Risk factors for postoperative ileus following elective laparoscopic right colectomy: a retrospective multicentric study.

PURPOSE: Postoperative ileus (POI) is associated with an elevated risk of other complications and increases the economic impact on healthcare services. The aim of this study was to identify pre-, intra- and postoperative risk factors associated with the development of POI following elective laparoscopic right colectomy. METHODS: Between 2004 and 2016, 637 laparoscopic right colectomies were performed. Data were analysed retrospectively thanks to the CLIHMET database. Potential contributing factors were analysed by logistic regression. RESULTS: Patients with POI (n = 113, 17.7%) were compared to those without postoperative ileus (WPOI) (n = 524, 82.3%). In the POI group, there were more men (62 vs 49%; p = 0.012), more use of epidural anaesthesia (19 vs 9%; p = 0.004), more intraoperative blood transfusion requirements (7 vs 3%; p = 0.018) and greater perioperative intravenous fluid administration (2000 vs 1750 mL; p < 0.001). POIs were more frequent when extracorporeal vascular section (20 vs 12%; p = 0.049) and transversal incision for extraction site (34 vs 23%; p = 0.044) were performed. Overall surgical complications in the POI group were significantly greater than in the control group WPOI (31.9 vs 12.0%; p < 0.0001). Multivariate analysis found the following independent POI risk factors: male gender (HR = 2.316, 1.102-4.866), epidural anaesthesia (HR = 2.958, 1.250-6.988) and postoperative blood transfusion requirement (HR = 6.994, 1.550-31.560). CONCLUSIONS: This study is one of the first to explore the CLIHMET database and the first to use it for investigating risk factors for POI development. Modifiable risk factors such as epidural anaesthesia and intraoperative blood transfusion should be used with caution in order to decrease POI rates.

Comparative Study With Propensity Score Matching Analysis of Two Different Methods of Transection During Hemi-Right Hepatectomy: Ultracision Harmonic Scalpel Versus Cavitron Ultrasonic Surgical Aspirator.

BACKGROUND: Several devices are available for liver parenchyma transection (LPT). The aim of this study was to compare the Ultracision Harmonic scalpel (UHS) with the Cavitron Ultrasonic Surgical Aspirator (CUSA) among patients who underwent hemi-right hepatectomies (RH) to homogenize transection areas. METHODS: From September 2012 to June 2015, 24 patients who underwent the UHS surgery approach were matched with 24 patients who underwent the CUSA transection procedure for RH using propensity score matching. RESULTS: Total operative time (TOT) was shorter in the UHS group, 240 minutes (range 172.5-298.8) versus 330 minutes (range 270-400) in the CUSA group ( P = .0002). The occurrence of hepatopathy (odds ratio = 17; 95% confidence interval = 1.02-230) and the use of the CUSA device (odds ratio = 8; 95% confidence interval = 0.98-77) were associated with a TOT exceeding 300 minutes in multivariate analysis ( P = .05). CONCLUSIONS: The UHS is a safe and effective method of LPT as compared to the use of the CUSA system. TOT is statistically decreased.

Augmented Reality Guidance for the Resection of Missing Colorectal Liver Metastases: An Initial Experience.

BACKGROUND: Modern chemotherapy achieves the shrinking of colorectal cancer liver metastases (CRLM) to such extent that they may disappear from radiological imaging. Disappearing CRLM rarely represents a complete pathological remission and have an important risk of recurrence. Augmented reality (AR) consists in the fusion of real-time patient images with a computer-generated 3D virtual patient model created from pre-operative medical imaging. The aim of this prospective pilot study is to investigate the potential of AR navigation as a tool to help locate and surgically resect missing CRLM. METHODS: A 3D virtual anatomical model was created from thoracoabdominal CT-scans using customary software (VR RENDER(®), IRCAD). The virtual model was superimposed to the operative field using an Exoscope (VITOM(®), Karl Storz, Tüttlingen, Germany). Virtual and real images were manually registered in real-time using a video mixer, based on external anatomical landmarks with an estimated accuracy of 5 mm. This modality was tested in three patients, with four missing CRLM that had sizes from 12 to 24 mm, undergoing laparotomy after receiving pre-operative oxaliplatin-based chemotherapy. RESULTS: AR display and fine registration was performed within 6 min. AR helped detect all four missing CRLM, and guided their resection. In all cases the planned security margin of 1 cm was clear and resections were confirmed to be R0 by pathology. There was no postoperative major morbidity or mortality. No local recurrence occurred in the follow-up period of 6-22 months. CONCLUSIONS: This initial experience suggests that AR may be a helpful navigation tool for the resection of missing CRLM.

Management of large hepatocellular carcinoma by sequential transarterial chemoembolization and portal vein embolization: a systematic review of the literature.

INTRODUCTION: Currently, the treatment of HCC is multidisciplinary. Surgery remains the gold standard although the management of large hepatocellular carcinoma remains challenging. Hepatic resection is increasingly performed with ever-expanding indications. However, postoperative liver failure remains a major cause of death after major hepatic resections. The purpose of this review is to report the results of large hepatocellular carcinoma (>5 cm or more nodules in the same lobe) management using sequential transarterial chemoembolization (TACE) and portal vein embolization (PVE) before major liver resections. EVIDENCE ACQUISITION: A literature search was performed using PubMed, Scopus, and Web of Science (WoS) from cited English publications. The search was last conducted in December 2014. Search phrases included "hepatocellular carcinoma", "liver resection", "transarterial chemoembolization", and "portal vein embolization". Clinical and survival parameters were extracted. When there was more than one publication from the same surgical team and/or authors, only the last publication in chronological order was considered for the study. Case reports, abstracts, letters, editorials, and expert opinions were not considered for the drafting of the study. After application of selective criteria, only 4 original studies were analyzed. EVIDENCE SYNTHESIS: No meta-analyses were found in the search. Among the 4 selected publications, 3 originated from Asia and 1 from Europe. The total number of patients treated with the method considered was 171 (range: 18-71). The mean size of the tumor was >5 cm. The gain of volume of the future remnant liver (FRL) was higher in the group with TACE+PVE as compared to the group with PVE alone (12% vs. 8%). A major hepatectomy was carried out in 166 patients (97%). Mortality rate ranged between 0% and 11%. The 5-year overall survival was between 43% and 72% and the 5-year recurrence-free survival was between 37% and 61%. CONCLUSIONS: Sequential TACE+PVE prior to a major hepatectomy for HCC was feasible, safe, and with excellent 5-year overall survival rates reported to be between 43% and 72%.