Endoscopic Ultrasound in the Diagnosis of Pancreatoduodenal Groove Pathology: Report of Three Cases and Brief Review of the Literature.

The pancreatoduodenal groove is a small area where pathologic processes involving the distal bile duct, duodenum, pancreatic head, ampulla of Vater, and retroperitoneum converge. Despite great advances in imaging techniques, a definitive preoperative diagnosis is challenging because of the complex anatomy of this area. Therefore, surgical intervention is frequently required because of the inability to completely exclude malignancy.
We report 3 cases of patients with different groove pathologies but similar clinical and imaging presentation, and show the essential role of endoscopic ultrasound (EUS) in making a specific preoperative diagnosis, excluding malignancy in the first case, changing diagnosis in the second case, and confirming malignancy in the third case. EUS was a fundamental tool in this cohort of patients, not only because of its ability to provide superior visualization of a difficult anatomical region, but because of the ability to guide precise, realtime procedures, such as fine-needle aspiration.

Surgical strategies for restoring liver arterial perfusion in pancreatic resections.

BACKGROUND: Hepatic perfusion failure represents an important risk factor for severe complications and death after pancreatic resections. Arterial reconstruction could be required during pancreatic surgery because of tumor infiltration, benign strictures, or as a consequence of accidental arterial injury during dissection. All these situations can be faced with a certain frequency in high-volume pancreatic centers, where surgeons must be aware of the different alternatives to deal with these intricate scenarios. PURPOSE: We herein describe the preoperative surgical planning as well as different surgical strategies for the restoration of arterial perfusion of the liver in pancreatic resections. CONCLUSION: A thorough preoperative evaluation is essential for planning pancreatic surgery and preparing the surgeon and patient for potentially high complex procedures. The various therapeutic alternatives presented in this technical report might represent a good solution for selected patients with no other potentially curative option than surgery.

[Prognostic factors after resection of hepatocellular carcinoma in the non-cirrhotic liver: presentation of 51 cases]. / Factores pronósticos del hepatocarcinoma en el hígado no cirrótico tras su resección: presentación de 51 casos.

BACKGROUND: Clinical presentation, treatment and prognosis of hepatocellular carcinoma depend on presence or absence of cirrhosis. In the literature there are few reports of hepatocellular carcinoma in non-cirrhotic patients. OBJECTIVE: To describe a consecutive series of resected patients with hepatocellular carcinoma in non-cirrhotic liver and to identify prognostic factors of recurrence and survival. MATERIAL AND METHODS: Between 1990 and 2006, 51 patients were operated on. Data were retrospectively analysed from a prospectively collected database. Single and multivariate analyses were performed to identify factors associated with survival and disease-free survival. RESULTS: Thirty-three patients were male, median age 49.8 years. A major hepatectomy was performed in 72%. Morbidity was 43% and mortality was 0%. One-, two- and three-year survival rates were 90%, 75% and 67%, respectively. One-, two- and three-year disease-free survival rates were 65%, 41% and 37%, respectively. Presence of vascular invasion and of positive nodes was statistically significant for survival in univariate analysis but had no statistical significance in multivariate analysis. CONCLUSIONS: Major hepatic resection is a safe treatment for hepatocellular carcinoma in non-cirrhotic patients. Both vascular invasion and presence of positive nodes were associated with poor survival. However, neither of them represented an independent variable.

Management of nonparasitic hepatic cysts.

BACKGROUND: The optimal management of nonparasitic hepatic cysts (NPHC) is a topic of debate. The purpose of this study was to evaluate our 17-year experience with NPHC. STUDY DESIGN: From January 1990 to August 2007, 131 consecutive patients with NPHC were evaluated and treated at our institution. Seventy-eight patients (60%) had simple hepatic cysts (SHC). The remaining 53 (40%) had polycystic liver disease (PLD). Morbidity, mortality, and recurrence rates for each of the two groups were evaluated. RESULTS: Thirty-seven patients underwent open deroofing (SHC, 24; PLD,13), 66 had laparoscopic deroofing (SHC, 46; PLD, 20), 19 had percutaneous drainage (SHC, 4; PLD, 15), 3 had major hepatic resections (PLD, 3), 4 had cystojejunostomy (SHC, 4), and 2 had combined hepatorenal transplantation (PLD, 2). Corresponding morbidity, mortality, and recurrence rates were, respectively: conventional deroofing: SHC, 29%, 0%, 8%; PLD, 8%, 0%, 0%; laparoscopic deroofing: SHC, 2%, 0%, 2%; PLD, 25%, 0%, 5%; percutaneous drainage: SHC, 0%, 0%, 75%; PLD, 0%, 0%, 20%; cystojejunostomy: SHC, 75%, 0%, 25%; major hepatic resections: PLD, 66%, 0%, 0%; and hepatorenal transplantation: PLD, 50%, 50%, 0%. CONCLUSIONS: Laparoscopic deroofing provided complete relief of symptoms for both SHC and PLD. Percutaneous drainage was our procedure of choice for infected liver cysts and potentially for patients who cannot tolerate general anesthesia. Liver and liver-kidney transplantations were reserved for patients with end-stage PLD alone and in association with end-stage renal disease, respectively.

Laparoscopic resection for liver tumors: initial experience in a single center.

BACKGROUND: Laparoscopic liver resections are 1 of the most complex procedures in hepatobiliary surgery. During the last 20 years, laparoscopic liver surgery has had an important development in specialized centers. OBJECTIVE: To describe the initial experience in laparoscopic liver resection for benign and malignant tumors, to assess its indications and outcomes, and to describe technical aspects of these resections. METHODS: Review of the records of 28 patients who underwent laparoscopic liver resection between November 2000 and November 2007. Analysis of the data regarding preoperative management and postoperative outcomes. RESULTS: Twenty-six liver resections were performed laparoscopically (20 purely laparoscopic, 3 hand assisted, and 3 hybrid technique) and 2 were converted to open surgery. The laparoscopic approach was attempted in 6% (28 out of 459) of the liver resections carried out in the analyzed period. Indications for resection were: benign tumors in 22 patients (78%) and malignant tumors in 6 patients (22%). Resections were minor in 27 patients (96%) and major in 1 patient (4%). Pringle maneuver was performed in 14 patients (50%). Margins were negative in all the cases. Mean operative time was 170 minutes (range 70 to 350), and the mean length of stay was 3 days (range 1 to 6). Mortality rate was 0%. Only 2 patients (7%) had postoperative minor complications (self-limited bile leaks). CONCLUSIONS: In selected patients with benign and malignant liver tumors, laparoscopic liver resections can be safely performed. This procedure must be carried out by the surgeons trained in both the hepatobiliary and laparoscopic surgery.

Diagnóstico y tratamiento de los quistes hepáticos no parasitarios: nueve años de experiencia / Diagnosis and treatment of nonparasitic liver cysts: our experience in 9 years

Antecedentes: El desarrollo de los procedimientos miniinvasivos ha renovado el interés de los cirujanos en el tratamiento de los quistes hepáticos no parasitarios. Objetivos: Evaluar las indicaciones y resultados de los procedimientos invasivos para el tratamiento de quistes hépaticos sintomáticos o complicados en un periodo de nueve años. Lugar de Aplicación: Sector especializado de Cirugía Hépato Bilio Pancreática Servicio de Cirugía General. Hospital Privado. Diseño: Observacional retrospectivo. Población y Métodos: En el período comprendido entre enero de 1990 y mayo de 1999 fueron tratados 54 pacientes con quistes hépaticos no parasitarios. Las indicaciones de tratamiento fueron: el desarrollo de síntomas relacionados a los quistes (dolor, saciedad y disnea) o complicaciones (sangrado e infección). En 33 pacientes con quistes hépaticos simples se realizaron 32 destechamientos, 17 laparoscópicos y 15 laparotómicos, 1 paciente con quiste complicado fue tratado mediante drenaje percutáneo. Diez pacientes con enfermedad poliquística del adulto (EPA) fueron sometidos a destechamiento quirúrgicos. Seis pacientes con EPA fueron sometidos a drenaje percútaneo de quistes infectados. Cinco pacientes con lesiones quísticas fueron sometidos a resecciones hepáticas por presentar lesiones neoplásicas: 2 cistoadenocarcinoma, 1 sarcoma quístico, 1 hepatocarcinoma y 1 adenoma sobre la enfermedad de Caroli. Resultados: Dos pacientes con quístes simples tratados por destechamiento presentaron recurrencia de su enfermedad. Un paciente desarrolló una bilirragia transitoria en el postoperatorio y posteriormente una eventración en la herida quirúrgica. Un paciente con enfermedad poliquística debió ser transplantado luego del destechamiento por insuficiencia renal y respiratoria falleciendo en el postoperatorio por TEP. Un enfermo presentó una bacteremia posterior a un drenaje percutáneo de quíste infectado. Conclusiones: Proponemos el destechamiento quirúrgico para tratamiento de los quístes sintomáticos de pacientes con quistes simple y enfermedad poliquística tipo I. El abordaje laparoscópico ha demostrado ser efectivo. El drenaje percutáneo es nuestra primera opción en el tratamiento de quistes infectados en EPA. Las neoplasias hépaticas pueden tener presentación quística, diagnóstico que al ser confirmado obliga a resecciones hepáticas oncológicas

Cierre primario del colédoco: una técnica vieja a utilizar en una época nueva? / Primary closure of common bile duct: unfrequently technique to use in a new era?

Antecedentes: El CPC es una técnica poco utilizada, debido a la presentación de complicaciones biliares en oportunidades severas y asociadas a litiasis residual. La evaluación intraoperatoria más precisa y los avances en las técnicas de sutura, estimulan a reevaluar esta técnica. Objetivo: Analizar los resultados, técnicas y criterios de selección utilizados en una población de pacientes con litiasis coledociana a quienes se realizó CPC luego de una coledocotomía. Lugar de aplicación: Sector especializado de Cirugía Hepato Bilio Pancreática. Servicio de Cirugía General. Hospital Privado. Diseño observacional retrospectivo. Población: Entre enero de 1994 y abril de 1997 se realizaron 85 coledocotomías por litiasis coledociana. A 32 pacientes seleccionados se les indicó CPC luego de la misma. representan el 37,2 por ciento de las coledocotomías realizadas en ese período. Trece de ellos fueron practicados por laparotomía, y los restantes 19 por laparoscopía. Se emplearon los siguientes criterios: Ausencia de litiasis residual, papila permeable, páncreas indemne, técnica de sutura satisfactoria. Se utilizó en 31 casos la fibrocoledoscopia intra operatoria. Método: revisión de historias clínicas, base de datos, radiografías y videos de las cirugías laparoscópicas. Se evaluaron las dificultades, morbilidad y mortalidad. Resultados: En 30 pacientes pudo completarse el procedimiento en forma satisfactoria. En dos casos la técnica no fue adecuada (filtración y estenosis) por lo que completó con la colocación de un tubo de Kehr y un catéter transcístico. En el postoperatorio cuatro pacientes presentaron bilirragia por el drenaje abdominal, que se resolvieron espontáneamente. No fue necesario reoperar a ningún paciente. No hubo colecciones biliares o coleperitoneo. No tuvimos mortalidad. Un enfermo tuvo colangitis a los 33 meses de la cirugía por litiasis coledociana que se resolvió con una papilotomía endoscópica. En otra paciente la colangioresonancia mostró litiasis coledociana asintomática. Conclusiones: El CPC puede ser realizado en forma segura en casos seleccionados, donde se cumplan los principios enunciados por Mirizzi. El uso de la fibrocoledocoscopia intraoperatoria, da mayor seguridad a esta evaluación. Las fístulas bibliares en el postoperatorio, son generalmente leves y de breve duración. Si se cuenta con los medios tecnológicos y con el entrenamiento adecuado, el CP puede ser realizado por vía laparotómica o laparoscópica