Giuseppe Currò

Asymptomatic Cholelithiasis in Children With Sickle Cell Disease Early or Delayed Cholecystectomy

Summary Background Data:Our study aimed to evaluate the role of elective laparoscopic cholecystectomy (LC) in children with sickle cell disease (SCD) and asymptomatic cholelithiasis and, furthermore, to determine whether the outcome is related to the operation timing. Methods:The records of 30 children with SCD diagnosed with cholelithiasis from June 1995 to September 2005 were retraspectively reviewed. All 30 children were asymptomatic at the time of the first visit, and an elective LC was proposed to all of them. The operation was accepted in the period of study by 16 children and refused by 14. During medical observation, 10 of the 14 children who refused surgery were admitted for severe biliary colics. Acute cholecystitis was diagnosed by abdominal ultrasound in 3 cases and in 1 case choledocholithiasis, ultrasonographically suspected, was confirmed by magnetic resonance cholangiopancreatography (MRCP) and treated during endoscopic retrograde cholangiopancreatography (ERCP). All children, emergency admitted, underwent LC after the onset of symptoms. The patients were divided up into 2 groups (A: asymptomatic; B: symptomatic) depending on clinical presentation and operation timing and the respective outcomes were compared. Results:Elective LC in asymptomatic children (group A) is safe with no major complications reported. During medical observation in children who refused elective surgery (group B), 6 biliary colics, 3 acute cholecystitis, and 1 choledocholithiasis were observed. Three sickle cell crises occurred in symptomatic children during biliary colics. The correlation between cholecystectomy performed in asymptomatic children (group A) and cholecystectomy performed in symptomatic children (group B) showed significant differences in the outcome. Morbidity rate and postoperative stay increased when children with SCD underwent emergency LC. Conclusions:Elective LC should be the gold standard in children with SCD and asymptomatic cholelithiasis to prevent the potential complications of biliary colics, acute cholecystitis, and choledocholithiasis, which lead to major risks, discomfort, and longer hospital stay.

STEATOSIS OF THE HEPATIC GRAFT AS A RISK FACTOR FOR POST-TRANSPLANT BILIARY COMPLICATIONS

Baccarani U, Isola M, Adani GL, Avellini C, Lorenzin D, Rossetto A, Currò G, Comuzzi C, Toniutto P, Risaliti A, Soldano F, Bresadola V, De Anna D, Bresadola F. Steatosis of the hepatic graft as a risk factor for post‐transplant biliary complications.
Clin Transplant 2009 DOI: 10.1111/j.1399‐0012.2009.01128.x.
© 2009 John Wiley & Sons A/S.

Incidental gall bladder carcinoma: does the surgical approach influence the outcome?

Background:  The aim of the study was to evaluate the outcome in patients with unsuspected gall bladder carcinoma diagnosed after cholecystectomy, comparing the laparoscopic approach with open surgery.

The invisible cholecystectomy: a different way

Letter to the Editor We read with interest the article from Cuesta et al. [1] regarding the so-called invisible cholecystectomy. We had the same enthusiasm after performing the first one-wound laparoscopic cholecystectomy back in 1997 [2], when the concept of no scar surgery, which became natural orifice transluminal endoscopic surgery (NOTES), did not exist. With our technique, we used two 10-mm trocars parallel to one another on the right and the left sides of the umbilical scar, leaving a small bridge of tissue between them, as described by Cuesta et al. [1]. At that time, we preferred to use 10-mm ports simply because the technology, in our opinion, did not allow clear vision with 5-mm scopes, and because we did not have available the 5-mm clip applier. In contrast to Cuesta et al. [1], we placed three transabdominal stay sutures mounted on a straight needle through the fundus and through both the medial and lateral aspects of the infundibulum to retract, stabilize, flag laterally the gallbladder, and expose the Calot triangle. We do not think it is possible using only one Kirschner wire to expose both the medial and the lateral aspects of the Calot triangle and obtain the same vision and safety achieved by the standard four-trocar approach. Instead, we suggest the use of more than one wire, or better yet, judging from our experience, transabdominal stay sutures. Our enthusiasm for this technique disappeared, however, after we conducted a prospective randomized study comparing the one-wound technique with the conventional fourtrocar approach. Cosmetic advantage was counterbalanced by longer operative time, nonsignificant differences in postoperative pain, nonsignificant cost-effectiveness advantages, and a higher incidence of umbilical incisional hernia due to a larger umbilical incision, which in our experience was 2.5 cm wide, compared with a width of 1.5 to 2 cm in the Cuesta experience. We have been offering and using the technique occasionally during the past 10 years only if the patient strongly desires the use of two 5-mm ports. The advent of NOTES [3], the actual limitations of the available flexible endoscopes, and the idea that the umbilicus is a scar existing since birth made us think to plan and then use a hybrid technique in which vision and specimen extraction are performed via an endoscope inserted transvaginally. Traction is obtained using transabdominal stay sutures, and cholecystectomy is performed through a 5-mm port inserted at the umbilicus using conventional 5-mm laparoscopic instruments. Our preliminary experience with the aforementioned technique seems to overcome the limitation of both the one-wound technique and pure NOTES.

Three-Dimensional (3D) Versus Two-Dimensional (2D) Laparoscopic Bariatric Surgery: a Single-Surgeon Prospective Randomized Comparative Study

BackgroundTo address the issue whether three-dimensional (3D) offers real operative time advantages to the laparoscopic surgical procedure, we have designed a single-surgeon prospective randomized comparison of 3D versus two-dimensional (2D) imaging during two different bariatric procedures.MethodsForty morbidly obese patients were randomized on the day of surgery by a random computer-generated allocation list to receive either a 3D high-definition (HD) display or 2D HD imaging system laparoscopic bariatric procedure by a single experienced surgeon. Forty operations were performed with either a 3D HD display or 2D HD imaging system. After the insertion of the access ports, both surgical procedures were divided in component tasks, and the execution times were compared.ResultsThe execution times for the entire procedure and the single tasks were not significantly different between the 2D and 3D groups during sleeve gastrectomy. The execution times for the entire procedure and the single tasks, except for the first one, were significantly different between the 2D and 3D groups during mini-gastric bypass (p < 0.05). The surgeon experienced better depth perception with the 3D system and subjectively reported less strain using 3D vision system rather than the 2D system particularly during longer procedure.Conclusions3D imaging seems to decrease the performance time of more difficult bariatric procedures, which involve surgical tasks as suturing and intestinal measurement. Further comparative studies are necessary to address the issue if novice surgeons could benefit from reduced learning curve requested with 3D vision and to verify with greater numbers if 3D imaging can reduce complications.

SILS and NOTES cholecystectomy: a tailored approach.

BACKGROUND Natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS) have been proposed as different solutions to further minimize the invasiveness of laparoscopy. In this article, we present our experience with NOTES and SILS over the last few years, trying to focus on identifying which technique should be offered to which patients at the beginning of 2010. PATIENTS AND METHODS Between January 2009 and January 2010, 100 patients were diagnosed with symptomatic cholelithiasis at our department. Considering our positive previous experiences with NOTES and SILS, we offered the hybrid NOTES approach to women over 40 years with no previous pelvic surgery or history of inflammatory pelvic disease and SILS to male patients and women excluded from the hybrid NOTES approach, with previous surgery in the upper right quadrant and gallbladder empyema being the main contraindications. RESULTS Twenty-six patients accepted the SILS or NOTES approach instead of standard laparoscopic cholecystectomy (LC). Seventy-four patients underwent standard LC via four trocars. In the hybrid NOTES transvaginal cholecystectomy, there were no problems or complications related to the culdotomy, trocar, or stay suture placement. There were no conversions, and all the procedures were performed as planned without complications. In the SILS cholecystectomy, there were no problems or complications related to the trocar or stay sutures placement. All the procedure were completed without complications. CONCLUSIONS NOTES and SILS are promising techniques that need new, dedicated instrumentations to reduce technical limitations. Randomized studies comparing SILS/NOTES and traditional laparoscopy are necessary to evaluate safety, efficacy, and potential benefits.

Ultrasound-guided radiofrequency-assisted segmental liver resection. A new technique

Segmental hepatectomy is appealing for several reasons including preservation of liver parenchyma, reduction of intraoperative blood loss, and blood replacement by dividing tissues along the anatomic planes. A simple technique guided by intraoperative ultrasound is described here using radio-frequency energy to create coagulative desiccation of segmental or subsegmental arterial and portal vessels. Thirty patients underwent a segmental resection using this technique without mortality and with minor morbidity. This technique has a major advantage of being easy and safe to apply. We believe it has a potentially important role in both open and laparoscopic liver surgery.

Radiofrequency-Assisted liver resection in cirrhotic patients with hepatocellular carcinoma

Radio‐frequency‐assisted liver resection has been shown to allow virtually bloodless procedures without the need for vascular exclusion manoeuvres. Our primary end‐point was to evaluate safety and feasibility of RF‐assisted liver resection in cirrhotic patients with hepatocellular carcinoma. Our second end‐point was to assess whether the RF‐assisted procedure influence the outcome in terms of morbidity and mortality.

Single-Incision Versus Three-Port Conventional Laparoscopic Right Hemicolectomy: Is There Any Real Need to Go Single?

BACKGROUND Preliminary results showed some benefits of single-incision laparoscopic surgery (SILS) over conventional laparoscopic colectomy, including better cosmesis, less postoperative pain, and faster recovery, but these results need further confirmation. In addition, the literature still lacks comparative studies between the two approaches to prove the above-mentioned advantages of SILS over conventional laparoscopy and, most importantly, its equivalent effectiveness in terms of initial oncological results. PATIENTS AND METHODS Two consecutive series of 10 patients undergoing three-port conventional laparoscopic right hemicolectomy (3PCL-RH) and single-incision laparoscopic right hemicolectomy, respectively, were compared in their short-term surgical and oncological outcomes. RESULTS Analysis of perioperative and postoperative outcomes revealed no significant differences between the two groups. In the SILS group an anastomotic leakage occurred, which was conservatively treated by continuous drainage, total parental nutrition, and antibiotic therapy. The analysis of oncological outcomes showed no differences in terms of length of distal tumor-free margin and harvest of lymph nodes. CONCLUSIONS Despite its feasibility for right hemicolectomy and its equivalent short-term surgical and oncological outcome compared with conventional laparoscopy, SILS demonstrated no significant advantages in terms of surgical incision length and postoperative course compared with 3PCL-RH. We acknowledge that the small sample size and the nonrandomized design are a limit of the study. Thus, prospective randomized controlled trials are recommended to prove the superiority of single-incision laparoscopic right hemicolectomy.

Laparoscopic cholecystectomy in children with chronic hemolytic anemia. Is the outcome related to the timing of the procedure

BackgroundThe aim of this study was to evaluate whether the outcome in children with chronic hemolytic anemia (CHA) and cholelithiasis undergoing laparoscopic cholecystectomy (LC) is related to the operation timing.MethodsFrom June 1995 to December 2004, 46 children with CHA were referred to our division of surgery for cholelithiasis. All 46 children were asymptomatic at the time of the first visit, and an elective LC was proposed to all of them before the onset of symptoms. The operation was accepted in the period of study by 24 children and refused by 22. The patients were divided into three groups (group A, asymptomatic; group B, symptomatic; and group C, emergency admitted) depending on clinical presentation and operation timing, and the respective outcomes were compared.ResultsElective LC in asymptomatic children (group A) is safe with no major complications reported. In children who refused surgery (groups B and C), we observed four sickle cell crises, four acute cholecystitis, and two choledocholithiasis, and all these complications were related to waiting. Two sickle cell crises occurred in symptomatic children waiting for surgery during biliary colic. The risk of emergency admission in children with cholelithiasis and CHA awaiting surgery was found to be high: 28% of the children admitted in emergency after a mean of 32 months (range, 22–36). Morbidity rate and postoperative stay increased when children with hemoglobinopathies underwent emergency LC.ConclusionsElective LC should be the gold standard in children with CHA and asymptomatic cholelithiasis in order to prevent the potential complications of cholecystitis and choledocholithiasis, which lead to major risks, discomfort, and longer hospital stay.