Stroke volume variation does not correlate with central venous pressure during hepatectomy.

BACKGROUND: Central venous pressure measurement has been the standard for patient monitoring during hepatectomy to assure low pressure and reduce blood loss. Recently SVV has been employed to monitor preload and guide fluid replacement during liver surgery. The aim of the study is to determine if SVV correlates with CVP values and may replace CVP measurement. METHODS: From January 2021 to February 2022 thirty patients undergoing 32 liver resections were included in the study. Repeated paired data of CVP and SVV were determined every 10 minutes throughout liver resection. The Correlation between CVP and SVV values was calculated. Analysis was then stratified by surgical approach, hilar clamping tempus, operative timing and PEEP values. RESULTS: A total number of 519 paired SSV/CVP values were recorded. Only a very weak correlation between SSV and CVP was detected (Pearson coefficient -0.122/ p=0.005). The results were unaltered after the stratified analysis by surgical approach, presence of hilar clamping, operative timing and PEEP use, revealing no correlation between SSV and CVP values. CONCLUSION: The CVP /SVV values do not show a relevant correlation during liver surgery. CVP measurement is still of value and should not be replaced by SVV monitoring to conduct a safe hepatectomy.

Controlled attenuation parameter-insulin resistance (CIR) score to predict non-alcoholic steatohepatitis.

The diagnosis of non-alcoholic steatohepatitis (NASH) requires liver biopsy. Patients with NASH are at risk of progression to advanced fibrosis and hepatocellular carcinoma. A reliable non-invasive tool for the detection of NASH is needed. We aimed at developing a tool to diagnose NASH based on a predictive model including routine clinical and transient hepatic elastography (TE) data. All subjects undergoing elective cholecystectomy in our center were invited to participate, if alcohol intake was < 30 g/d for men and < 15 g/d for women. TE with controlled attenuation parameter (CAP) was obtained before surgery. A liver biopsy was taken during surgery. Multivariate logistic regression models to predict NASH were constructed with the first 100 patients, the elaboration group, and the results were validated in the next pre-planned 50 patients. Overall, 155 patients underwent liver biopsy. In the elaboration group, independent predictors of NASH were CAP value [adjusted OR (AOR) 1.024, 95% confidence interval (95% CI) 1.002-1.046, p = 0.030] and HOMA value (AOR 1.847, 95% CI 1.203-2.835, p < 0.001). An index derived from the logistic regression equation to identify NASH was designated as the CAP-insulin resistance (CIR) score. The area under the receiver operating characteristic curve (95%CI) of the CIR score was 0.93 (0.87-0.99). Positive (PPV) and negative predictive values (NPV) of the CIR score were 82% and 91%, respectively. In the validation set, PPV was 83% and NPV was 88%. In conclusion, the CIR score, a simple index based on CAP and HOMA, can reliably identify patients with and without NASH.

Long-term outcome of patients with biliary pancreatitis not undergoing cholecystectomy. A retrospective study.

BACKGROUND AND OBJECTIVE: most acute pancreatitis cases are of biliary origin and cholecystectomy is recommended to prevent recurrence. However, some patients will never be referred for surgery. In this study, the long-term follow-up of this group of patients was reviewed. METHODS: all new cases of biliary pancreatitis from January 2015 to December 2017 that did not undergo cholecystectomy were analyzed. Epidemiologic data and Charlson's comorbidity index (CCI) were recorded. Recurrent episodes of pancreatitis or biliary events and mortality during the follow-up period were recorded. RESULTS: a total of 104 patients were included in the study (30.4 % of all biliary pancreatitis cases) and the median age was 82 years (range, 27-96). Average CCI was 5 (range, 0-18) and the median follow-up period was 37 months (range, 1-70). A total of 41 patients (39.4 %) had gallstone-related complications. Twenty-three patients (22,1 %) had recurrent pancreatitis and 34 (32,7 %) developed biliary events. Twenty-five patients died during follow-up (24 %) but only in 6 (5,8 %) was death due to gallstone-related complications. Non-related mortality was 15.5 % in patients who refused surgery and 25 % in multiple-comorbidity patients. CONCLUSION: patients who did not undergo cholecystectomy were at high risk for biliary events and pancreatitis recurrence. Conservative treatment and surgical abstention should be individualized and reserved for patients with multiple comorbidities with a short life expectancy.

Hepatic PEcoma: an unusual tumor in an infrequent location.

Perivascular epithelioid cell neoplasms (PEComas) are a tumor family defined as such just a couple of decades ago. They make an unusual group of neoplasms, which can appear in different locations of the organism. PEComas are usually considered to be benign tumors, but there are some histological features that make some subgroups suspicious of malignancy. The treatment of these tumors consist in their surgical resection, with no current effective complementary oncological treatment known. We present the clinical case of a woman that underwent surgery for a resection of a hepatic lesion labeled afterwards as a PEComa with malignant features.

Los tumores de células neoplásicas perivasculares epitelioides (PEComas) son una familia de tumoraciones caracterizada apenas un par de décadas antes. Componen un grupo inusual de neoplasias, que puede aparecer en distintas localizaciones del organismo. Por lo general, los PEComas se consideran tumores benignos, pero hay ciertas características histológicas que hacen de algunos subgrupos lesiones sospechosas de una malformación maligna. El tratamiento de estos tumores consiste en la resección quirúrgica, pero no existe tratamiento oncológico por completo eficaz. Se presenta el caso clínico de una mujer sometida a la resección de una lesión hepática con diagnóstico posterior de PEComa con rasgos de proceso maligno.

Choledocholithiasis recurrence following laparoscopic common bile duct exploration. / Recurrencia de coledocolitiasis tras exploración laparoscópica de la vía biliar principal.

INTRODUCTION: Choledocholithiasis may be treated following an endoscopic approach or by laparoscopic common bile duct exploration (LCBDE). Stone recurrence following endoscopic management has been extensively investigated. We analyze the risk factors associated with stone recurrence following LCBDE. METHODS: Patients who underwent LCBDE from February 2004 to July 2016 were examined in an univariate and multivariate analysis to assess the association of stone recurrence with the following variables: gender; age; hepatopathy; dyslipidemia, obesity or diabetes mellitus; previous abdominal surgery; presence of cholecystitis, cholangitis or pancreatitis; preoperative liver function tests, number of retrieved stones; method of common bile duct clearance and closure; presence of impacted or intrahepatic stones; conversion to open surgery and postoperative morbidity. RESULTS: A total of 156 patients were included. Recurrence rate for choledocholithiasis was 14.1% with a mean time to recurrence of 38.18 month. Age was the only independent risk factor for stone recurrence at univariate and multivariate analysis. No patient aged under 55 years developed new common bile duct stones, and 86.4% of the recurrences occurred in patients aged above 65. CONCLUSIONS: Age is the only independent risk factor associated to choledocholithiasis recurrence following LCBDE. Different mechanism in common bile duct stone development may be present for younger and older patients.

Comparative Study of Three Bile Duct Closure Methods Following Laparoscopic Common Bile Duct Exploration for Choledocholithiasis.

BACKGROUND: There are three choledochotomy closure methods available following laparoscopic common bile duct exploration: T-tube insertion, antegrade stenting, and primary choledochorrhaphy. We reviewed the experience of 12 years at our center searching for the optimal closure technique. METHODS: We analyzed retrospectively 146 patients that underwent one of the three closure methods from February 2004 to March 2016. Hospital stay, need for readmission, incidence of early and long-term complications, and biliary leakage development and their clinical impact were determined for each technique. RESULTS: Hospital stay was more prolonged, and need for readmission was higher in the T-tube group. Nine patients of the T-tube group (17.3%), 5 patients (8.6%) of the antegrade stenting group, and 1 patient of the primary suture group (2.8%) developed Dindo-Clavien ≥3 complications (P = .076). The incidence of biliary leakage was 3.8%, 8.6%, and 16.7% for the T-tube group, antegrade stenting group, and primary suture group, respectively. There was no grade C biliary fistula in the primary suture group, and all grade B leaks in these patients were only due to prolonged duration. The T-tube removal caused adverse events in 21.1% of the patients, and complications directly related with stents occurred in 9.6%. CONCLUSION: Antegrade stents or T-tube insertion do not provide any added value for choledochotomy closure but are charged with specific morbidity. On the contrary, despite biliary leaks being more frequent after primary suture, they are of little clinical consequence and may be managed on an outpatient basis.