Textbook outcome in patients with biliary duct injury during cholecystectomy

BACKGROUND

Iatrogenic bile duct injury (BDI) during cholecystectomy is associated with a complex and heterogeneous management owing to the burden of morbidity until their definitive treatment. This study aimed to define the textbook outcomes (TOs) after BDI with the purpose to indicate the ideal treatment and to improve it management.

METHODS

We collected data from patients with an BDI between 1990 and 2022 from 27 hospitals. TO was defined as a successful conservative treatment of the iatrogenic BDI or only minor complications after BDI or patients in whom the first repair resolves the iatrogenic BDI without complications or with minor complications.

RESULTS

We included 808 patients and a total of 394 patients (46.9%) achieved TO. Overall complications in TO and non-TO groups were 11.9% and 86%, respectively (P < .001). Major complications and mortality in the non-TO group were 57.4% and 9.2%, respectively. The use of end-to-end bile duct anastomosis repair was higher in the non-TO group (23.1 vs 7.8, P < .001). Factors associated with achieving a TO were injury in a specialized center (adjusted odds ratio [aOR], 4.01; 95% CI, 2.68-5.99; P < .001), transfer for a first repair (aOR, 5.72; 95% CI, 3.51-9.34; P < .001), conservative management (aOR, 5.00; 95% CI, 1.63-15.36; P = .005), or surgical management (aOR, 2.45; 95% CI, 1.50-4.00; P < .001).

CONCLUSION

TO largely depends on where the BDI is managed and the type of injury. It allows hepatobiliary centers to identify domains of improvement of perioperative management of patients with BDI.

Textbook outcome in urgent early cholecystectomy for acute calculous cholecystitis: results post hoc of the S.P.Ri.M.A.C.C study

INTRODUCTION

A textbook outcome patient is one in which the operative course passes uneventful, without complications, readmission or mortality. There is a lack of publications in terms of TO on acute cholecystitis.

OBJETIVE

The objective of this study is to analyze the achievement of TO in patients with urgent early cholecystectomy (UEC) for Acute Cholecystitis. and to identify which factors are related to achieving TO.

MATERIALS AND METHODS

This is a post hoc study of the SPRiMACC study. It´s a prospective multicenter observational study run by WSES. The criteria to define TO in urgent early cholecystectomy (TOUEC) were no 30-day mortality, no 30-day postoperative complications, no readmission within 30 days, and hospital stay ≤ 7 days (75th percentile), and full laparoscopic surgery. Patients who met all these conditions were taken as presenting a TOUEC.

OUTCOMES

1246 urgent early cholecystectomies for ACC were included. In all, 789 patients (63.3%) achieved all TOUEC parameters, while 457 (36.6%) failed to achieve one or more parameters and were considered non-TOUEC. The patients who achieved TOUEC were younger had significantly lower scores on all the risk scales analyzed. In the serological tests, TOUEC patients had lower values for in a lot of variables than non-TOUEC patients. The TOUEC group had lower rates of complicated cholecystitis. Considering operative time, a shorter duration was also associated with a higher probability of reaching TOUEC.

CONCLUSION

Knowledge of the factors that influence the TOUEC can allow us to improve our results in terms of textbook outcome.

Development and validation of a novel risk score to predict overall survival following surgical clearance of bilobar colorectal liver metastases

BACKGROUND

Bilobar liver metastases from colorectal cancer pose a challenge for obtaining a satisfactory oncological outcome with an adequate future liver remnant. This study aimed to assess the clinical and pathological determinants of overall survival and recurrence-free survival among patients undergoing surgical clearance of bilobar liver metastases from colorectal cancer.

METHODS

A retrospective international multicentre study of patients who underwent surgery for bilobar liver metastases from colorectal cancer between January 2012 and December 2018 was conducted. Overall survival and recurrence-free survival at 1, 2, 3 and 5 years after surgery were the primary outcomes evaluated. The secondary outcomes were duration of postoperative hospital stay, and 90-day major morbidity and mortality rates. A prognostic nomogram was developed using covariates selected from a Cox proportional hazards regression model, and internally validated using a 3:1 random partition into derivation and validation cohorts.

RESULTS

A total of 1236 patients were included from 70 centres. The majority (88 per cent) of the patients had synchronous liver metastases. Overall survival at 1, 2, 3 and 5 years was 86.4 per cent, 67.5 per cent, 52.6 per cent and 33.8 per cent, and the recurrence-free survival rates were 48.7 per cent, 26.6 per cent, 19.2 per cent and 10.5 per cent respectively. A total of 25 per cent of patients had recurrent disease within 6 months. Margin positivity and progressive disease at liver resection were poor prognostic factors, while adjuvant chemotherapy in margin-positive resections improved overall survival. The bilobar liver metastases from colorectal cancer-overall survival nomogram was developed from the derivation cohort based on pre- and postoperative factors. The nomogram's ability to forecast overall survival at 1, 2, 3 and 5 years was subsequently validated on the validation cohort and showed high accuracy (overall C-index = 0.742).

CONCLUSION

Despite the high recurrence rates, overall survival of patients undergoing surgical resection for bilobar liver metastases from colorectal cancer is encouraging. The novel bilobar liver metastases from colorectal cancer-overall survival nomogram helps in counselling and informed decision-making of patients planned for treatment of bilobar liver metastases from colorectal cancer.

Benefica chirurgia. A global surgery project focusing on hernia surgery

BACKGROUND

The aim of international health cooperation projects is to alleviate the deficiencies in the area of health in low resource settings. Hernia surgery is a procedure that is well suited to these missions, due to its low morbidity, the fact that it can be performed on an outpatient basis, and the improvement in quality of life that it provides.

OBJECTIVE

To describe the results of Benefica Chirurgia (BC), a Spanish non-profit humanitarian association in hernia pathology.

METHODS

Five one-week surgical campaigns were carried out in Ecuador between 2015 and 2019, involving anesthetists, general and pediatric surgeons. Surgical and medical equipment was provided and transported by BC. ASA I/II patients underwent surgery.

RESULTS

Surgery was performed on 240 patients with hernia pathology on 27 days. Sixty-three per cent of patients were male and the mean age was 48.2 years (range: 1-83). Hernia location was inguinal in 113 patients, umbilical in 101, and other in 26. The anesthetic technique used was spinal in 185 patients (77.1%), local plus intravenous sedation in 31 (12.9%), and general in 24 (10%). The surgical technique used was hernioplasty in 191 patients, herniorrhaphy in 31, incisional hernia repair in 15 and herniotomy in three. Surgery was performed on an outpatient basis in 98.4% of cases. Morbidity was 2%. Long-term postoperative evaluation is very complex.

CONCLUSION

These campaigns make a significant contribution to health in low resource settings and provide great personal satisfaction for those involved. Standards achieved in the immediate postoperative period were similar to those obtained at the surgeons' centers in Europe. However, it is difficult to establish the rates of recurrence and chronic pain.

Vascular injury during cholecystectomy: A multicenter critical analysis behind the drama

BACKGROUND

The management of a vascular injury during cholecystectomy is still very complicated, especially in centers not specialized in complex hepatobiliary surgery.

METHODS

This was a multi-institutional retrospective study in patients with vascular injuries during cholecystectomy from 18 centers in 4 countries. The aim of the study was to analyze the management of vascular injuries focusing on referral, time to perform the repair, and different treatments options outcomes.

RESULTS

A total of 104 patients were included. Twenty-nine patients underwent vascular repair (27.9%), 13 (12.5%) liver resection, and 1 liver transplant as a first treatment. Eighty-four (80.4%) vascular and biliary injuries occurred in nonspecialized centers and 45 (53.6%) were immediately transferred. Intraoperative diagnosed injuries were rare in referred patients (18% vs 84%, P = .001). The patients managed at the hospital where the injury occurred had a higher number of reoperations (64% vs 20%, P ˂ .001). The need for vascular reconstruction was associated with higher mortality (P = .04). Two of the 4 patients transplanted died.

CONCLUSION

Vascular lesions during cholecystectomy are a potentially life-threatening complication. Management of referral to specialized centers to perform multiple complex multidisciplinary procedures should be mandatory. Late vascular repair has not shown to be associated with worse results.

Prediction of peritoneal soiling in acute appendicitis with simple clinical and laboratory data. Prospective, multicenter, cohort study of 2,645 adult patients nationwide

BACKGROUND AND AIMS

In order to facilitate the preoperative prediction of complicated appendicitis, we propose a complementary approach by selecting an endpoint defined by the intraoperative finding of peritoneal soiling (PS).

METHODS

Over a 6-month period, 38 centers (5% of all public hospitals) attending emergency general surgery patients on a 24-hour, 7-days a week basis, enrolled consecutive adult patients requiring appendectomy. Patients were stratified according to the absence or the finding of PS during the surgical procedure.

RESULTS

A total of 2645 patients were included; median age (IQR) was 35 (22-51) years, 44.3% were female. The laparoscopic approach was used in 70.8% of appendectomies. In a third of patients (31.7%), there was PS with pus around the appendix, or bowel contents, free pus, or blood in the peritoneal cavity. To develop the prediction model, 1764 patients were randomly selected for the derivation cohort and the remaining 881 patients were assigned to the validation cohort. On multivariable logistic regression analysis of all patients, two clinical variables (age, and pulse) and three laboratory variables (serum urea, serum sodium, and white blood cell count) were individually associated (P < .05) with a greater probability of having PS (Hosmer-Lemeshow chi, 1.63; P = .99; C-statistic, 0.7). Based on the multivariable regression model, both static and dynamic nomograms were developed for the prediction of PS in patients with acute appendicitis.

CONCLUSIONS

The entry of simple clinical and laboratory variables in the dynamic nomogram may be useful in guiding the initial management of patients with acute appendicitis in resource-limited settings.

Reaching a consensus on the definition of "difficult" cholecystectomy among Spanish experts. A Delphi project. A qualitative study

BACKGROUND

Being able to predict preoperatively the difficulty of a cholecystectomy can increase safety and improve results. However, there is a need to reach a consensus on the definition of a cholecystectomy as "difficult". The aim of this study is to achieve a national expert consensus on this issue.

METHODS

A two-round Delphi study was performed. Based on the previous literature, history of biliary pathology, preoperative clinical, analytical, and radiological data, and intraoperative findings were selected as variables of interest and rated on a Likert scale. Inter-rater agreement was defined as "unanimous" when 100% of the participants gave an item the same rating on the Likert scale; as "consensus" when ≥80% agreed; as "majority" when the agreement was ≥70%. The delta of change between the two rounds was calculated.

RESULTS

After the two rounds, the criteria that reached "consensus" were bile duct injury (96.77%), non-evident anatomy (93.55%), Mirizzi syndrome (93.55%), severe inflammation of Calot's triangle (90.32%), conversion to laparotomy (87.10%), time since last acute cholecystitis (83.87%), scleroatrophic gallbladder (80.65%) and pericholecystic abscess (80.65%).

CONCLUSION

The ability to predict difficulty in cholecystectomy offers important advantages in terms of surgical safety. As a preliminary step, the items that define a surgical procedure as difficult should be established. Standardization of the criteria can provide scores to predict difficulty both preoperatively and intraoperatively, and thus allow the comparison of groups of similar difficulty.

Liver and lung hydatid cysts with transdiaphragmatic rupture treated by radical surgery

Hydatidosis is a parasitic disease caused by Echinococcus granulosus, a tapeworm that is endemic in certain parts of the world. We present a case of hepatopulmonary hydatidosis with diaphragm involvement and close contact with the suprahepatic inferior vena cava treated with radical surgery. We discuss therapeutical surgical options (approach and type of surgery).

Simplified risk-prediction for benchmarking and quality improvement in emergency general surgery. Prospective, multicenter, observational cohort study

BACKGROUND AND AIMS

Emergency General Surgery (EGS) conditions account for millions of deaths worldwide, yet it is practiced without benchmarking-based quality improvement programs. The aim of this observational, prospective, multicenter, nationwide study was to determine the best benchmark cutoff points in EGS, as a reference to guide improvement measures.

METHODS

Over a 6-month period, 38 centers (5% of all public hospitals) attending EGS patients on a 24-h, 7-days a week basis, enrolled consecutive patients requiring an emergent/urgent surgical procedure. Patients were stratified into cohorts of low (i.e., expected morbidity risk <33%), middle and high risk using the novel m-LUCENTUM calculator.

RESULTS

A total of 7258 patients were included; age (mean ± SD) was 51.1 ± 21.5 years, 43.2% were female. Benchmark cutoffs in the low-risk cohort (5639 patients, 77.7% of total) were: use of laparoscopy ≥40.9%, length of hospital stays ≤3 days, any complication within 30 days ≤ 17.7%, and 30-day mortality ≤1.1%. The variables with the greatest impact were septicemia on length of hospital stay (21 days; adjusted beta coefficient 16.8; 95% CI: 15.3 to 18.3; P < .001), and respiratory failure on mortality (risk-adjusted population attributable fraction 44.6%, 95% CI 29.6 to 59.6, P < .001). Use of laparoscopy (odds ratio 0.764, 95% CI 0.678 to 0.861; P < .001), and intraoperative blood loss (101-500 mL: odds ratio 2.699, 95% CI 2.152 to 3.380; P < .001; and 500-1000 mL: odds ratio 2.875, 95% CI 1.403 to 5.858; P = .013) were associated with increased morbidity.

CONCLUSIONS

This study offers, for the first time, clinically-based benchmark values in EGS and identifies measures for improvement.

Liver resection and ablation for squamous cell carcinoma liver metastases

Background

Limited evidence exists to guide the management of patients with liver metastases from squamous cell carcinoma (SCC). The aim of this retrospective multicentre cohort study was to describe patterns of disease recurrence after liver resection/ablation for SCC liver metastases and factors associated with recurrence-free survival (RFS) and overall survival (OS).

Method

Members of the European–African Hepato-Pancreato-Biliary Association were invited to include all consecutive patients undergoing liver resection/ablation for SCC liver metastases between 2002 and 2019. Patient, tumour and perioperative characteristics were analysed with regard to RFS and OS.

Results

Among the 102 patients included from 24 European centres, 56 patients had anal cancer, and 46 patients had SCC from other origin. RFS in patients with anal cancer and non-anal cancer was 16 and 9 months, respectively (P = 0.134). A positive resection margin significantly influenced RFS for both anal cancer and non-anal cancer liver metastases (hazard ratio 6.82, 95 per cent c.i. 2.40 to 19.35, for the entire cohort). Median survival duration and 5-year OS rate among patients with anal cancer and non-anal cancer were 50 months and 45 per cent and 21 months and 25 per cent, respectively. For the entire cohort, only non-radical resection was associated with worse overall survival (hazard ratio 3.21, 95 per cent c.i. 1.24 to 8.30).

Conclusion

Liver resection/ablation of liver metastases from SCC can result in long-term survival. Survival was superior in treated patients with liver metastases from anal versus non-anal cancer. A negative resection margin is paramount for acceptable outcome.

Spanish multicenter study of surgical resection of pancreatic tumors infiltrating the celiac axis: does the type of pancreatectomy affect results?

BACKGROUND

Pancreatectomy plus celiac axis resection (CAR) is performed in patients with locally advanced pancreatic cancer. The morbidity rates are high, and no survival benefit has been confirmed. It is not known at present whether it is the type of pancreatectomy, or CAR itself, that is the reason for the high complication rates.

METHODS

Observational retrospective multicenter study.

INCLUSION CRITERIA

patient undergoing TP, PD or DP plus CAR for a pancreatic cancer.

RESULTS

Sixty-two patients who had undergone pancreatic cancer surgery (PD,TP or DP) plus CAR were studied. Group 1: 17 patients who underwent PD/TP-CAR (13TP/4PD); group 2: 45 patients who underwent DP-CAR. Groups were mostly homogeneous. Operating time was longer in the PD/TP group, while operative complications did not differ statistically in the two groups. The number of lymph nodes removed was higher in the PD/TP group (26.5 vs 17.3), and this group also had a higher positive node ratio (17.9% vs 7.6%). There were no statistical differences in total or disease-free survival between the two groups.

CONCLUSION

It seems that CAR, and not the type of pancreatectomy, influences morbidity and mortality in this type of surgery. International multicenter studies with larger numbers of patients are now needed to validate the data presented here.

Systematic review of the mesopancreas: concept and clinical implications

BACKGROUND

In 2007, Gockel et al. coined the term mesopancreas (MP). In the next 10 years, a limited number of publications about MP have been published, but little is known about the oncological benefit of MP resection. We performed a systematic review of the literature on MP.

METHODS

An electronic search was performed in PubMed, EMBASE, Cochrane, Latindex, Scielo, and Koreamed databases until 15 June 2017 to identify all published articles dealing with the subject of MP. Some language restriction was done (Chinese and Rumanian).

RESULTS

The search yielded 51 articles; 28 articles were selected as relevant. All were retrospective studies focused more on describing technical variants, feasibility and safety than on the cancer results. The R0 rate in patients with MP resection ranged between 57 and 96.7%. In all the articles with a control group, the R0 rate was higher in the MP excision group. Survival data were explicitly stated only in five series.

CONCLUSION

MP is a difficult-to-excise retropancreatic area. In theory, it is agreed that MP excision raises the rate of R0 resections, which in turn reflected in an improvement in the oncological results; however, at present there are no randomized studies to prove this. Achieving a worldwide consensus on its concept, landmarks, excision technique and oncological results is essential.

Major hepatectomies in liver cystic echinococcosis: A bi-centric experience. Retrospective cohort study

Surgical treatment of liver cystic echinococcosis (LCE) could be conservative or radical. Radical surgery includes liver resection, but usually are minor hepatectomy in favourable segments. Experience in major hepatectomy (MH) for LCE is limited.

METHODS

Retrospective study.

PERIOD

January 2007-December 2014.

INCLUSION CRITERIA

liver infestation with Echinococcus granulosus causing active or complicated cysts. Epidemiological, clinical, radiological and surgical data were studied.

RESULTS

145 patients underwent surgery for LCE. MH was performed in 49 patients (34%) with 81 cysts. 51% of patients were women. Mean age: 56 years. Sixteen patients (32.7%) had recurrent disease. The mean diameter cyst was 9.9 cm. The MH performed were right hepatectomy (n = 15), left hepatectomy (6) and others (n = 28). The reason for MH was occupation of the entire lobe (14), severe vascular or biliary involvement (17), or a combination of the two (18). Major morbidity (Clavien III-V) was 26%. Mortality was 2%. Mean hospital stay: 15.3 days. At follow-up (mean: 31 months) the rate of liver recurrence after MH was 0%.

CONCLUSIONS

MH is feasible in LCE, with a major morbidity rate of (26%), and zero recurrence. Indications of MH are occupation of an entire lobe, extreme biliary or vascular involvement or recurrent cysts.

Is radical surgery feasible in liver hydatid cysts in contact with the inferior vena cava?

BACKGROUND

Cysts in contact with the inferior vena cava (IVC) represent a challenge for hepato-pancreatico-biliary surgeons. Although the literature on the topic is scarce, the most widely accepted approach is conservative surgery. Partial cyst resection is recommended, because radical resection is considered a high-risk procedure.

STUDY DESIGN

This was a retrospective study over the period January 2007-December 2012. We operated on 103 patients with liver hydatidosis. A total of 32 patients (31 %) had a liver cyst in contact with the IVC. We proposed a cyst classification based on location of the cyst and length of contact and degrees of involvement of the IVC.

RESULTS

Median size of the contacting cyst measured by computed tomography (CT) was 12 cm. On CT, median length of contact with the IVC was 37 mm. The median degree of involvement was 90°. Radical surgery was performed in 20 patients (62.5 %). No IVC resection was done. Morbidity rate was 28 %, and mortality was 3 %. In follow-up (median 27 months), no relapses or problems related to IVC flow were detected. Postoperative stay and transfusion rate were higher in the conservative surgery group, but these patients presented fewer complications. There was no relationship between circumferential grades and length of contact with the IVC and the type of surgery performed.

CONCLUSIONS

Liver hydatid cysts in contact with the IVC are large cysts usually located in the right liver. They do not normally cause clinical symptoms related to IVC contact. Radical surgery is feasible, and was performed in 60 % of our series, but it is technically demanding. We propose a classification of cysts in contact with the IVC.

Tricks and tips in pancreatoduodenectomy

Pancreaticoduodenectomy (PD) is the standard surgical treatment for tumors of the pancreatic head, proximal bile duct, duodenum and ampulla, and represents the only hope of cure in cases of malignancy. Since its initial description in 1935 by Whipple et al, this complex surgical technique has evolved and undergone several modifications. We review three key issues in PD: (1) the initial approach to the superior mesenteric artery, known as the artery-first approach; (2) arterial complications caused by anatomic variants of the hepatic artery or celiac artery stenosis; and (3) the extent of lymphadenectomy.

[Disconnected panreatic duct syndrome]

Disconnected pancreatic duct syndrome (DPDS) is characterized by disruption of the main pancreatic duct with a loss of continuity between the pancreatic duct and the gastrointestinal tract caused by ductal necrosis after severe acute necrotizing pancreatitis treated medically, by percutaneous drainage, or necrosectomy. There are no clear epidemiological data on the real incidence of DPDS; approximately 10 to 30% of patients with severe acute pancreatitis could develop DPDS. The existing literature is scarce, the terminology is confusing and therapeutic algorithms are not clearly defined. Both endoscopic and surgical management have been described. We have performed a sytematic review of the literature on DPDS.

Cysto-biliary communication in liver hydatidosis

BACKGROUND

Liver hydatidosis is a severe health problem in endemic areas. Due to migration from these countries to other zones, now it is a worldwide problem. Liver hydatidosis can provoke many complications (abscess, fistula to adjacent organs, migration, etc.), but the most frequent and one of the most severe complication is the communication between the cyst and the biliary tree.

AIM

The aim of this study is to perform a review on the epidemiology, clinical features, diagnostic methods, and therapeutic options to treat the communication between the cyst and the biliary tree.

RESULTS

Due to the lack of randomized clinical trial or meta-analysis on this topic, we performed a classical review and included our personal algorithm.

CONCLUSIONS

The communication between the cyst and the biliary tree varies from a small communication to a frank intrabiliary rupture. The percentage of patients with the communication between the cyst and the biliary tree is not well known because there is no accepted definition. The therapeutic options are multiple and related to the size of the communication, the location of the cyst, and the experience of the hepatobiliary surgeon. ERCP is now an important tool for the treatment of the communication between the cyst and the biliary tree.

Walled-off pancreatic necrosis

Acute severe pancreatitits may be complicated by the development of 'walled-off pancreatic necrosis' (WOPN), which is characterised by a mixture of solid components and fluids on imaging studies as a consequence of organised pancreatic tissue necrosis. We present here an overview of the definition, clinical features, and diagnostic and therapeutic management of this clinical condition, which is mostly based on consensus as adequate clinical trials are lacking.

Gallbladder tuberculosis: False-positive PET diagnosis of gallbladder cancer

Gallbladder tuberculosis (GT) is an extremely rare disease, and very few cases have been reported in the literature. The first case of GT was described in 1870 by Gaucher. A correct preoperative diagnosis of GT is unusual, and it is frequently confused with various gallbladder diseases. We present a new case of a patient who underwent surgery with the preoperative diagnosis of gallbladder cancer after a false positive positron emission tomography scan in the diagnostic work-up.

Time course of intraoperative cytokine levels in liver transplant recipients

We evaluated the levels of several cytokines (interleukin [IL]-2, IL-4, IL-6, IL-10, tumor necrosis factor [TNF]-alpha, and interferon [IFN]-gamma) in plasma samples obtained before surgical intervention (T0) and during intraoperative liver transplantation: after induction of anesthesia (I-1), 15 minutes of anhepatic phase (I-2), 5 minutes before reperfusion (I-3), 10 minutes after reperfusion (I-4), 20 minutes after reperfusion (I-5), 60 minutes after reperfusion (I-6), and 1 hour after liver transplantation (I-7). Cytokine levels were determined using a technique which combines ELISA technique and flow cytometry. The study was approved by the local clinical research (ethics) committee. Written informed consent was obtained from patients' relatives. Twenty patients (14 men, 6 women) aged 23 to 61 years, recipients of a liver transplantation were studied. The cytokine IL-2 plasma values were maintained during the whole study period, with a slight increase at 15 minutes of anhepatic phase (I-2). IL-4 showed a peak value 20 minutes after reperfusion (I-5). IL-6 increased its plasma value starting at 15 minutes of anhepatic phase (I-2), maintaining high concentrations during the whole intraoperative period. IL-10 increased progressively, reaching a maximum 1 hour after transplantation (I-7). TNF-alpha reached maximum plasma levels 20 minutes after reperfusion (I-5), whereas IFN-gamma showed a peak at 15 minutes of anhepatic phase (I-2). Our results indicate that the anhepatic phase (I-2) is the earliest phase during which proinflammatory and anti-inflammatory cytokines, such as IL-6 and IL-10, respectively, are involved during liver transplantation. We conclude that IL-6 is the first cytokine involved in the inflammatory response during liver transplantation.

Early postoperative response of cytokines in liver transplant recipients

We evaluated the early postoperative response of several cytokines (IL-2, IL-4, IL-6, IL-10, TNF-alpha, IFN-gamma) prior to liver transplantation (T(0)) as well as 1, 6, and 12 hours and 1, 2, 3, 5, and 7 days afterward. Cytokine concentrations were correlated with serum levels of bilirubin as a predictor of postoperative complications. Cytokine levels were determined in plasma samples from 16 liver transplant recipients (13 men, 3 women) aged 43 to 61 years. IL-6 and IL-10 reached their maximum concentrations 1 hour after transplantation. Each increase in IL-6 correlated to a rise in IL-10. IL-2, IL-4, TNF-alpha, and IFN-gamma had a particular time-course for each patient studied. Bilirubin fell to almost normal values but not in cases of postoperative complications, where IL-6 showed values four times higher compared to those of liver transplant recipients who did not show postoperative complications. IL-6 and IL-10 plasma concentrations and serum bilirubin level might be useful as a predictive factor of postoperative complications in liver transplant recipients.

Indications and therapeutical options in hepatolithiasis

OBJECTIVE

to present our experience with the treatment of hepatolithiasis.

EXPERIMENTAL DESIGN

a retrospective study. Every patient operated on during 2002-2004.

RESULTS

mean age was 68.2 years. All patients were male. Two patients had been operated on before. The other three suffered from: monolobar Caroli s disease (1), cholangiocarcinoma (1), and hepatolihtiasis without clear etiologic factors (1). All of them had intrahepatic and extrahepatic litihiasis. Clinical signs included: pain in RUQ, fever, and jaundice. Bilirubin was 3.5 mg/dl (min: 1.7, max: 5.9), GGT: 676.2 IU/l (min: 29, max: 2039), and alkaline phosphatase: 400 IU/l (min: 100, max: 1136). Abdominal ultrasounds always correctly diagnosed HL. CT (3 patients) only diagnosed one case. ERCP (3 patients) and cholangio-MRI (2 patients) always diagnosed HL correctly. Surgical procedures were: hepatojejunostomy with lavage of bile duct (2 cases) and hepatectomy (3 cases) -both right (1) and left (2). We always performed an intraoperative ultrasonography and choledoscopy. Morbidity was: biliary fistula (1 case) treated by percutaneous drainage. No mortality occurred. Median stay was 8.8 days. Mean follow-up is 12 months (min: 11, max: 20). No relapse has been observed.

CONCLUSIONS

HL is infrequent in Spain. Surgical treatment, usually liver resection, obtains good results with low morbidity and mortality.

Time course of antioxidant enzyme activities in liver transplant recipients

Reactive oxygen species (ROS) play a central role in ischemia-reperfusion injury after organ transplantation. They are degraded by endogenous radical scavengers such as antioxidant enzymes. The purpose of this study was to evaluate the temporal variations of antioxidant enzyme activities in liver transplant recipients. The study was performed in 13 liver transplant patients (11 men and 2 women). Blood samples were obtained pre- and postsurgical intervention: before transplant (T(0)), and 1, 6, 12, 24, 48, and 72 hours, as well as 5 and 7 days thereafter. We determined total and specific superoxide dismutase (SOD) activity, catalase (CAT), glutathione peroxidase (GPX), and glutathione reductase (GR) activities as well as malondialdehyde (MDA) and low-density lipoproteins (LDL). The results showed increased SOD and mainly GPX activities after liver transplantation, which correlated with MDA levels. Total SOD activity was mainly represented by Mn-SOD (75%) and Cu,Zn-SOD (25%), whereas Fe-SOD was not detected. In conclusion, the enhanced antioxidant enzyme activities reported in this study indicated a control of oxidative stress generated in liver transplantation. In this sense, although MDA levels showed an enormeous increase at 1 hour after transplantation, the lipid peroxidation was compensated for by GPX activity.

Split for two adults: what is the real feasibility?

INTRODUCTION

A split liver for two adults is a good theoretical option but the number of cases is low. We have tried to assess the feasibility of this technique.

MATERIALS AND METHODS

From April 2002 to April 2004, we evaluated 81 donors of which only 59 (72.8%) were used for transplantation of which 10 were grafted in other centers (pediatric or emergency code). Among the 49 donors the criteria for splitting were: ages >14 and <50 years, weight >70 and <100 kg, less than 3 days in the intensive care unit (ICU), hemodynamic stability, Na(+) < 160 mg/L, liver enzymes elevated no more than twofold, no macroscopic steatosis, and procurement in our hospital.

RESULTS

The mean donor age was 50.7 years (range: 16 to 77) of whom 25 were men (51%). The mean weight was 65.7 kg (range: 50 to 100) and days of ICU stay, 3 (range: 1 to 23). Six grafts (12%) were split. The reasons for not splitting were: age (n = 26 [53%]), weight (n = 17 [34.7%]), UCI >3 days (n = 9 [18.3%]), Na(+) > 160 (n = 1 [2%]), blood liver test elevated (n = 5 [10.2%]), steatosis (n = 6 [12.2%]), and procurement outside our center (n = 20 [40.8%]). The donors not suitable for splitting had: only one criteria (n = 12 [24.4%]; 2 (n = 23 [46.9%], 3 (n = 6 [12.2%]) or 4 (n = 2 [4.1%]). If we had had two suitable recipients, we could performed six more liver transplantations (12.2% increase).

CONCLUSIONS

The theoretical feasibility of a split liver for two adults is 12.2%, but the actual probability is lower because of lack of two adequate candidates.

Postlaparoscopic cholecystectomy bile leak secondary to an accessory duct of Luschka

Complications produced by the sectioning of a nonvisualized duct of Luschka are uncommon during laparoscopic cholecystectomy. From 1999 through 2003, we performed 1351 laparoscopic cholecystectomies in our department and observed 2 cases (0.15%) of bile leakage due to duct of Luschka injury. Injury during laparoscopic cholecystectomy is usually produced by an excessively deep plane of dissection and by the anatomical localization of this accessory duct. Clinical symptoms are scarce after duct of Luschka injury. Numerous diagnostic methods have been used to detect these injuries. Nevertheless, careful clinical examination is still of the utmost importance. Noninvasive treatments are usually effective. In patients who present with acute abdomen, as in our cases, or who are not cured by noninvasive treatments, exploratory laparotomy is the best approach. The surgical treatment consists of a lavage of the abdominal cavity, closure of the duct of Luschka, and intraoperative cholangiography to confirm that the biliary tree is intact.

Signet-ring-cell carcinoma of the Vater's ampulla

CONTEXT

Most tumors affecting Vater's Ampulla are adenocarcinomas and other histological variants are less frequent. A review of the literature revealed only seven previously reported cases of signet ring cell carcinoma of the ampulla of Vater. The presence of this kind of tumor has no clear histological explanation. Two possible theories have been proposed: the presence of gastric heterotopia in the ampulla of Vater or the existence of a perivaterian duodenal heterotopia of ulcerous etiology as the origin of a signet ring cell tumor which secondarily invades the ampulla of Vater.

CASE REPORT

We performed a pancreatoduodenectomy in a 67-year-old woman with a T2N0M0 ampulla tumor. A histologic study revealed a signet ring cell neoplasm.

CONCLUSION

Etiology and survival of signet ring cell carcinoma of Vater's ampulla is not well-defined in the literature due to the extreme rarity of this disease. Duodenopancreatectomy with pylorus preservation is the treatment of choice.

Retroperitoneal actinomycosis due to dropped gallstones

Dropped bile and gallstones after accidental perforation of the biliary gallbladder is a frequent event during laparoscopic cholecystectomy and is generally of no clinical importance. However, calculi left in the abdominal cavity can produce a series of severe late complications. We present a patient with retroperitoneal actinomycosis produced by dropped gallstones after a laparoscopic cholecystectomy.

Pneumomediastinum as a complication of extraperitoneal laparoscopic inguinal hernia repair

A 52-year-old man with left indirect groin hernia was admitted for elective inguinal repair using the totally extraperitoneal (TEP) approach. After an uneventful intubation, TEP repair of the hernia was performed with three midline trocars. Immediately after extubation, the patient noted severe chest pain. There was a decrease in PaO2 saturation, and neck subcutaneous emphysema was detected. There was no emphysema of the abdomen or of the back. A chest film and thoracic computed tomographic (CT) scan confirmed the presence of pneumomediastinum without pneumothorax. The patient was discharged without complications.