Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

Systemic immune response after open tension-free inguinal hernia repair under different anesthetic alternatives: a prospective comparative study

PURPOSE

The purpose of the present study was a comparison of the systemic inflammatory response intensity through the estimation of C- reactive protein and albumin levels before and after open tension free inguinal hernia repair performed under different anesthetic alternatives.

PATIENTS AND METHODS

Totally, 125 inguinal hernia patients scheduled for unilateral primary open tension free inguinal repair unRomader local (50 patients), spinal (50 patients) and general anesthesia (25 patients) have been included in this prospective study.

RESULTS

The group of local anesthesia was associated with the higher postoperative serum levels of albumin compared to the group of general anesthesia (P 0.013). Local anesthesia was also associated with higher postoperative serum albumin levels compared to regional anesthesia but however the difference was not statistically significant (P 0.282). The group of local anesthesia was also associated with the lower postoperative levels of CRP compared to the regional (P 0.0094) and general anesthesia (P 0.0009) groups.

CONCLUSION

Local anesthesia proved superior to regional or general anesthesia for open tension free inguinal hernia repair in the given patient sample from the standpoint of the inflammatory and acute phase response.

An enhanced outpatient modality for the treatment of hemorrhoidal disease: preliminary results

Surgical treatment of haemorrhoids is, primarily, performed on an outpatient basis, and as so, the reduction of the operative time and the hospitalization duration is necessary. In order to achieve these results, both the surgical procedure and the anaesthesia modality should be optimized. Therefore, in this randomized controlled trial, we proposed the hemorrhoidal arteries ligation under pudendal nerve block, as an enhanced outpatient modality, versus the standard of doppler guided hemorrhoidal arteries ligation under spinal anaesthesia. Preliminary results showed that the experimental group was characterized by a similar to the control arm, symptoms remission rate, a lower operation duration and an improved postoperative recovery.

Loop stomas with a subcutaneously placed bridge device

AIM

To describe and evaluate a new technique for supporting a loop stoma with a simple removable subcutaneous bridge device.

METHODS

Fifty-five patients underwent a procedure resulting in a loop stoma. Thirty patients had a loop colostomy and twenty-five a loop ileostomy. In all cases, the stoma was supported with a removable subcutaneous redivac drain fixed to the skin.

RESULTS

There was no incidence of mechanical obstruction, stenosis, retraction, mucosal erosion or subcutaneous infection. Daily cleaning and care of the stoma was very simple, and the removal of the bridge device was carried out without opening the collecting bag.

CONCLUSION

Our proposed technique is safe and feasible without considerable complications.

Clinicopathological differences between right- and left-sided colonic tumors and impact upon survival

AIM

This study is to analyze the clinicopathological differences between right- and left-sided colonic tumors and to evaluate the impact upon the patient's survival.

METHODS

In a period of 5 years (2004-2009), 453 patients were diagnosed with colorectal cancer.

RESULTS

From a total of 453 patients diagnosed with colon cancer, 56.5% of them were men, while 43.5% of them were women. Right-sided colonic tumors were diagnosed in 54.53% of the patients compared to the 45.47% of patients with left-sided colonic tumors. The size of colonic tumors is statistically significant greater in right-sided colonic tumors compared to left ones (P < 0.001). Left-sided colon cancer patients identified to have a statistically significant better overall 5-year survival rate compared to right-sided ones (P < 0.001).

CONCLUSION

Based upon our results, there is a different biological profile between right- and left-sided colonic tumors.

Effect of histamine on the electrophysiology of the human parietal pleura

INTRODUCTION

Histamine is involved in the pathogenesis of numerous diseases and regulates the permeability of different tissues. The aim of this study is to investigate the effects of histamine on the electrophysiology of human parietal pleura and the underlying mechanisms involved.

MATERIALS AND METHODS

Pleural specimens were obtained from patients subjected to thoracic surgery and were mounted in Ussing chambers. Histamine solutions (1μM to 1mM) were applied in native and pretreated specimens with dimetindene maleate, cetirizine, ranitidine, amiloride and ouabain. Trans-mesothelial resistance was determined (R(TM)).

RESULTS

Histamine induced a rapid R(TM) increase on the mesothelial (p = 0.008) and a decrease on the interstitial surface (p = 0.029). This effect was dose-dependent and was totally abolished by dimetindene maleate, cetirizine and amiloride and partially by ranitidine and ouabain.

CONCLUSIONS

Histamine induces acute electrochemical changes in human pleura mainly via interaction with the H(1) and partially with the H(2) histamine receptors. It also interferes with trans-cellular permeability and therefore may participate in pleural fluid recycling.

Permeability alterations after surgical trauma in normal rabbit peritoneum

BACKGROUND

To investigate whether surgical trauma in a rabbit adhesion formation model and the administration of normal saline (N/S), icodextrin (ID) and/or dimetindene maleate (DM) changes the permeability of the normal rabbit parietal peritoneum.

MATERIALS AND METHODS

A total of 45 female rabbits were operated on for adhesion formation and were euthanized 10 days later. In some rabbits, ID or N/S was instilled intraabdominally during operation, whereas in others DM was infused intravenously. In others, ID plus DM or no agent was used. Specimens were obtained postoperatively and were mounted between Ussing chambers. Amiloride was used to investigate Na(+) channels. Transmesothelial resistance (R(TM)) was determined as a permeability indicator.

RESULTS

Amiloride increased the R(TM) of both surfaces. Surgical trauma increased R(TM) and partially inhibited the effect of amiloride. ID and N/S increased R(TM) and inhibited the effect of amiloride. Use of DM did not change R(TM) and did not inhibit the effect of amiloride. Use of ID plus DM slightly increased R(TM), but the effect of amiloride was blocked.

CONCLUSIONS

Surgical trauma impairs the permeability of the normal rabbit parietal peritoneum. ID or N/S surmounted this effect, but DM did not, suggesting that surgical trauma is a diffuse process. Antiadhesion measures influence peritoneal physiology.

Prevention of postoperative adhesion formation by individual and combined administration of 4 per cent icodextrin and dimetindene maleate

BACKGROUND

To date, no single method has been successful in eliminating peritoneal adhesion formation after major abdominal surgery. This study evaluated the individual and possible synergistic effect of a local intraperitoneal barrier, 4 per cent icodextrin, and an intravenously administered antihistamine drug, dimetindene maleate, in the prevention of adhesion development following surgical trauma.

METHODS

De novo experimental adhesions were induced by standardized trauma of the peritoneum and large bowel in 120 New Zealand White rabbits. The animals were randomized into four groups receiving intraperitoneal saline, intraperitoneal 4 per cent icodextrin (60 ml), intravenous dimetindene maleate (0.1 mg/kg) and 4 per cent icodextrin-dimetindene in combination (n = 30 per group). Ten days later, adhesion scores and incidence were assessed by two independent surgeons. and surface area by computer-aided planimetry.

RESULTS

Treatment with either icodextrin or dimetindene maleate significantly reduced adhesion scores and increased the incidence of adhesion-free animals in an equipotent manner. The effect of combined treatment on severity, incidence and surface area of adhesions was more pronounced than that of each drug administered separately.

CONCLUSION

Combined administration of 4 per cent icodextrin and dimetindene maleate may be used safely and efficaciously to prevent surgically induced adhesions.

The role of antibiotic prophylaxis in elective tension-free mesh inguinal hernia repair: results of a single-centre prospective randomised trial

Hernia repair is one of the so-called clean operations. Many surgeons, however, use antibiotics, especially in the mesh repair era, without strong evidence to support this policy. We conducted a single-centre prospective randomised trial with a view to clarify this issue on a scientific basis. From January 2000 all patients undergoing elective inguinal hernia repair using a tension-free polypropylene mesh technique, provided they fulfilled predetermined criteria, were randomised to have a single dose of amoxicillin and clavoulanic acid or placebo in a double-blind manner. The main end point was to detect any difference in infectious complication rates - with specific interest to wound infection rates - between the two groups. Between January 2000 and June 2004, 386 patients entered the study (364 men and 22 women, median age 63 years, range 15-90 years) and were randomised to have antibiotic prophylaxis (group A, n = 193) or placebo (group B, n = 193). The two groups were comparable regarding demographic data. In total, 19 (5%) cases with infectious complications were detected. Fourteen of these were wound infections (3.7%). There were five cases of wound infection in group A and nine in group B (p = 0.4, Fisher's exact test). All wound infections were treated with antibiotics. The wound was opened in some cases. Mesh removal was not required in any of the cases. From the results of this study it does not appear that antibiotic prophylaxis offers any benefits in the elective mesh inguinal hernia repair.

Local treatment of a loop colostomy prolapse with a linear stapler

Stomal prolapse is considered to be a common complication especially following loop colostomies. A variety of methods has been reported for the management of this condition, with many of them requiring extensive reconstruction of the stoma under anesthesia. We report a simple and fast technique for the local correction of the prolapse under minor sedation. A linear stapler device was applied for the amputation and reconstruction of the prolapse stoma at the desired level.

Gastrografin administration in the treatment of postoperative delayed gastric emptying

Five cases of delayed gastric emptying (DGE) are reported. Three patients had pancreatic head carcinoma and underwent a Whipple operation during which truncal vagotomy and gastrectomy were performed. The remaining two patients underwent vagotomy and gastrectomy because of benign peptic ulcer. In one of the pancreatectomy cases, the pylorus was at first preserved, but after DGE developed, a gastrectomy was carried out, which did not result in any improvement. The duration of DGE was 16-72 days, during which time the patients were under total parenteral or enteral nutrition. There were no other major complications. The patients received prokinetic agents (metoclopramide, erythromycin) but without any improvement. Finally, all patients were treated with Gastrografin, 40 ml every two hours, via a nasogastric tube. In all cases, gastric motility was restored within 20-36 hours.

Liver resection for metastatic non-colorectal non-neuroendocrine hepatic neoplasms

AIMS

Major liver surgery can be performed safely and hepatic resection for metastatic disease is increasingly carried out. However, the role of liver resection for hepatic metastases from non-colorectal, non-neuroendocrine (NCNN) cancers is unknown. Our aim was to evaluate our experience from hepatectomies for NCNN metastases. A retrospective study of 170 patients with liver resection performed the last 8 years was performed in two liver units in affiliated university hospitals.

METHODS

Eighteen patients underwent liver resection for NCNN tumours. Origins included kidney (n=6), breast (n=4), gastric tumours (n=4), intestinal leiomyosarcoma (n=2) and malignant melanoma and in one patient a metastatic papillary of unknown origin was found. Eleven patients underwent a hepatic lobectomy and seven had local resections. Ten hepatectomies were performed at the same time with the primary tumour resection (synchronous resections) with five of those in an en bloc fashion with the primary tumour.

RESULTS

There were no post-operative deaths and the peri-operative morbidity was minimal. During a median follow-up time of 3.2 years, 14 patients are alive with one of them having developed pulmonary metastases.

CONCLUSION

In carefully selected patients with NCNN liver metastasis, liver resection can prolong survival as well and improve quality of life.

Portosystemic shunt for the treatment of portal vein thrombosis following orthotopic liver transplantation

The efficacy of the portosystemic shunt operation for the treatment of portal vein thrombosis following orthotopic liver transplantation was demonstrated. From 1 July 1988 to 31 December 1991 42 portosystemic shunt operations were performed at our centre. In six of these cases portal vein thrombosis after orthotopic liver transplantation (OLT) was the indication for the procedure. All the patients retained adequate liver function but they demonstrated manifestations of significant portal hypertension, mainly variceal rebleeding. Two of the patients were children. Three patients underwent distal splenorenal shunt (DSRS), one mesocaval and one side-to-side splenorenal shunt and the last one side-to-side splenorenal shunt which was converted to DSRS 2 weeks later. All these patients were doing well after 30 months mean follow-up time without rebleeding or other signs of portal hypertension and none had so far required retransplantation.

Pathological changes of hepatic artery and portal vein, after allyl-alcohol and carbon tetrachloride administration. An experimental study

BACKGROUND

Allyl-alcohol (AA) and carbon tetrachloride (CC14) are known to cause peritoneal and pericentral liver necrosis, respectively. This study investigates pathological changes of hepatic artery and portal vein after simultaneous administration of AA and CC14 in rats.

METHODS

The study comprised 130 male Wistar rats divided randomly into 2 groups: I (n=10) sham and II (n=120) AA injection (intraperitoneally: 0.62 mmol/kg) and rhinogastric administration of CC14 (0.66 ml/kg, 1:1 volume dilution in corn oil). After injection was completed, animals of group II were assigned in 12 categories and sacrificed 2, 4, 6, 12, 18, 24, 33, 48, 57, 81, and 153 hrs after. Tissue was obtained from the left anterior lobe and the hilum of the liver, and histological examination included H&E, silver methenamine and van Giesson stains.

RESULTS

Liver sections from group II (AA+CC14) demonstrated periportal together with pericentral necrosis; the peak was 57 hrs after injection. In all 120 cases, H&E stain showed evidence of regeneration originated from zone 2, extending to zone 1 and occasionally to zone 3, and accomplished mainly by non-necrotic cell proliferation. Sections from the liver hilum showed thrombosis of the portal vein, whereas the hepatic artery and its branches developed a variety of changes. Initially (2, 4 hrs), endothelial hypertrophy was observed which was followed by focal fibrinoid necrosis of the arterial wall (6 hrs). Later on (9-153 hrs) the following findings were present: hyperplasia and non-isometric cytoplasmic vacuolisation of media, disruption of the elastic lamina, aggregation of foam cells and macrophages in intima, media, and focally in adventitia of hepatic artery; and lymphocytic inflammation of intimal and periadventitial area. In 2 cases (153 hrs) hepatic artery thrombosis was present.

CONCLUSIONS

Additionally to liver parenchymal changes, simultaneous administration of allyl-alcohol and carbon tetrachloride in rats results to vascular changes mainly in the hepatic artery and its branches. During liver parenchymal regeneration, the hepatic artery and its branches develop microscopic features that morphologically resemble those of atherosclerosis. These changes may result in hepatic artery thrombosis and or obstruction.

Bile leakage following T-tube removal in orthotopic liver transplantation

BACKGROUND/AIMS

Biliary tract complications constitute a common cause of post-operative morbidity after orthotopic liver transplantation. Bile leakage following T-tube removal, even if uncommon, can also seriously influence post-operative recovery. This report outlines the diagnostic and therapeutic policy used to treat this complication in a large liver transplantation center.

METHODOLOGY

Fourteen consecutive cases of bile leakage after T-tube removal are presented. Abdominal pain was the most common symptom and acute abdomen developed in one third of the patients. Ultrasonography was the most common imaging technique used.

RESULTS

Five patients were treated conservatively with or without percutaneous drainage of the biloma and 9 patients underwent an exploratory laparotomy. Ligation of the T-tube tract was the most common technique used. All patients had an uneventful clinical course.

CONCLUSIONS

Clinical signs are the most important factor in the diagnosis of this complication, and should be treated surgically if the patient does not improve within 24-48 hours under conservative management. Inadequate fibrous T-tube tract formation due to immunosuppression or the underlying disease could be an explanation for the development of this complication.

Multidisciplinary management of hepatocellular carcinoma

BACKGROUND/AIMS

The continuing poor prognosis for patients with hepatocellular carcinoma drives a search for new adjuvant therapies. Targeted locoregional immuno-chemotherapy is one of the most promising.

MATERIALS AND METHODS

From 1990 to 1996, 193 patients who were not eligible for liver resection were treated in a prospective randomized study. Ninety-one patients received locoregional targeted chemotherapy only via an arterial catheter (Group A), and 102 received combined locoregional immuno-chemotherapy via two arterial catheters (Group B).

RESULTS

Overall survival was significantly different (10.2 months vs 22.3 months), favoring Group B. Complications and side effects of treatment were minimal in Group B and easily handled. Even in Group A, side effects were less severe than effects normally associated with systemic chemotherapy.

CONCLUSIONS

Even though the current prognosis for patients with Hepatocellular Carcinoma remains poor, targeted locoregional immuno-chemotherapy has proven to be of benefit in terms of quality of life and survival.

Hepatic artery pseudoaneurysm following laparoscopic cholecystectomy: transcatheter intraarterial embolization

We present a case of hepatic artery injury with pseudoaneurysm formation following laparoscopic cholecystectomy. A 29-year-old man was referred to our hospital with right upper quadrant pain, jaundice and upper gastrointestinal bleeding one month after laparoscopic cholecystectomy. Gastroscopy showed mucosal erosions at the gastroesophageal junction. The patient did well after medical treatment only and was discharged one week later. However, ten days later he was readmitted with recurrent upper gastrointestinal bleeding. Usual laboratory tests, routine imagine diagnostic procedures and selective hepatic arteriogram were performed. Usual laboratory tests and routine imagine diagnostic procedures were inconclusive, but selective hepatic arteriogram showed a right hepatic artery pseudoaneurysm. The diagnosis of hemobilia was established. Embolization of the aneurysm with coils was carried out. Bleeding was controlled, the patient was discharged one week later and since then he remains under close follow up without any evidence of bleeding recurrence. We believe that the intraarterial embolization of a pseudoaneurysm is a safe and effective method to manage some complications such as bleeding or hemobilia.

Fibrin glue for sealing the needle track in fine-needle percutaneous lung biopsy using a coaxial system: Part II--Clinical study

PURPOSE

Following percutaneous lung biopsy (PLB), we used fibrin glue as a sealant in 26 patients for the purpose of decreasing the incidence of pneumothorax.

METHODS

All 26 patients (group A) had chronic obstructive pulmonary disease (COPD). The results for group A were compared with a control group of 32 patients (group B), also with COPD and in whom fibrin glue was not used. All biopsies were conducted under computed tomography (CT) using a coaxial needle system consisting of 19-gauge and 22-gauge needles.

RESULTS

Pneumothorax developed in five patients (19.2%) in group A and in one instance, drainage was required (3.8%). In group B, pneumothorax developed in 13 patients (40.6%) and in six instances (18.8%) drainage was required. Comparing the use of chest-tube drainage in the two groups, a statistical significance was observed, p < 0.0025). No adverse reactions related to the fibrin glue were observed.

CONCLUSION

Our results indicate that fibrin glue is a safe sealing material for lung PLB and serves to decrease the incidence and, in particular, the severity of pneumothorax, especially in high-risk patients.

Orthotopic liver transplantation for benign hepatic neoplasms

OBJECTIVE

To evaluate the frequency and outcome of liver transplantation for symptomatic, unresectable, benign hepatic neoplasms.

DESIGN

Retrospective study.

SETTING

Presbyterian University Hospital, a tertiary care referral center for liver transplantation affiliated with the University of Pittsburgh (Pa).

PATIENTS

All 3239 liver transplant recipients at the University of Pittsburgh from January 1981 until January 1993.

RESULTS

Twelve (0.37%) of 3239 patients required liver transplantation for benign, highly symptomatic hepatic neoplasms that were unresectable. Origins included adenoma (n = 6), mesenchymal hamartoma (n = 2), massive hepatic lymphangiomatosis (n = 1), hilar fibrous angiodysplasia (n = 1), focal nodular hyperplasia (n = 1), and hemangioma (n = 1). There were three perioperative deaths and two late deaths at 56 and 84 months. The remaining patients are alive, with follow-up ranging from 36 to 145 months. Median survival for the nine patients who survived the perioperative period is 88 months. The early deaths were attributable to hemorrhagic complications (n = 2) and necrotizing pancreatitis (n = 1). The two late deaths were due to disseminated aspergillosis and hepatitis-associated cirrhosis.

CONCLUSION

Patients with severe symptoms from benign hepatic neoplasms that are not resectable can be treated by total hepatectomy and orthotopic liver transplantation, with the expectation of good long-term results.

Acute pancreatitis after liver transplantation: incidence and contributing factors

In order to assess the incidence and possible predisposing and contributing factors in the development of acute pancreatitis after liver transplantation, we reviewed the medical records of all 1832 adult patients who underwent 2161 orthotopic liver transplantation (OLTx) procedures in our center between January 1987 and September 1992. Of these patients, 55 (3% incidence) developed clinical pancreatitis and 247 (13.4% incidence) developed hyperamylasemia (biochemical pancratitis). Overall mortality in cases of clinical pancreatitis was 63.6%. The mortality in cases of hyperamylasemia was similar to that found in the general liver transplant population (i.e., 23%). A strong correlation was found between pancreatitis after liver transplantation and end-stage liver disease due to hepatitis B (30% of the cases, P = 0.00001). Extensive surgical dissection around the pancreas (P < 0.05), the type of biliary reconstruction following liver transplantation (P < 0.05), and the number of liver grafts received by the same patient (P = 0.00001) appeared to be possible contributing factors as did the duration of venovenous bypass and the quantity of IV calcium chloride administered intraoperatively.

Liver transplantation for Alagille's syndrome

Twenty-three children with Alagille's syndrome and end-stage liver disease underwent liver transplantation with cyclosporine and low-dose steroid immunosuppression. Two to 9 years (mean, 4.4 years) after surgery, 13 (57%) of the children were still alive, with normal liver function. Three of the fatalities were due to cardiovascular failure secondary to associated cardiopulmonary disease. Mortality was higher among patients who had more severe cardiac disease and patients who had previously undergone a Kasai procedure. Although it has a higher than average risk, liver transplantation can be efficacious in patients with Alagille's syndrome and end-stage liver disease.

Hepatic artery pseudoaneurysm ligation after orthotopic liver transplantation--a report of 7 cases

Pseudoaneurysm (PA) is a rare but life-threatening complication of liver transplantation. The authors present their experience on 7 patients treated by ligation of a post-OLT PA. Hepatic artery ligation or embolization was performed from 10 to 70 days after liver transplantation. Of the seven patients, four survived, one developed a biliary stricture, treated by percutaneous balloon dilatation, two died of a complication not related to treatment, and one died of multiple organ failure.