Oscar Mazza

Intraoperative Management and Repair of Bile Duct Injuries Sustained during 10,123 Laparoscopic Cholecystectomies in a High-Volume Referral Center

BACKGROUNDnBile duct injury (BDI) remains the most serious complication of laparoscopic cholecystectomy (LC). The best strategy in terms of timing of repair is still controversial. The purpose of the current study is to review the experience in the intraoperative repair of bile duct injuries sustained during LC at a high-volume referral center.nnnSTUDY DESIGNnSingle-institution retrospective analysis of a prospectively collected database. Patients with diagnosis of BDI sustained during LC between October 1991 and November 2010 were extracted.nnnRESULTSnAmong 10,123 LC performed during the study period, 19 patients had a BDI sustained during the procedure. Intraoperative cholangiography was routinely used. Bile duct injury was diagnosed intraoperatively in 17 patients (89.4%). Mean age was 56.4 years (range 18 to 81 years) and 15 patients were women (88%). According to the Strasberg classification of BDI, there were 3 type C lesions, 12 type D lesions, and 2 type E2 lesions. There were no associated vascular injuries. Twelve cases (71%) were converted to open surgery. The repairs included 10 primary biliary closures, 4 Roux-en-Y hepaticojejunostomies, 2 end to end anastomosis, and 1 laparoscopic transpapillary drainage. Postoperative complications occurred in 5 patients (29.4%). During the follow-up period, early biliary strictures developed in 2 patients (11.7%) and were treated by percutaneous dilation and a Roux-en-Y hepaticojejunostomy with satisfactory long-term results.nnnCONCLUSIONSnThe current series represents one of the largest single-center experiences in terms of intraoperative repair of BDI sustained during LC. The results suggest that a high level of intraoperative diagnosis is possible, where intraoperative cholangiography is a useful tool. The intraoperative repair of BDI sustained during LC by experienced hepatobiliary surgeons either by open or laparoscopic approach appears of paramount importance to assure optimal results.

Pyogenic liver abscess: current status and predictive factors for recurrence and mortality of first episodes

BACKGROUNDnIn times of modern surgery, transplantation and percutaneous techniques, pyogenic liver abscess (PLA) has essentially become a problem of biliary or iatrogenic origin. In the current scenario, diagnostic approach, clinical behavior and therapeutic outcomes have not been profoundly studied. This study analyzes the clinical and microbiological features, diagnostic methods, therapeutic management and predictive factors for recurrence and mortality of first episodes of PLA.nnnMETHODSnA retrospective single-center study was conducted including 142 patients admitted to the Hospital Italiano de Buenos Aires, between 2005 and 2015 with first episodes of PLA.nnnRESULTSnPrevailing identifiable causes were biliary diseases (47.9%) followed by non-biliary percutaneous procedures (NBIPLA, 15.5%). Seventeen patients (12%) were liver recipients. Eleven patients (7.8%) died and 18 patients (13.7%) had recurrence in the first year of follow up. The isolation of multiresistant organisms (pxa0=xa00.041) and a history of cholangitis (pxa0<xa00.001) were independent risk factors for recurrence. Mortality was associated with serum bilirubin >5xa0mg/dL (pxa0=xa00.022) and bilateral involvement (pxa0=xa00.014) in the multivariate analysis.nnnCONCLUSIONnNBPLA and PLA after transplantation may be increasing among the population of PLA in referral centers. History of cholangitis is a strong predictor for recurrence. Mortality is associated to hiperbilirrubinemia and anatomical distribution of the lesions.

Surgical strategies for restoring liver arterial perfusion in pancreatic resections

BackgroundHepatic perfusion failure represents an important risk factor for severe complications and death after pancreatic resections. Arterial reconstruction could be required during pancreatic surgery because of tumor infiltration, benign strictures, or as a consequence of accidental arterial injury during dissection. All these situations can be faced with a certain frequency in high-volume pancreatic centers, where surgeons must be aware of the different alternatives to deal with these intricate scenarios.PurposeWe herein describe the preoperative surgical planning as well as different surgical strategies for the restoration of arterial perfusion of the liver in pancreatic resections.ConclusionA thorough preoperative evaluation is essential for planning pancreatic surgery and preparing the surgeon and patient for potentially high complex procedures. The various therapeutic alternatives presented in this technical report might represent a good solution for selected patients with no other potentially curative option than surgery.

Primary Hepatic Lymphoma: Features of a Puzzling Disease

Primary hepatic lymphoma (PHL) is a very rare liver tumor. It is described as a lymphoma localized and limited to the liver without extrahepatic involvement [1], and represents about 0.016 % of all non-Hodgkin lymphoma cases [2]. Clinical presentation is nonspecific. As other lymphoproliferative diseases usually presents with constitutional symptoms, and B symptoms often appear (fever, weight loss, and night sweats). It frequently mimics other hepatic tumors, there so diagnosis becomes difficult and is often made intraor postoperatively. Treatment is controversial regarding surgical and chemotherapy indications [3, 4]. Due to its prevalence, there are no controlled studies, and the recommendations made are based on case reports or series of limited amount of patients. We present a case of a PHL, which despite the multiple diagnostic methods implemented, definitive diagnosis was made after surgery and histological analysis of the lesion.

Protocol for extended antibiotic therapy after laparoscopic cholecystectomy for acute calculous cholecystitis (Cholecystectomy Antibiotic Randomised Trial, CHART)

Introduction Acute calculous cholecystitis represents one of the most common complications of cholelithiasis. While laparoscopic cholecystectomy is the standard treatment in mild and moderate forms, the need for antibiotic therapy after surgery remains undefined. The aim of the randomised controlled Cholecystectomy Antibiotic Randomised Trial (CHART) is therefore to assess if there are benefits in the use of postoperative antibiotics in patients with mild or moderate acute cholecystitis in whom a laparoscopic cholecystectomy is performed. Methods and analysis A single-centre, double-blind, randomised trial. After screening for eligibility and informed consent, 300 patients admitted for acute calculus cholecystitis will be randomised into two groups of treatment, either receiving amoxicillin/clavulanic acid or placebo for 5 consecutive days. Postoperative evaluation will take place during the first 30u2005days. Postoperative infectious complications are the primary end point. Secondary end points are length of hospital stay, readmissions, need of reintervention (percutaneous or surgical reinterventions) and overall mortality. The results of this trial will provide strong evidence to either support or abandon the use of antibiotics after surgery, impacting directly in the incidence of adverse events associated with the use of antibiotics, the emergence of bacterial resistance and treatment costs. Ethics and dissemination This study and informed consent sheets have been approved by the Research Projects Evaluating Committee (CEPI) of Hospital Italiano de Buenos Aires (protocol N° 2111). Results The results of the trial will be reported in a peer-reviewed publication. Trial registration number NCT02057679.

Enucleación laparoscópica de una neoplasia intraductal papilar mucinosa de ramos periféricos localizada en la cabeza del páncreas. Una nueva alternativa

The surgical strategy for treating intraductal papillary mucinous neoplasm (IPNM) of the peripheral branches continues to be controversial. The extension of the surgical resection is still under debate, especially in patients with non-invasive lesions. In these patients, the objective is to preserve as much of the remaining parenchyma as possible. We present the case of a 39-year-old man with a history of recurring episodes of acute pancreatitis. Multislice computed tomography (MSCT) and magnetic resonance cholangiopancreatography (MRCP) showed a pancreatic cyst located in the posterior region of the head of the pancreas, which probably communicated with the main pancreatic duct (Fig. 1). The size of the tumor was 19 mm. Serum levels of CA 19.9 and CEA were normal. The preoperative evaluation was completed with endoscopic ultrasound, which ruled out the presence of other nodules. With the diagnosis of IPNM of the peripheral branches, we decided to resect the lesion. The patient was taken to the operating room with the intention of performing a laparoscopic Whipple procedure. An extended Kocher maneuver was done with complete mobilization of the head of the pancreas. Intraoperative ultrasound enabled us to precisely locate the lesion, which was protruding from the posterior side. At that time, we decided to perform enucleation with preservation of the pancreatic parenchyma and the duodenum. The cyst was dissected with an electroscalpel, and the communicating duct was identified and ligated while preserving the main pancreatic duct and enucleating the tumor (Fig. 2). The frozen histology sections of the cyst showed lowgrade dysplasia. The patient recovered without complications and was discharged from the hospital on the fifth day post-op. The definitive pathology report determined the lesion to be a borderline IPNM. The patient has been symptom-free after 4 months of follow-up. The extension of the pancreatic resection for the surgical treatment of peripheral branch IPNM continues to be a topic of debate. In patients with non-invasive tumors, the long-term results in terms of endocrine and exocrine pancreatic insufficiency should be taken into special consideration. Conservative procedures seem to be an alternative to major pancreatic resections in this type of disease. Central and distal spleen-preserving pancreatectomies have become common treatments in cystic tumors and IPNM of peripheral branches without suspected malignancy. But preservation of the pancreatic parenchyma can be difficult for lesions located in the head of the pancreas or in the uncinate process, for which pancreaticoduodenectomy continues to be the traditional approach. For this reason, enucleation can be useful in these difficult locations. Little has been published in the international literature with regards to the enucleation of benign peripheral branch

Acute Pancreatitis After Laparoscopic Transcystic Common Bile Duct Exploration: An Analysis of Predisposing Factors in 447 Patients

IntroductionIn laparoscopic transcystic common bile duct exploration (LTCBDE), the risk of acute pancreatitis (AP) is well recognized. The present study assesses the incidence, risk factors, and clinical impact of AP in patients with choledocholithiasis treated with LTCBDE.MethodsA retrospective database was completed including patients who underwent LTCBDE between 2007 and 2017. Univariate and multivariate analyses were performed by logistic regression.ResultsAfter exclusion criteria, 447 patients were identified. There were 70 patients (15.7%) who showed post-procedure hyperamylasemia, including 20 patients (4.5%) who developed post-LTCBDE AP. Of these, 19 were edematous and one was a necrotizing pancreatitis. Patients with post-LTCBDE AP were statistically more likely to have leukocytosis (pu2009<u20090.004) and jaundice (pu2009=u20090.019) before surgery and longer operative times (OT, pu2009<u20090.001); they were less likely to have incidental intraoperative diagnosis (pu2009=u20090.031) or to have biliary colic as the reason for surgery (pu2009=u20090.031). In the final multivariate model, leukocytosis (pu2009=u20090.013) and OT (pu2009<u20090.001) remained significant predictors for AP. Mean postoperative hospital stay (HS) was significantly longer in AP group (pu2009<u20090.001).ConclusionThe risk of AP is moderate and should be considered in patients with preoperative leukocytosis and jaundice and exposed to longer OT. AP has a strong impact on postoperative HS.

Extended antibiotic therapy versus placebo after laparoscopic cholecystectomy for mild and moderate acute calculous cholecystitis: A randomized double-blind clinical trial

Background: Acute calculous cholecystitis (ACC) is the most common complication of cholelithiasis. Laparoscopic cholecystectomy (LC) is the gold standard treatment in mild and moderate forms. Currently there is consensus for the use of antibiotics in the preoperative phase of ACC. However, the need for antibiotic therapy after surgery remains undefined with a low level of scientific evidence. Methods: The CHART (Cholecystectomy Antibiotic Randomised Trial) study is a single‐center, prospective, double blind, and randomized trial. Patients with mild to moderate ACC operated by LC were randomly assigned to receive antibiotic (amoxicillin/clavulanic acid) or placebo treatment for 5 consecutive days. The primary endpoint was postoperative infectious complications. Secondary endpoints were as follows: (1) duration of hospital stay, (2) readmissions, (3) reintervention, and (4) overall mortality. Results: In the per‐protocol analysis, 6 of 104 patients (5.8%) in the placebo arm and 6 of 91 patients (6.6%) in the antibiotic arm developed postoperative infectious complications (absolute difference 0.82 (95% confidence interval, −5.96 to 7.61, P = .81). The median hospital stay was 3 days. There was no mortality. There were no differences regarding readmissions and reoperations between the 2 groups. Conclusion: Although this trial failed to show noninferiority of postoperative placebo compared to antibiotic treatment after LC for mild and moderate ACC within a noninferiority margin of 5%, the use of antibiotics in the postoperative period does not seem justified, because it was not associated with a decrease in the incidence of infectious and other types of morbidity in the present study.

Major and Minor Duodenal Papilla Neuroendocrine Tumors in Type 1 Neurofibromatosis: Case Report

Type 1 neurofibromatosis (NF1), or von Recklinghausen disease, is one of the most common autosomal-dominant disorders with an incidence of 1 in every 2500 to 3000 births. NF1 is caused by a germline mutation in NF1 tumor suppressor gene located on chromosome 17q11.2. The NF1 gene encodes neurofibromin, a cytoplasmic protein which plays a fundamental role in negative regulation of the Ras cellular proliferation pathway. Therefore, patients with NF1 are at higher risk of developing various tumors, such as neurofibromas, neurofibrosarcomas, stromal tumors, neuroendocrine tumors, and gliomas [1–3]. About 5–25 % of patients with NF1 have gastrointestinal manifestations such as neurofibromas, gastrointestinal stromal tumors (GISTs) of the small bowel, and periampullary neuroendocrine tumors (NETs); however, only 5 % of them have been reported as symptomatic [4, 5]. Neuroendocrine tumors are derived from cells from the Langerhans islets in the pancreas and from enteroendocrine cells in the digestive system. Clinically they may be divided in two groups: functioning and non-functioning tumors. In the first group, the tumors produce a clinical syndrome, due to the secretion of a specific peptide (i.e., insulinoma, gastrinoma, etc.). The term carcinoid is reserved for those which produce a syndrome secondary to the secretion of serotonin and histamine, although originally the term was used to name all neuroendocrine tumors. Non-functioning neuroendocrine tumors may produce compression symptoms according to their location, unspecific abdominal pain, hemorrhage, obstructive jaundice, or a palpable mass [6]. The association between NF1 and neuroendocrine tumors is well described; however, there is only one other report to date of two synchronous neuroendocrine tumors.

Intraductal Papillary Neoplasm of the Bile Duct (IPNB): Case Report and Literature Review of a Challenging Disease to Diagnose

Intraductal papillary neoplasm of the bile duct (IPNB) is defined as a bile duct epithelial tumor characterized by papillary proliferation within the bile duct lumen [1, 2]. It has been established as a precursor lesion towards cholangiocarcinoma and includes previous categories of premalignant biliary lesions. There are certain morphological features of these tumors, especially intraductal papillary growth pattern, that are similar to IPMN of the páncreas. Opposed to cystic mucinous tumors, the IPNB shows communication with the biliary tract and no ovarian like stroma (OLS) in the pathology findings [3]. IPNB develops through the adenoma-carcinoma sequence and usually progresses slowly compared to classic intrahepatic bile duct carcinoma [1, 3, 4]. An invasive component is present in approximately 40–80% of reported cases [5]. These tumors can originate from anywhere along the biliary tree, including intrahepatic and extrahepatic bile ducts. The main clinical features are intermittent abdominal pain, acute cholangitis, and jaundice but in some patients IPNB remain asymptomatic for a long period of time [3–5]. Due to the unusual presentation of IPNB, its identification represents a diagnostic challenge. Given the malignant potencial, surgical resection with adequate margins is the standard treatment. In this case report, we describe the cytologic, histopathologic, clinical features, and surgical treatment of IPNB with invasive adenocarcinoma in a 72-year old male patient.