of an echinococcic cyst. Detailed knowledge of such a variation is of importance in liver resection and transplantation. Furthermore, such an accessory duct may be liable to inadvertent transection or ligation during cholecystectomy. Figure 1 Accessory right hepatic duct1 into which the cystic duct drains. The accessory right hepatic duct drains extrahepatically into the common bile duct. CHD, common hepatic duct; CD, cystic duct

A large accessory liver lobe

A rare, large, type 1 accessory hepatic lobe1 was identified in a young female patient presenting with periodic abdominal pain. Computed tomography was used to demonstrate the lobe during investigations and revealed a pseudopapillary pancreatic tumour (Gruber–Frantz tumour) (Figs 1 and ​and2).2). Segmental resection of the pancreatic body with preservation of the head and tail was performed, along with resection of the accessory lobe, which was connected to the intra-abdominal ligaments rather than to the main liver. Figure 1 Computed tomography image of a large accessory liver lobe (1) and Gruber–Frantz tumour (2) with contours outlined Figure 2 Intraoperative photograph showing a large accessory liver lobe (1) and main liver (2)

Is Sutureless Pancreaticogastrostomy More Effective than Single-Layer Duct-to-Mucosa Pancreaticojejunostomy in Pancreaticoduodenectomy?

OBJECTIVE The present study aimed to assess the safety of pancreatic anastomosis after pancreaticoduodenectomy (PD) and to compare the results of sutureless pancreatogastrostomy (PG) with those of single-layer duct-to-mucosa pancreatojejunostomy (PJ) after PD in patients with malignant disease of the pancreatic head and of the periampullary region. MATERIALS AND METHODS The study included 173 consecutive patients undergoing PD from May 2009 to December 2015 at a single surgical center. Single-layer duct-to-mucosa PJ was performed in 52 patients and sutureless PG in the remaining 123. The primary endpoint was the safety of the procedures, which was assessed as the occurrence of complications during hospitalization. Postoperative pancreatic fistula (POPF) was classified as grade A, B, or C according to the International Study Group of Pancreatic Fistula classification. RESULTS We found that the incidence of POPF was 11.52%. With regard to POPF, the present study showed no significant difference in the two groups (p=0.043). The incidence of Grade C POPF was significantly higher in the PJ group than in the PG group (p=0.001), which was been reflected in the form of a higher rate of postoperative hemorrhage (p=0.001), intra-abdominal abscess (p=0.012), and septic shock (p=0.012) events in the PJ group. CONCLUSION The evaluation of short-term outcomes demonstrates that suturelessPG is a feasible and safe technique, associated with lower life-threatening complications than single-layer duct-to-mucosa PJ. If long-term functional outcomes confirm similar results, sutureless PG could become a valid alternative for pancreatic anastomosis after PD in patients with soft pancreas and high morbidity.

P-0182INTERNATIONALIZATION OF RESEARCH ON QUALITY OF LIFE IN RECTAL CANCER

Background: In the recent years, an increasing attention is currently paid to the improvement of individual patients’ quality of life. Rectum cancer incidence rate continuously increases and this serious challenge requires united efforts by scientists from all over the world. In this scientometric investigation we aimed at analyzing the structure and annual dynamics of the international scientific communications in the field of quality of life in rectal cancer.

Anal canal pressure after ileal pouch-anal anastomosis with strengthened internal anal sphincter.

INTRODUCTIONThe aim of sphincter-saving operative techniques and creation of intestinal reservoirs is to improve the quality of life for patients with restorative proctocolectomy.METHODSIn this study, 48 consecutive patients (19 males and 29 females of ages between 19 and 55 years; mean age, 35.52 years) with ulcerative colitis and familial adenomatous polyposis underwent ileal pouch–anal anastomosis after proctocolectomy in 1986 to 2002. In 26 patients (54.17 percent of the cases), 10 males and 16 females, ileal pouch–anal anastomosis was performed after a modified surgical technique for strengthening the internal anal sphincter by creation of a smooth muscle cuff through plication of a mucosectomized segment of residual rectum. Basal resting anal canal pressure and pressure after voluntary contraction were recorded preoperatively, one month after surgery, and every six months for two years.RESULTSOne month after the operation manometric results showed significantly higher values of resting pressure in patients with a plicated rectal segment than values measured preoperatively (P < 0.001). This effect was absent after the standard ileal pouch–anal anastomosis. With the rectal plication technique, basal pressure increased from a preoperative value of 69 ± 6 mmHg up to 80 ± 6 mmHg at the end of the second postoperative year (P < 0.001).CONCLUSIONSWe concluded that ileal pouch–anal anastomosis with rectal plication perhaps improved sphincter function. The operative technique did not affect anal squeeze pressure. Patients’ quality of life was improved for those undergoing the modified ileal pouch–anal anastomosis.