Salvatore Lazzara

Laparoscopic cholecystectomy in cirrhotic patients

Background: This study aimed to evaluate the safety of laparoscopic cholecystectomy for patients with cirrhosis. Methods: The records of 22 laparoscopic cholecystectomies performed in patients with cirrhosis Child–Pugh A and B, from January 1995 to July 2001 were retrospectively reviewed. Results: No deaths occurred. Conversion to open cholecystectomy was necessary in two cases. The average operative time was 115 min, which was significantly shorter than that for patients undergoing open cholecystectomy. None of the patients required blood transfusion. Intraoperative problems occurred in two patients who experienced liver bed bleeding. Postoperative morbidity occurred in 36% of the patients and included hemorrhage, wound complications, intraabdominal collections, and cardiopulmonary complications, but all were controlled. The patients were dismissed after an average of 4 days. Conclusion: The authors believe laparoscopic cholecystectomy can be performed safely in selected patients with cirrhosis Child–Pugh A and B who manifest indication for surgery. Laparoscopic cholecystectomy offers several advantages over open cholecystectomy: lower morbidity, shorter operative time, and reduced hospital stay.

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.

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.

Fever of unknown origin due to intrahepatic wooden toothpick

Ingestion of foreign bodies is a common clinical problem, but intrahepatic migration is an exceptional occurrence. Clinical history is not helpful. Abdominal ultrasonography and CT are fundamental to exclude surgical causes of fever of unknown origin. Laparoscopic segmental liver resection is recommendable to avoid generalized peritonitis.

Reversible bilio-pancreatic diversion with explorable excluded stomach-the Messina technique.

The authors propose a reversible bilio-pancreatic diversion with access to the bypassed stomach. In the Messina technique, bilio-pancreatic diversion is accomplished by transecting the stomach without gastric resection, as already described by Resa et al. In addition, a temporary gastrostomy is performed on the excluded stomach and allows direct postoperative exploration of the duodenum and the biliary tree. The Messina bilio-pancreatic diversion technique (MBPDT) seems to be safe and effective. The authors propose the MBPDT in a morbidly obese patient undergoing bariatric surgery when a malabsorptive operation is required, as it makes the original Scopinaro operation reversible, the bilio-pancreatic area explorable postoperatively, the operation shorter, and does not cause any significant increase in the postoperative complication rate. Larger numbers and longer follow-up, however, are needed to further confirm our data.

Evaluation of CTNNB1 and TP53 variability in patients with hepatocellular carcinoma and occult hepatitis B virus infection.

Hepatitis B virus (HBV) infection plays a major role in hepatocellular carcinoma (HCC) development. Much evidence suggests that HBV also maintains its pro-oncogenic properties in cases of occult HBV infection (OBI). Mutations of the beta-catenin and p53 genes (CTNNB1 and TP53, respectively) may be associated with HCC occurrence in patients with overt HBV infection, whereas such genetic mutations have not been investigated in HCC patients with OBI thus far. We investigated the genetic heterogeneity of CTNNB1 exon 3 and all of the TP53 exons in tumor DNA extracts from a unique cohort of 61 HCC patients (all previously tested for HBV DNA and for its integration into the hosts genome), including 34 OBI-positive, 20 HBV surface antigen (HBsAg)/OBI-negative, and 7 HBsAg-positive cases. No CTNNB1 exon 3 mutations or TP53 mutations were detected in any case. The homo- or heterozygous TP53 R72P polymorphism was found in 18 of 61 cases (29.5%), although no differences in its prevalence between OBI and non-OBI cases as well as between cases with and without viral integration were revealed. In conclusion, CTNNB1 and TP53 somatic mutations seem to be a rare event in patients with HCC in our area and in cases with either overt or occult HBV infection.