Adjuvant chemotherapy is associated with better oncological outcomes after ALPPS for colorectal liver metastases

ALPPS enables complete tumor resection in a shorter interval and a larger number of patients than classic two-stage hepatectomies. However, there is little evidence regarding long-term outcomes in patients with colorectal liver metastases (CLM). This study aims to evaluate the short and long-term outcomes of ALPPS in patients with CRM. Single-cohort, prospective, observational study. Patients with unresectable CLM due to insufficient liver remnant who underwent ALPPS between June 2011 and June 2021 were included. Of 32 patients treated, 21 were male (66%) and the median age was 56 years (range = 29-81). Both stages were completed in 30 patients (93.7%), with an R0 rate of 75% (24/32). Major morbidity was 37.5% and the mortality nil. Median overall survival (OS) and recurrence-free survival (RFS) were 28.1 and 8.8 months, respectively. The 1-3, and 5-year OS was 86%, 45%, and 21%, and RFS was 42%, 14%, and 14%, respectively. The only independent risk factor associated with poor RFS (5.7 vs 11.6 months; p = 0.038) and OS (15 vs 37 months; p = 0.009) was not receiving adjuvant chemotherapy. KRAS mutation was associated with worse OS from disease diagnosis (24.3 vs. 38.9 months; p = 0.025). ALPPS is associated with favorable oncological outcomes, comparable to traditional strategies to increase resectability in patients with CLM and high tumor burden. Our results suggest for the first time that adjuvant chemotherapy is independently associated with better short- and long-term outcomes after ALPPS. Selection of patients with KRAS mutations should be performed with caution, as this could affect oncological outcomes.

An extension of the characteristic curve model of plant species behavior in heavy metal soils

This article proposes a mathematical model to characterize phytoremediation processes in soils contaminated with heavy metals. In particular, the proposed model constructs characteristic curves for the concentrations of several metals (As, Cd, Cu, Fe, Pb, Sb, and Zn) in soils and plants based on the experimental data retrieved from several bibliographical sources comprising 305 vegetal species. The proposed model is an extension of previous models of characteristic curves in phytoremediation processes developed by Lam et al. for root measurements using the bioconcentration factor. However, the proposed model extends this approach to consider roots, as well as aerial parts and shoots of the plant, while at the same time providing a less complex mathematical formula compared to the original. The final model shows an adjusted R2 of 0.712, and all its parameters are considered statistically significant. The model may be used to assess samples from a given plant species to identify its potential as an accumulator in the context of soil phytoremediation processes. Furthermore, a simplified version of the model was constructed using an approximation to provide an easy-to-compute alternative that is valid for concentrations below 37,000 mg/kg. This simplified model shows results similar to the original model for concentrations below this threshold and it uses an adjusted factor defined as [Formula: see text] that must be compared with a threshold depending on the metal, type of measurement, and target (e.g., accumulator or hyperaccumulator). The full model construction shows that 90 out of the 305 species assessed have a potential behavior as accumulators and 10 of them as hyperaccumulators. Finally, out of the 1405 experimental measurements, 1177 were shown to be accumulators or hyperaccumulators. In particular, 85% of the results coincide with the reported values, thus validating the proposed model.

Characteristic curve modeling of plant species behavior in soils with heavy metals

Many vegetal species can accumulate great amounts of metallic elements in their tissues. For this reason, they are called metal hyperaccumulators. An indicator of great interest in environmental sciences is the bioconcentration factor because it is recognized for establishing the potential accumulation of chemicals in organisms. Particularly in soil phytoremediation processes, it measures the capacity of a certain plant to capture metals, in terms of soil concentration. According to their behavior, four types of plants can be distinguished regarding soil concentration increase: indicator, excluder, accumulator, and hyperaccumulator. This study proposes a new model to categorize plants according to their behavior related to soil concentration increase, using several characteristic curves obtained from 1288 experimental measurements collected from different bibliographic sources. The metals analyzed were Cu, Fe, Pb, and Zn. The proposed model is obtained through linear regression and nonlinear transformations to model the expected behavior of plants in high concentration conditions. In particular, the basic equation of the model has three key components to represent the expected concentration in the plant root given the final soil concentration level, the type of species, and specific metal: a linear factor that determines the growth for low concentration values, an exponential factor that determines its decrease for high concentration values, and a logarithmic factor that limits the maximum value that can be reached in practice and influences the decay for high concentration values. After fitting the experimental data using linear regression, the proposed model has a 0.084 R2 determination coefficient and all of its parameters are considered significant. Furthermore, it shows that 60 of the 257 species assessed behave as accumulators and 10 of them as hyperaccumulators. The main contribution of this model is its ability to handle soils with high concentrations, where it would be hard for plants to achieve concentrations similar to or higher than the substrate containing them. Thus, the conventional criterion of the bioconcentration factor would incorrectly categorize a plant as an excluder. In contrast, this new model allows assessing plant effectiveness in a phytoremediation process of highly concentrated affected sites, such as mine tailings.

Neutrophil-to-lymphocyte ratio vs C-reactive protein as early predictors of anastomotic leakage after colorectal surgery: A retrospective cohort study

Introduction

Colorectal surgery (CRS) is associated with high morbidity rates, being anastomotic leakage (AL) one of the most serious complications with an incidence as high as 15%, accounting for up to a third of mortality in these procedures. The identification of pre-clinical markers may allow an early diagnosis and a timely intervention. The objective of the present study was to compare the performance of neutrophil-to-lymphocyte ratio (NLR) vs C-reactive protein (CRP) as early predictors of AL in CRS.

Methods

A retrospectively analyzed consecutive patients who underwent a colorectal surgery with anastomosis from June 2015 to April 2019. Receiver-operating characteristic (ROC) curves were used to find the cutoff points with the best diagnostic performance of AL.

Results

A total of 116 patients were included. From 43 patients (37%) who developed a total of 63 complications, 9 (7.76%) presented with an AL with a median of 8 days (range: 5–9). No significant differences were found for NLR between patients with vs without AL. In contrast, median CRP was significantly higher in patients who subsequently presented with AL, both on day 4 (164 vs 64, p = 0.04) and 5 (94 vs 44, p < 0.001) after surgery. The best predictive performance through ROC curves was found on postoperative day 5, with a CRP value of >54 mg/dL (AUC: 0.81, Sensitivity: 89%, Specificity: 61%).

Conclusions

CRP appears superior to NLR as an early predictor of AL following CRS. The best diagnostic performance was obtained on postoperative day 5 with a cutoff value of >54 mg/dL.

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In the present study, CRP was found to be superior to NLR as an early predictor of clinically significant AL following CRS.

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The best predictive performance was obtained at postoperative day 5 with a cutoff value > 54 mg/dL.

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The importance of this finding may contribute during the hospital stay from the third postoperative day to the early diagnosis of LA.

Neutrophil-to-lymphocyte ratio as a predictor of complicated acute diverticulitis: A retrospective cohort study

Introduction

Currently, the debate on the usefulness of Neutrophil to Lymphocyte Ratio (NLR) as a predictor of complications in acute diverticulitis (AD) remains open, especially, the relation to the severity of the disease, the clinical impact, and the necessity of minimally invasive or emergency surgical procedures. On the other hand, its diagnostic efficacy has not been studied even in our field. The objective of the present study was to determine the utility and diagnostic precision of NLR in complicated acute diverticulitis (cAD).

Methods

Descriptive, retrospective cohort and analytical study. Patients older than 18 years with a diagnosis of AD were included, from 2013 to 2018. Demographic variables, days of hospitalization, leukocyte count, neutrophils, lymphocytes, ESR, CRP, and NLR were analyzed. The sensitivity and specificity for the diagnosis of cAD were determined using ROC curves.

Results

325 patients were included. Of these 196 (60%) were men. The median age was 52 years. A total of 30 (9%) were categorized as cAD. The patients with cAD presented mean values in the leukocyte count (14.02 ± 4.49 × 10⁹/l; p < 0.01), CRP (119.60 ± 87.67; p < 0.01) and NLR (7.61 ± 4.03; p < 0.01). An NLR cutoff value ≥ 4.2 was identified as the most appropriate to distinguish cAD, with a sensitivity of 80%, a specificity of 64%, NPV of 96%, and PPV of 18%.

Conclusion

NLR is a predictive marker of cAD, with a cut-off point of 4.2 being the best diagnostic approach.

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About 10–15% of patients with acute diverticulitis (AD) can develop complications.

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The neutrophil-lymphocyte ratio (NLR) is a useful biomarker in predicting of severity of AD.

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The purpose was to determine the usefulness and diagnostic accuracy of NLR in complicated acute diverticulitis (cAD).

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An NLR cutoff value ≥ 4.2 was identified as the most appropriate to distinguish cAD.

Minimally invasive splenectomy in grade IV splenic trauma: A case report associated with high-grade renal trauma

INTRODUCTION AND IMPORTANCE

In closed abdominal trauma, the spleen is the most frequently injured organ (30-45%). Splenic lesions grades IV-V have higher failure rates with nonoperative management (NOM). The minimally invasive approach is an alternative when NOM fails. This is the first reported case of a patient with splenic and left renal trauma, both grade IV, with combined management, which consisted of a minimally invasive surgical resolution of the splenic trauma and a conservative management of the renal trauma, with a satisfactory recovery of the patient. This contributes to understanding the benefits of minimally invasive surgery in moderate splenic trauma associated with other high-grade injuries.

CASE PRESENTATION

We present a 45-year-old woman with a multiple trauma after a motorbike vs car traffic accident. On physical examination, she was hemodynamically stable, with abdominal guarding and generalized rebound tenderness associated with multiple upper and lower limb fractures. An abdominal CT scan revealed grade IV splenic and left renal trauma, with moderate hemoperitoneum. A minimally invasive laparoscopic approach for hemoperitoneum drainage and splenectomy was performed.

CLINICAL DISCUSSION

There is currently no consensus to define the indications for minimally invasive treatment on splenic trauma. While laparotomy is the standard treatment, it is not without potential severe complications, while laparoscopy providing a treatment option in selected cases with hemodynamic stability.

CONCLUSION

The role of the minimally invasive approach is safe and feasible in selected patients with high-grade splenic lesions and hemodynamic stability, including the association with other organic lesions such as kidney trauma.

Titanium clip migration after cholecystectomy: original technique for laparoscopic transcystic extraction when endoscopic retrograde cholangiopancreatography fails

Surgical clip migration into the common bile duct (CBD) is a rare complication after laparoscopic cholecystectomy (LC). Few cases of surgical clip migration have been reported in the literature, and most of them have been successfully treated with endoscopic retrograde cholangiopancreatography (ERCP). We present a 71-year-old woman with 48 h of abdominal pain, jaundice and fever 6 years after laparoscopic cholecystectomy. She was diagnosed with common bile duct obstruction from surgical clip migration. After failure of ERCP, the patient was successfully treated with an innovative approach by laparoscopic transcystic extraction using endoscopic hose-type biopsy forceps. The presented technique was feasible and safe in expert hands, representing a valuable alternative to avoid the need of a choledochotomy in patients with unsuccessful ERCP.

Totally Laparoscopic Mini-ALPPS Using a Novel Approach of Laparoscopic-Assisted Transmesenteric Portal Vein Embolization

BACKGROUND

The initial mortality rates of associating liver partition and portal vein occlusion for staged hepatectomy (ALPPS) were high. However, recent data from the International Registry show a continuous reduction of early mortality and major morbidity due to risk adjustment in patient selection and less invasive techniques in stage-1 surgery. During the first ALPPS International Consensus in 2015, we introduced a paradigm inversion of ALPPS, the so-called "Mini-ALPPS."

METHODS

We combined a partial liver partition with a novel technique of laparoscopic-assisted percutaneous cannulation of the inferior mesenteric vein for intraoperative transmesenteric portal vein embolization. We report here for the first time, a case of a successful totally laparoscopic Mini-ALPPS, and describe in detail the technical aspects of this new approach.

RESULTS

A 61-year-old man with a 6 cm hepatocellular carcinoma compromising the right glissonian pedicle in a fibrotic liver was treated by an extended right hepatectomy using the laparoscopic Mini-ALPPS approach. The patient had an uneventful first stage and was discharged 3 days after. A CT scan performed on postoperative day 8 showed sufficient future liver remnant volume after a 59% hypertrophy. An extended right hepatectomy was uneventfully completed and the patient was discharged 5 days after surgery. The histopathological analysis indicated advanced F4 liver fibrosis and negative tumor margins.

CONCLUSIONS

This technical innovation allows avoiding a laparotomy to access the mesenteric venous territory and the risks of liver remnant injuries during percutaneous transhepatic approach. This new alternative may result of great utility not only in ALPPS but also for many different circumstances and scenarios.

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.

Intermediate-term survival and quality of life outcomes in patients with advanced colorectal liver metastases undergoing associating liver partition and portal vein ligation for staged hepatectomy

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is an innovative, 2-staged hepatectomy which has elicited controversy within the international hepatobiliary community. Uptake of ALPPS has been limited due to concerns related to evidence of high morbidity and mortality, and scant oncologic and outcome data on quality of life (Qol). Demonstrating reasonable long-term benefits with a short-term risk is necessary to support more widespread endorsement of ALPPS. Our aim was to describe the intermediate-term survival and patient-reported quality of life outcomes after an ALPPS.

METHODS

Prospectively collected data from 2 high-volume ALPPS centers, who were pioneers with the technique, were combined and analyzed for disease-free and overall survival from date of the ALLPS. Only patients treated for colorectal liver metastases with >6 month postoperative follow-up were included. All patients had bilateral colorectal liver metastases with an initially unresectable tumor load, and received preoperative chemotherapy. Information concerning the demographics of the patients, characteristics of the tumor, and treatment were analyzed. The well-validated European Organization for Research and Treatment for Cancer Quality of Life Core Questionnaire version 3.0 questionnaire was used to assess patient quality of life.

RESULTS

A total of 58 patients underwent ALPPS for colorectal liver metastases, and 47 patients met our inclusion criteria. There were no perioperative mortalities, and the rate of severe complications was 21%. At 3 years post-ALPPS, the overall survival was 50%, while the disease-free survival was 13%. The commonest site of first recurrence was the liver alone (38%). Patient-reported quality of life after ALPPS was similar to reference values for general population.

CONCLUSION

In select patients operated at experienced centers, ALPPS results in low perioperative risk, satisfactory overall survival, and excellent quality of life. Hepatic recurrence and not systemic recurrence is the most common site of relapse after ALPPS.

Intrahepatic cholangiojejunostomy for complex biliary stenosis after pediatric living-donor liver transplantation

The treatment of biliary stenosis after pediatric LDLT is challenging. We describe an innovative technique of peripheral IHCJ for the treatment of patients with complex biliary stenosis after pediatric LDLT in whom percutaneous treatment failed. During surgery, the percutaneous biliary drainage is removed and a flexible metal stylet is introduced trough the tract. Subsequently, the most superficial aspect of the biliary tree is recognized by palpation of the stylet's round tip in the liver surface. The liver parenchyma is then transected until the bile duct is reached. A side-to-side anastomosis to the previous Roux-en-Y limb is performed over a silicone stent. Among 328 pediatric liver transplants performed between 1988 and 2015, 26 patients developed biliary stenosis. From nine patients requiring surgery, three patients who had received left lateral grafts from living-related donors due to biliary atresia were successfully treated with IHCJ. After a mean of 45.6 months, all patients are alive with normal liver morphological and function tests. The presented technique was a feasible and safe surgical option to treat selected pediatric recipients with complex biliary stenosis in whom percutaneous procedures or rehepaticojejunostomy were not possible, allowing complete resolution of cholestasis and thus avoiding liver retransplantation.

Parenchymal-sparing liver surgery in patients with colorectal carcinoma liver metastases

Liver resection is the treatment of choice for patients with colorectal liver metastases (CLM). However, major resections are often required to achieve R0 resection, which are associated with substantial rates of morbidity and mortality. Maximizing the amount of residual liver gained increasing significance in modern liver surgery due to the high incidence of chemotherapy-associated parenchymal injury. This fact, along with the progressive expansion of resectability criteria, has led to the development of a surgical philosophy known as “parenchymal-sparing liver surgery” (PSLS). This philosophy includes a variety of resection strategies, either performed alone or in combination with ablative therapies. A profound knowledge of liver anatomy and expert intraoperative ultrasound skills are required to perform PSLS appropriately and safely. There is a clear trend toward PSLS in hepatobiliary centers worldwide as current evidence indicates that tumor biology is the most important predictor of intrahepatic recurrence and survival, rather than the extent of a negative resection margin. Tumor removal avoiding the unnecessary sacrifice of functional parenchyma has been associated with less surgical stress, fewer postoperative complications, uncompromised cancer-related outcomes and higher feasibility of future resections. The increasing evidence supporting PSLS prompts its consideration as the gold-standard surgical approach for CLM.

Impact of routine intraoperative cholangiography during laparoscopic cholecystectomy on bile duct injury

BACKGROUND

The role of intraoperative cholangiography (IOC) in the diagnosis, prevention and management of bile duct injury (BDI) remains controversial. The aim of the present study was to determine the value of routine IOC in the diagnosis and management of BDI sustained during laparoscopic cholecystectomy (LC) at a high-volume centre.

METHODS

A retrospective analysis of a single-institution database was performed. Patients who underwent LC with routine IOC between October 1991 and May 2012 were included.

RESULTS

Among 11,423 consecutive LCs IOC was performed successfully in 95.7 per cent of patients. No patient had IOC-related complications. Twenty patients (0.17 per cent) sustained a BDI during LC, and the diagnosis was made during surgery in 18 patients. Most BDIs were type D according to the Strasberg classification. The sensitivity of IOC for the detection of BDI was 79 per cent; specificity was 100 per cent. All injuries diagnosed during surgery were repaired during the same surgical procedure. Two patients developed early biliary strictures that were treated by percutaneous dilatation and a Roux-en-Y hepaticojejunostomy with satisfactory long-term results.

CONCLUSION

The routine use of IOC during LC in a high-volume teaching centre was associated with a low incidence of BDI, and facilitated detection and repair during the same surgical procedure with a good outcome.

Groove pancreatitis vs groove pancreatic adenocarcinoma. Report of two cases and review of the literature

Groove pancreatitis (GP) is a rare form of segmental chronic pancreatitis affecting the groove area (anatomic space between the head of the pancreas, the duodenum and the common bile duct). Its clinical and radiological presentation may be similar to groove pancreatic adenocarcinoma (GPA). Nevertheless, treatment and prognosis are totally different. We report two cases of both GP and GPA and review the relevant aspects that may help to clarify the differential diagnosis between these two rare entities. The first patient is a 57-year-old man with a history of chronic alcohol consumption who presented with persistent abdominal pain. The CT-scan findings suggested GP. Due to the persistence of symptoms despite medical treatment, a pancreaticoduodenectomy was performed. Pathologic evaluation confirmed the diagnosis of GP. The second patient is a 72-year-old male who presented with cholestasis and weight loss. The tumor marker CA 19-9 was increased The CT-scan findings were consistent with duodenal dystrophy. In order to rule out malignancy a pancreaticoduodenectomy was performed. Pathologic evaluation revealed a pancreatic head adenocarcinoma (T3-N1-M0). GP is a rare entity that should be suspected in patients with a history of heavy alcohol consumption who complain of chronic abdominal pain and weight loss. Patients without a clear diagnosis even after a through imaging work-up, or those in whom symptoms are persistent in spite of medical therapy, should undergo surgical exploration.

New surgical strategy to induce liver hypertrophy: role of MDCT-volumetry to monitor and predict liver growth

BACKGROUND/AIMS

To describe the role of MDCT-volumetry to monitor and predict liver hypertrophy in a recently introduced surgical technique in patients needing hepatectomy.

METHODOLOGY

This prospective study was approved by the local research and ethics committee and patient informed consent was obtained. Twelve consecutive patients were selected for associating liver partition and portal vein ligation for staged-hepatectomy procedure. The mean absolute the future-liver-remnant (FLR) and FLR/total liver volume (TLV) ratio was calculated before and after surgery to determine the degree of hypertrophy. Six days after surgery a new CT-examination was performed to determine the FLR-volume and FLR/TLV. If the enlargement of the FLR was the expected a second-step surgery was performed. Continuous variables are expressed as mean (range). A p<0.05 was considered significant.

RESULTS

The mean pre-operative FLR-volume was 402 mL and the FLR/TLV was 27%. The mean post-operative FLR-volume 6 days after the first step was 702 mL (range 521-1030 mL) being the mean difference between preoperative and postoperative FLR volume 303 mL (p<0.0001). The mean volume increase was 80% ranged from 21-139%. At day six, FLR/TLV was 46.5% (range 33.5-67.7), morbidity was 41% and mortality 0%.

CONCLUSIONS

MDCT-volumetry has a key role in decision-making, monitoring and predicting liver hypertrophy pre- and postoperatively.

[Robotic total mesorectal excision for rectal cancer]

Laparoscopic total mesorectal excision (TME) has proven to be feasible and safe. However, it represents a major technical challenge, since it involves the dissection of the rectum in a confined space such as the bony pelvis using un-ergonomic surgical devices. This difficulty is accentuated in patients with distal tumors and high body mass index (BMI), in which the surgical margins and the hypogastric nerves may be affected. Therefore, robotic surgery aims to overcome these limitations that conspire against the mininvasive surgical approach of rectal cancer. We present an obese (BMI = 32 kg/m2) 82-year-old man with a history of smoking and prostate cancer that was recently diagnosed with a middle rectal adenocarcinoma at 9 cm from the anal verge. Rectal examination evidenced a mobile lesion. Computed tomography scan ruled out metastases and at the local staging by MRI, the tumor was considered as T3-N0 with free circumferential margins. Surgical treatment was decided and a hybrid technique was used combining an initial laparoscopic approach followed by the robotic TME. The patient had a full recovery and was discharged three days after surgery without complications. Pathological examination revealed a low-grade adenocarcinoma with mesorectal invasion, free circumferential and distal margins, and 24 negative lymph nodes (pT3-pN0-pM0/Stage II). Robotic TME was performed safely in an obese patient. It facilitated dissection maneuvers in a confined space with proper identification and preservation of the hypogastric nerves, allowing retrieving an intact mesorectum. Prospective randomized trials will define the role of this new technology.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): tips and tricks

BACKGROUND

Posthepatectomy liver failure is the most severe complication after major hepatectomies and it is associated with an insufficient future liver remnant (FLR). Associating liver partition and portal vein ligation (PVL) has recently been described as a revolutionary strategy to induce a rapid and large FLR volume increase. We aim to describe our surgical technique, patient management, and preliminary results with this new two-stage approach.

TECHNIQUE

During the first stage, liver partition and PVL of the diseased hemiliver are performed. The completion surgery is carried out after volumetric studies have demonstrated a sufficient FLR and provided the patient is in good condition. This is usually achieved after 7 days. In the second step, the patient undergoes a completion surgery with right hepatectomy, right trisectionectomy, or left trisectionectomy.

RESULTS

Fifteen patients with advanced liver tumors were treated. Nine patients were males and the mean age was 54 years old. The mean difference between the preoperative and postoperative FLR volume was 303 ml (p < 0.001), which represented a mean volume increase of 78.4 %. All resections were R0. Morbidity and mortality rates were 53 and 0 %, respectively. The average hospital stay was 19 days.

CONCLUSIONS

The presented technique was feasible and safe in the hands of experienced hepatobiliary surgeons, with satisfactory short-term results. It induces rapid liver hypertrophy and at the same time it offers the possibility of cure to patients previously declared unresectable.

Intraoperative management and repair of bile duct injuries sustained during 10,123 laparoscopic cholecystectomies in a high-volume referral center

BACKGROUND

Bile 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.

STUDY DESIGN

Single-institution retrospective analysis of a prospectively collected database. Patients with diagnosis of BDI sustained during LC between October 1991 and November 2010 were extracted.

RESULTS

Among 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.

CONCLUSIONS

The 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.

How to avoid postoperative liver failure: a novel method

BACKGROUND

Postoperative liver failure (PLF) is the most feared and severe complication after extensive liver resections.

METHODS

We present an innovative surgical technique that has been employed for the treatment of three patients (two with multiple colorectal liver metastases and one with hilar cholangiocarcinoma) whose livers were previously considered locally unresectable because of an insufficient future liver remnant (FLR). In-situ liver transection with right portal vein ligation was implemented.

RESULTS

Six days after surgery a volumetric computed tomography (CT)-scan showed 40-80% hypertrophy of the FLR. The patients then underwent a completion surgery with right hepatectomy or right trisectionectomy. None of the patients developed PLF during a mean hospital stay of 16 days. After a mean follow-up of two months, the three of them are free of disease.

CONCLUSIONS

This technique induced rapid growth of the FLR, greater than that reported with portal vein occlusion alone. It represents a promising advance in oncological liver surgery that readdresses the current management of patients with primarily unresectable liver disease. Such a revolutionary strategy allows a two-stage surgical approach during a single hospital stay and without PLF. However, further research is needed to determine the long-term outcomes of this technique and to explain the occurrence of such enhanced liver regeneration.

Successful circumferential free tracheal transplantation in a large animal model

BACKGROUND

Long segment tracheobronchial stenoses are associated with high morbi-mortality rates and difficult treatment. Transplantation hasn't proved to be useful yet. Currently, the successful results achieved in small animal models couldn't be satisfactorily accomplished or extrapolated in large mammals. We aimed to evaluate the viability of orthotopic tracheal autoimplantation in an ovine model.

METHODS

All animals underwent tracheal transplantation of 4 cm (5-7 rings) of the cervical trachea and were divided randomly in two groups: isolated autoimplantation (Group A/6) and autoimplantation with omental wrapping (Group B/6). Clinical follow up and weekly bronchoscopical examinations were performed. The grafts were macroscopically, histologically, and bacteriologically analyzed.

RESULTS

In group A, four animals achieved their planed survival and were sacrificed up to 60 days after transplantation with viable grafts. In group B, only two sheep had successful results. Graft failure with infection, necrosis and severe stenosis was observed in the rest of the animals from both groups. Pseudomonas aeruginose was isolated in all cases. The main complication of the omental pedicle was vascular congestion and peritracheal hemorrhage.

CONCLUSIONS

Contrary to the data reported to date, we found that tracheal transplantation is viable in a large mammal like the sheep. The main complication observed in this animal model was graft infection. The use of an omental pedicle with the technique applied worsened the grafts survival. The encouraging results obtained in this investigation justify further research in order to manage graft infection, leading us to establish a suitable large animal model for allotransplantation.

Hepatic artery reconstruction first for the treatment of hilar cholangiocarcinoma bismuth type IIIB with contralateral arterial invasion: a novel technical strategy

BACKGROUND

En-bloc liver resection with the extrahepatic bile duct is mandatory to obtain tumour-free surgical margins and better long-term outcomes in hilar cholangiocarcinoma (CC). One of the most important criteria for irresectability is local extensive invasion to major vessels. As hilar CC Bismuth type IIIB often requires a major left hepatic resection, the invasion of the right hepatic artery (RHA) usually contraindicates this procedure.

METHODS

The authors describe a novel technique that allowed an oncological resection in two patients with hilar CC Bismuth type IIIB and contralateral arterial invasion. Arterial reconstruction between the posterior branch of the RHA and the left hepatic artery (LHA) was performed as the first surgical step. Once arterial vascular flow was restored, a left trisectionectomy with caudate lobe resection and portal vein reconstruction was performed.

RESULTS

In both patients an R0 resection was achieved. Both patients made a full recovery and were discharged within 14 days of surgery. Both patients remain free of disease at 18 months.

CONCLUSIONS

This new technique allows a R0 resection to be achieved in patients with Bismuth type IIIB hilar CC with contralateral arterial involvement.

Ileocolic intussusception due to intestinal metastatic melanoma. Case report and review of the literature

The small intestine is a frequent site of melanoma metastases and the most common cause of secondary intestinal tumors. Even though, its presentation with intestinal obstruction due to intussusception is very rare. We present a 47-year-old woman with a medical history of facial melanoma operated 17 years ago and recently diagnosed of cervical recurrence who complained of abdominal pain of one week duration accompanied with vomiting and abdominal distension. Computed tomography (CT) scan revealed marked distension of the small intestine with features suggesting intussusception of the distal ileum. At laparoscopic exploration a massive ileocolic intussusception was found with invagination of the last 60 cm of ileum inside the cecum and ascending colon. Surgical reduction revealed a tumor of approximately 2 cm in the distal end of the intussuscepted intestine acting as the lead point. Resection of non-viable ileum along with the tumor and end-to-end anastomosis was performed. Many other lesions of smaller size were found distantly in the proximal small bowel but were not treated. The patient had a full recovery and was discharged three days after surgery. Pathological examination showed metastatic melanoma and a positron emission tomography (PET) scan confirmed disseminated disease with brain metastasis. The patient died three months after surgery. Intestinal occlusion due to metastatic disease is a rare condition but should be taken into account particularly in patients with history of cancer. Surgical intervention with a mini-invasive laparoscopic approach is feasible. Intestinal resection and anastomosis is mandatory for either curative or palliative intentions providing a satisfactory treatment.

[Pattern of antimicrobial susceptibility in uropathogen isolates from children]

The bacteriological profile in children with culture-positive bacteriuria was analyzed during a 5-year period. Escherichia coli was the most common cause of urinary tract infections (57%), followed by Streptococcus faecalis (11%), Pseudomonas aeruginosa (8%), and Proteus mirabilis (6%). Results of antimicrobial susceptibility testing indicated that cephalosporins (first, second and third generation) and nitrofurantoin are the best empirical oral treatment for urinary infections in children. Fosfomycin is a valid option in some cases. In hospitalized children treatment must be initiated with a third-generation cephalosporin, and gentamicin can be added in severely ill inpatients. These treatments can be modified when microbiological results become available.

[Safe minor surgery in patients taking anticoagulants]

The effectiveness of a commercial drug containing fibrinogen, thrombin and factor XIL (Tissucol, Immuno) was assessed in 127 patients receiving oral anticoagulant treatment with acenocoumarin who were subjected to 183 minor surgical procedures: 107 exodontia, 53 periodontal procedures, 17 combinations of the former, 4 liver biopsies and 2 skin biopsies. All but the liver biopsies were performed in the outpatient clinic. Mild haemorrhage appeared in 21 instances. None of the patients required systemic administration of coagulation factors, and the maneuvers did not take any longer than in patients with integrity of the coagulation mechanisms. The outstanding benefits of this technique are: less discomfort for patients, who can be subjected to a single procedure while otherwise requiring several sessions; anticoagulation needs not be discontinued, subcutaneous heparin being otherwise necessary; low risk of complications and avoidance of substitutive therapy; lesser economic burden, as no hospital admission is needed.