Roberto Scilletta

Bile duct injury during laparoscopic cholecystectomy without intraoperative cholangiography: a retrospective study on 1,100 selected patients.

Background: Whether to routinely or selectively use intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) has been a controversial issue for many years. Many authors maintain that IOC decreases the rate of biliary complications such as bile duct injuries, biliary leak, and missed common bile duct (CBD) stones. However, in contrast to these claims, many centers have opted to perform LC without IOC. In this retrospective study, the results of a series of 1,100 LCs, all of which involved major biliary complications and which were performed without the use of IOC, were reviewed. Methods: Data from 1,100 selected patients (728 females and 372 males) undergoing LC without the use of IOC from January 2003 to November 2011 were analyzed. One hundred and seventy LCs were performed by young surgeons during the learning curve, and 930 by surgeons with over 10 years of experience. Two techniques were used to create pneumoperitoneum: the Veress technique in 319 cases (29%) and the Hasson technique in the remaining 781 cases (71%). Patients with a suspicion of CBD stones were excluded from the study. Results: Two CBD injuries (0.18%) and three biliary leaks (0.27%) were detected among this group. Thirty-three patients (3%) needed conversion to open cholecystectomy. Missed CBD stones were reported in 4 cases (0.36%). There was no postoperative mortality. Conclusion: LC can be performed safely without the use of IOC and with acceptable low rates of biliary complications. An accurate preoperative evaluation of clinical risk factors, precise operative procedures, and conversion to an open approach in doubtful cases are important measures which must be taken to prevent CBD injury.

Does transient elastography (FibroScan®) have a role in decision making in hepatocellular carcinoma?

OBJECTIVES Portal hypertension has been reported as a negative prognostic factor and a relative contraindication for liver resection. This study considers a possible role of fibrosis evaluation by transient elastography (FibroScan(®)) and its correlation with portal hypertension in patients with cirrhosis, and discusses the use of this technique in planning therapeutic options in patients with hepatocellular carcinoma (HCC). METHODS A total of 77 patients with cirrhosis, 42 (54.5%) of whom had HCC, were enrolled in this study during 2009-2011. The group included 46 (59.7%) men. The mean age of the sample was 65.2 years. The principle aetiology of disease was hepatitis C virus (HCV)-related cirrhosis (66.2%). Liver function was assessed according to Child-Pugh classification. In all patients liver stiffness (LS) was measured using FibroScan(®). The presence of portal hypertension was indirectly defined as: (i) oesophageal varices detectable on endoscopy; (ii) splenomegaly (increased diameter of the spleen to ≥ 12 cm), or (iii) a platelet count of <100,000 platelets/mm(3). RESULTS Median LS in all patients was 27.9 kPa. Portal hypertension was recorded as present in 37 patients (48.1%) and absent in 40 patients (51.9%). Median LS values in HCC patients with and without portal hypertension were 29.1 kPa and 19.6 kPa, respectively (r = 0.26, P < 0.04). Liver stiffness was used to implement the Barcelona Clinic Liver Cancer algorithm in decisions about treatment. CONCLUSIONS   The evaluation of liver fibrosis by transient elastography may be useful in the follow-up of patients with cirrhosis and a direct correlation with portal hypertension may aid in the evaluation of surgical risk in patients with HCC and in the choice of alternative therapies.

Evaluation of fibrosis in cirrhotic elderly patients with HCC

BackgroundHepatocellular carcinoma (HCC) is usually associatedwith liver cirrhosis and is the principal cause of deathamong patients with cirrhosis [1]. Apart from livertransplantation that may cure both conditions, treat-ment of HCC and cirrhosis is complex because of theneed to be oncologically radical but simultaneously con-servative. Hepatectomy is considered an invasiveapproach and has a marginal role in the treatment ofHCC [2,3]. The value of hepatic fibrosis is considered apredictive factor of outcome in patients with HCCundergoing liver resection [4].Materials and methodsA retrospective analysis of 77 cirrhotic patients, 42 ofthem with hepatocellular carcinoma, observed from2008 to 2010 was performed. The mean age was 65.2years old with 46 men and 31 women. As regards cir-rhosis etiology, 51 patients presented cirrhosis HCV-related, 9 HBV-related, 3 alcohol-related, 2 HBV-HDVco-infections and 12 other etiology. Liver function wasassessed according to the Child-Pugh classification: 60patients were in Child A, 13 in Child B and 4 in ChildC. In all patients liver stiffness measurement (LSM) wasperformed using transient elastography (Fibroscan

Gallbladder agenesis: laparoscopic views of a significant diagnostic challenge

about the biliary nature of her pain, was evaluated by the surgical service. She had an abdominal ultrasound, which showed a difficult visualization of her gallbladder. She subsequently underwent an MR scan (Fig. 1), which was read looking for possible acute cholecystitis or a sclerotic and atrophic gallbladder. the exam evidenced an anomaly in the anatomy of the pancreatic duct, suggesting a hypothesis of pancreas divisum (an anatomical finding related to GA). She was discharged with plans for possible laparoscopic cholecystectomy in 4–6 weeks. In the interim, she had recurrence of her symptoms, and again presented to our department. her laboratory testing was notable for an unremarkable basic metabolic panel and liver enzymes. At this point, we decided to do a laparoscopy [1] to resolve any doubt. No gallbladder was visualized, Introduction

Decision making in elderly HCC

Background The decision making process in hepato-cellular carcinoma (HCC) relies on multiple factors. Hepatic surgery, in fact, has to take into consideration a patient’s general medical condition, performance status, underlying liver disease, functional hepatic reserve. All these factors affect hepatic metabolism, flux and regeneration mechanism conditioning future liver remnant volume. What is more, hepatic regeneration is delayed, even if not completely impaired, in the elderly. Nevertheless age is not always properly taken into account.

Laparoscopic surgery in elderly patients with sliding hiatal hernia

Background Surgery is recommended as treatment for the sliding hiatal hernia (SHH) in order to create a barrier to reflux of gastric contents into the esophagus and into the upper airways where could cause aspiration pneumonia. The aim of this study was to evaluate the results of laparoscopic surgery in elderly patients over 65 years, with SHH with typical and atypical respiratory symptoms, who have been followed up for 5 years.