Rosario Vecchio

Bile duct injury after laparoscopic cholecystectomy: The United States experience

AbstractBackground: Forty series reporting experience with laparoscopic cholecystectomy in the United States from 1989 to 1995 were reviewed. A total of 114,005 cases were analyzed and 561 major bile duct injuries (0.50%) and 401 bile leaks from the cystic duct or liver bed (0.38%) were recorded. Intraoperative cholangiography (IOC) was attempted in 41.5% of the laparoscopic cholecystectomies and was successful in 82.7%. In major bile duct injuries, the common bile duct/common hepatic duct were the most frequently injured (61.1%) and only 1.4% of the patients had complete transection. Methods: When reported, most of the bile duct injuries were managed surgically with a biliary-enteric anastomosis (41.8%) or via laparotomy and t-tube or stent placement (27.5%). The long-term success rate could not be determined because of the small number of series reporting this information. The management for bile leaks usually consisted of a drainage procedure (55.3%) performed endoscopically, percutaneously, or operatively. Results: The morbidity for laparoscopic cholecystectomy, excluding bile duct injuries or leaks, was 5.4% and the overall mortality was 0.06%. It was also noted that the conversion rate to an open procedure was 2.16%. Conclusions: It is concluded based on this review of laparoscopic cholecystectomies that the morbidity and mortality rates are similar to open surgery. In addition, the rate of bile duct injuries and leaks is higher than in open cholecystectomy. Furthermore, bile duct injuries can be minimized by lateral retraction of the gallbladder neck and careful dissection of Calot’s triangle, the cystic duct–gallbladder junction, and the cystic duct–common bile duct junction.

Modifications of coagulation and fibrinolytic parameters in laparoscopic cholecystectomy

Background: The incidence of deep vein thrombosis and pulmonary embolism following laparoscopic surgery is unknown and studies on alterations of hemostasis after laparoscopy are inconclusive. Methods: In this study we prospectively evaluated changes in prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen (Fg), antithrombin III (ATIII), prothrombin fragment F 1 + 2, beta-thromboglobulin (bTG) and D-dimer (D-D), preoperatively and 24 h after laparoscopic surgery in 16 patients. Results: Comparing pre- and postoperative values, no statistical differences were observed in aPTT, F1 + 2, and ATIII measurements. Postoperative PT values increased slightly (p ~ 0.05) after surgery. Conversely, Fg, bTG, and D-D values were statistically higher in the 24-h evaluation (p = 0.008, 0.01, and 0.045, respectively). Conclusions: These data suggest that laparoscopic surgery induces activation of coagulation and fibrinolytic pathways and, additionaly, bTG elevation, which has never been reported and might account for postoperative platelet activation and a greater risk of thrombogenicity. Therefore, routine thromboembolic prophylaxis in patients undergoing laparoscopic surgery is recommended.

Laparoscopic common bile duct exploration.

Abstract. In recent years, laparoscoscopic common bile duct exploration has become the procedure of choice in the management of choledocholithiasis in several laparoscopic centers. The increasing interest for this laparoscopic approach is due to the development of instrumentation and technique, allowing the procedure to be performed safely, and it is also the result of the revised role of endoscopic retrograde cholangiopancreatography, which has been questioned because of its cost, risk of complications and effectiveness. Many surgeons, however, are still not familiar with this technique. In this article we discuss the technique and results of laparoscopic common bile duct exploration. Both the laparoscopic transcystic approach and choledochotomy are discussed, together with the results given in the literature. When one considers the costs, morbidity, mortality and the time required before the patient can return to work, it would appear that laparoscopic cholecystectomy with common bile duct exploration is more favorable than open surgery or laparoscopic cholecystectomy with preoperative or postoperative endoscopic sphincterotomy. However, the technique requires advanced laparoscopic skills, including suturing, knot tying, the use of a choledochoscope, guidewire, dilators and balloon stone extractor. Although laparoscopic common bile duct exploration appears to be the most cost-effective method to treat common bile duct stones, it should be emphasized that this procedure is very challenging, and it should be performed by well-trained laparoscopic surgeons with experience in biliary surgery.

Transduodenal sphincteroplasty with transampullary septectomy for stenosing papillitis

The papilla of Vater and its sphincter of Oddi, lying at the confluence of the bile and pancreatic ducts in man, have long been suspected as a source of upper abdominal pain. Enlarging the opening of the transpapillary segment of the bile and major pancreatic ducts by using a transduodenal sphincteroplasty with transampullary septectomy resulted in death in a patient with a peripapillary diverticulum and pancreas divisum. Eight-six patients followed for 1 to 10 years experienced a 75% success rate. Thirty-six patients had a marked stenosis of their duct of Wirsung, suggesting that their pain was primarily from the pancreas. The remainder had either a generalized narrowing (40 patients) or a normal (7 patients) papilla. Pain was not satisfactorily resolved in patients with an associated pancreas divisum, chronic pancreatitis, and recurrent episodes of acute pancreatitis with alcoholism.

Portal Vein Thrombosis After Laparoscopic and Open Splenectomy

INTRODUCTION Portal vein thrombosis (PVT) could be a life-threatening complication after splenectomy if not diagnosed promptly and treated properly. Risk factors of PVT are not completely clarified. Spleen size and underlying hematologic diseases are main potential risk factors for this complication. Laparoscopic surgery might increase the risk of developing PVT, as it reduces the blood flow in the portal system due to the pneumoperitoneum but, on the other hand, it seems to be associated with less postoperative modifications of coagulation parameters than open surgery, thus preventing PVT itself. The authors reviewed their series on open and laparoscopic splenectomies, pointing out their experience on PVT and discussing their surveillance and prophylaxis programs to prevent this complication. MATERIALS AND METHODS In this series, the authors report their experience on postsplenectomy PVT in 162 patients who have been splenectomised (102 operated on laparoscopically and 60 by open surgery). RESULTS PVT was clinically observed in 1 case out of 60 open splenectomies and in 3 cases out of 102 laparoscopic procedures. Patients were treated with conservative anticoagulation therapy. In one case, additional ileal resection was needed. Mortality was 0%. CONCLUSION Low-molecular-weight heparin should be administered to all patients who have been splenectomised, especially if they are at high risk of PVT. If symptoms appear, patients need to be treated with high-dose heparin followed, after at least 3 weeks, by oral anticoagulant therapy.

Stenosis of the Sphincter of Oddi

Stenosing papillitis is the narrowing of the lower end of the biliopancreatic ducts, possibly as a result of repeated passage of gallstones or recurrent attacks of acute pancreatitis. Severe episodes of upper abdominal pain years after cholecystectomy are the principal symptom. The diagnostic evaluation should exclude other conditions and demonstrate an abnormal manometric profile of the papillary region on transendoscopic retrograde study. Analgesic therapy is the common treatment. Transduodenal sphincteroplasty and transampullary septectomy are indicated in some patients.

Long-Term Results After Splenectomy in Adult Idiopathic Thrombocytopenic Purpura: Comparison Between Open and Laparoscopic Procedures

BACKGROUND Only a few studies have addressed long-term results comparing laparoscopic and open splenectomy in idiopathic thrombocytopenic purpura (ITP). We analyzed the 1-year results comparing age, sex, length of preoperative steroid therapy, diagnosis-to-splenectomy interval, and preoperative platelet count in relation to postoperative response after open and laparoscopic splenectomy. SUBJECTS AND METHODS Data collected from two groups, treated by laparoscopic and open splenectomy, respectively, of 20 patients each were retrospectively reviewed. Positive response to splenectomies, evaluated according to the International Working Group guidelines reported by the American Society of Hematology, was statistically related through Students t test and the Pearson correlation test to the above-mentioned factors. RESULTS Positive response to splenectomy was observed in 80% and 85% of patients, respectively, in the laparoscopic and open groups (P > .10). No statistical differences were observed comparing each of the studied factors between laparoscopic and open splenectomy responder patients (P > .10). When percentage increase of postoperative platelet count was related to diagnosis-to-splenectomy interval, a positive correlation was found in the laparoscopic group (r = 0.544, P < .05). In addition, a significant negative correlation in both groups was observed comparing preoperative platelet count and percentage postoperative platelet increase, with a greater increase of postoperative platelet count in patients with a lower preoperative platelet count (laparoscopic group, r = -0.663; open group, r = -0.656; P < .01). CONCLUSIONS In this series long-term results after laparoscopic splenectomy in ITP patients were as effective as after the open approach. Higher postoperative platelet percentage increase was achieved in both groups in patients with a lower preoperative platelet count. Finally, laparoscopic splenectomy in this study seems to be superior to the open approach in patients with a longer diagnosis-to-splenectomy interval.

New Trends in the Surgical Treatment of Colorectal Cancer Liver Metastases

Colorectal cancer is one of the most common solid tumors affecting people around the world. A significant proportion of patients with colorectal cancer will develop or will present with liver metastases. In some of these patients, the liver is the only site of metastatic disease. Thus, surgical treatment approaches are an appropriate and important treatment option in patients with liver-only colorectal cancer metastases. Resection of colorectal cancer liver metastases can produce long-term survival in selected patients, but the efficacy of liver resection as a solitary treatment is limited by two factors. First, a minority of patients with liver metastases have resectable disease. Second, the majority of patients who undergo successful liver resection for colorectal cancer metastases develop recurrent disease in the liver, extrahepatic sites, or both. In this paper, in addition to the results of liver resection for colorectal cancer metastases, we will review the results of cryoablation, heat ablation, and hepatic arterial chemotherapy using a surgically implanted pump. Each of these surgical treatment modalities can produce long-term survival in a subset of patients with liver-only colorectal cancer metastases, whereas systemic chemotherapy used alone rarely results in long-term survival in these patients. While surgical treatments provide the best chance for long-term survival or, in some cases, the best palliation in patients with colorectal cancer liver metastases, it is clear that further improvements in patient outcome will require multimodality therapy regimens.

Drug rash with eosinophilia and systemic signs syndrome in a patient with multiple sclerosis

INTRODUCTION Drug rash with eosinophilia and systemic signs (DRESS) syndrome is defined by the triad of fever, dermatitis, and internal organ involvement, characteristically occurring with a delay of 3 to 8 weeks after the initiation of treatment with the associated drug. We describe a case of DRESS syndrome in a patient with multiple sclerosis (MS), characterized by a very high eosinophilia and cholestatic hepatitis. CASE SUMMARY A 44-year-old white woman with primary progressive MS receiving a multidrug of PO baclofen 75 mg/d, PO piracetam 3 g/d, and IV mitoxantrone 10 mg administered once a month presented to the Multiple Sclerosis Center, University of Catania, Catania, Italy. Eight weeks after the introduction of the latter 2 drugs, the patient had clinical and histological signs of severe cholestatic syndrome followed by hypereosinophilia. All treatments were stopped on admission. Laboratory tests (serologic viral markers, autoantibody pattern antinuclear autoantibodies, antismooth muscle autoantibodies, antimitochondrial autoantibodies, antineutrophil-cytoplasmic autoantibodies, antiliver-kidney-microsomes), abdomen ultrasound, and magnetic resonance cholangiopancreatography did not reveal a cause of the cholestatic syndrome. A liver biopsy was performed because of the persistence of the clinical signs. A Naranjo rating of 4 suggested that mitoxantrone was possibly associated with the occurrence of DRESS. Six months after the first symptoms of DRESS appeared, laboratory tests were normal. Although there are few diagnostic methods for confirming an adverse drug hypersensitivity reaction, a skin prick test suggested a marked positivity for mitoxantrone at all concentrations (100%, 50%, 10%). During the first 72 hours, reaction was characterized by skin edema, erythema, and itchiness in the site of inoculation of the drug. The local reaction started to regress after 72 hours, with a complete restitution ad integrum in 6 days. A blue discoloration of skin remained for an additional 13 days. CONCLUSION We report a case of DRESS syndrome possibly associated with mitoxantrone in a patient with MS.

Laparoscopic surgery in sickle cell disease

We read with great interest the article Elective Laparoscopic Cholecystectomy: Treatment of Choice for Cholelithiasis in Children With Sickle Cell Disease? published in Surgical Endoscopy 2001;15:301–304. We agree with the authors [5] that laparoscopic surgery in these patients is beneficial, although carbon dioxide insuffation and ipoventilation resulting from diaphragm elevation might be important cofactors in the development of postoperative complications related to sickle cell disease (SCD). However, we discuss some points based on our experience with laparoscopic surgery in seven adult patients with sickle cell disease, which has been published recently [6]. First, we think that blood transfusion or automated red cell exchange is indicated only in selected patients. The role of preoperative blood transfusion and SCDrelated postoperative complications still is unclear. Several studies [2, 3] suggest that dilution of sickle cell by means of transfusion decreases perioperative vasoocclusive crisis. Conversely, the Cooperative Study of Sickle Cell Disease reported by Koshy et al. [4] showed that the interelation between transfusions and postoperative SCD-related morbidity is not so linear, depending on the risk level of surgical procedures, and also on the hemoglobin (Hb) genotypes (HbSS, HbSC, HbSbthal) of SCD. In low-risk surgical procedures, diseaserelated complications were lower in transfused than in untransfused patients with HbSS disease. This association of preoperative transfusion and lower postoperative morbidity was not found in moderate-risk surgery. This study [4] also showed that perioperative transfusion was beneficial regardless of the surgical risk level for HbSC disease, whereas on the contrary, mortality and morbidity were paradoxically higher (although not statistically) in transfused than in untransfused patients with HbSb thal disease. We transfused our patients when it was necessary before surgery to achieve a satisfactory Hb level (exceeding 9 g/dl) with a percentage of HbS less than 40%. Using this strategy, it was found that two patients did not need any transfusion. Three patients received a single treatment with packed red blood cells, and only in two cases were sequential transfusion administered. No mortality and only one case of transient lower extremity pain were observed. Second, we paid much attention to the perioperative monitoring and treatment regimen used with these patients during laparoscopic surgery. Besides the standard evaluations, we followed a particularly accurate strategy for intraoperative and postoperative monitoring of ventilation, acid–base balance, and temperature control. Preoperatively, we started hyperhydratation with Ringer lactate solution, which was continued for 1 to 2 days after laparoscopy. During surgery, we performed repeated arterial blood gas tests and continuous esophageal temperature measurement. Also, we always used a warming intravenous infusion device and a warm airflow blanket to ensure adequate maintenance of the patient’s temperature. Postoperative administration of supplemental oxygen and incentive spirometry also, have been recommended frequently in our cases. The rationale for this strategy is in our belief that early recognition of ventilation-to-perfusion mismatch and acid–base balance modifications or temperature lowering is instrumental for timely correction and appropriate treatment of adverse events that can lead to increasedmorbidity andmortality. Third, during laparoscopic cholecystectomy performed in patients with sickle cell disease, we always explored the common bile duct with a routine intraoperative ultrasonography. The incidence of common bile duct stones in sickle cell patients has been reported to reach 30% [1], and several patients may not have any preoperative symptoms or suspicion signs of choledocholithiasis on laboratory tests or ultrasound. Although exploration of the common bile duct can be performed with intraoperative cholangiography, we now feel comfortable also with intraoperative ultrasound, which, in experienced hands, is reliable and accurate, less invasive, and in many instances, complementary to intraoperative cholangiography. With preoperative suspicion of common bile duct stones, we have performed preoperative endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic clearing of stones. In their Surgical Endoscopy article, the authors [5], mentioned three patients with a preoperative suspicion of common bile duct stones that they managed with intraoperative cholangiography. We think this could be a correct strategy if with an intraoperative diagnosis of common bile duct stones, either a laparoscopic or an open common bile duct exploration is planned. We did not understand, however, why after a negative intraoperative cholangiography in these three reported cases, the authors decided to perform a postoperative ERCP. Letter to the editor