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.

Laparoscopic bile duct exploration during pregnancy: a multi-center case series and literature review.

BACKGROUND: The physiological changes of pregnancy increase the risk of gallstone formation and choledocholithiasis. Traditionally, endoscopic retrograde cholangiopancreatography (ERCP) has been the main approach for managing choledocholithiasis during pregnancy, but recent progress in laparoscopic bile duct exploration (LBDE) has demonstrated this technique as a safe and effective alternative option. METHODS: A retrospective multicenter study of all patients who underwent LBDE during pregnancy from five centers with proven experience in LBDE between January 2010 and June 2020 was performed. The primary endpoint was to analyze the role of LBDE during pregnancy and to further characterize its position as a safe and effective alternative for the management of choledocholithiasis. A systematic review of the published literature relating to LBDE during pregnancy until February 2022 was also performed. RESULTS: Five institutions reported performing LBDE during pregnancy in 8 patients. Median surgical time was 75 min (range: 60-140 min). The bile duct was cleared successfully in all patients, and the median hospital stay was 2 days (range: 1-3 days). The literature review identified a total of 7 patients with a successful CBD clearance rate of 86%. There were no major maternal, fetal, or pregnancy-related complications in any of the total 15 patients included. The symptomatic common bile duct lithiasis with deranged liver function tests was the most frequent indication (n=7). CONCLUSION: LBDE during pregnancy appears to be safe and effective. More evidence reporting outcomes of LBDE during pregnancy is needed before any strong recommendations can be made.

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.

EAES rapid guideline: updated systematic review, network meta-analysis, CINeMA and GRADE assessment, and evidence-informed European recommendations on the management of common bile duct stones.

BACKGROUND: Choledocholithiasis presents in a considerable proportion of patients with gallbladder disease. There are several management options, including preoperative or intraoperative endoscopic cholangiopancreatography (ERCP), and laparoscopic common bile duct exploration (LCBDE). OBJECTIVE: To develop evidence-informed, interdisciplinary, European recommendations on the management of common bile duct stones in the context of intact gallbladder with a clinical decision to intervene to both the gallbladder and the common bile duct stones. METHODS: We updated a systematic review and network meta-analysis of LCBDE, preoperative, intraoperative, and postoperative ERCP. We formed evidence summaries using the GRADE and the CINeMA methodology, and a panel of general surgeons, gastroenterologists, and a patient representative contributed to the development of a GRADE evidence-to-decision framework to select among multiple interventions. RESULTS: The panel reached unanimous consensus on the first Delphi round. We suggest LCBDE over preoperative, intraoperative, or postoperative ERCP, when surgical experience and expertise are available; intraoperative ERCP over LCBDE, preoperative or postoperative ERCP, when this is logistically feasible in a given healthcare setting; and preoperative ERCP over LCBDE or postoperative ERCP, when intraoperative ERCP is not feasible and there is insufficient experience or expertise with LCBDE (weak recommendation). The evidence summaries and decision aids are available on the platform MAGICapp ( https://app.magicapp.org/#/guideline/nJ5zyL ). CONCLUSION: We developed a rapid guideline on the management of common bile duct stones in line with latest methodological standards. It can be used by healthcare professionals and other stakeholders to inform clinical and policy decisions. GUIDELINE REGISTRATION NUMBER: IPGRP-2022CN170.

Multi-institutional expert update on the use of laparoscopic bile duct exploration in the management of choledocholithiasis: Lesson learned from 3950 procedures.

BACKGROUND: Recently there has been a growing interest in the laparoscopic management of common bile duct stones with gallbladder in situ (LBDE), which is favoring the expansion of this technique. Our study identified the standardization factors of LBDE and its implementation in the single-stage management of choledocholithiasis. METHODS: A retrospective multi-institutional study among 17 centers with proven experience in LBDE was performed. A cross-sectional survey consisting of a semi-structured pretested questionnaire was distributed covering the main aspects on the use of LBDE in the management of choledocholithiasis. RESULTS: A total of 3950 LBDEs were analyzed. The most frequent indication was jaundice (58.8%). LBDEs were performed after failed ERCP in 15.2%. The most common approach used was the transcystic (63.11%). The overall series failure rate of LBDE was 4% and the median rate for each center was 6% (IQR, 4.5-12.5). Median operative time ranged between 60-120 min (70.6%). Overall morbidity rate was 14.6%, with a postoperative bile leak and complications ≥3a rate of 4.5% and 2.5%, respectively. The operative time decreased with experience (P = .03) and length of hospital stay was longer in the presence of a biliary leak (P = .04). Current training of LBDE was defined as poor or very poor by 82.4%. CONCLUSION: Based on this multicenter survey, LBDE is a safe and effective approach when performed by experienced teams. The generalization of LBDE will be based on developing training programs.

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.

Influence of surgical site infection on oncological prognosis after curative resection for colorectal cancer: An observational single-institution study.

BACKGROUND: An exacerbated inflammatory response to post-operative infection could favor an environment in which residual viable tumor cells present in the surgical bed, bloodstream, or occult micrometastases can survive and progress to produce local or distant recurrence. In this regard, a surgical site infection (SSI) could be an important risk factor for disease progression. This study aimed to investigate the impact of SSI on long-term survival and recurrence of colorectal cancer. METHODS: Patients who underwent curative-intent resection for colorectal carcinoma between 2011 and 2013 were retrospectively analyzed. Overall and disease-free survival (DFS) and local recurrence rate for patients with and without SSI were analyzed. RESULTS: One hundred and thirty-eight patients were included in the study. Fifty-one (37%) patients showed SSI but revealed no differences in recurrence rate and overall survival compared with non-infected patients. However, the stratified analysis revealed that patients with an intra-abdominal abscess or an organ-space-infection showed a higher recurrence rate and a decreased 5-year overall and DFS. CONCLUSIONS: SSI may have an influence on the oncological prognosis and, therefore, could be considered a recurrence factor. Further multi-institutional studies are necessary to conclude a causal association.

ANTECEDENTES: Una respuesta inflamatoria exacerbada por una infección postoperatoria podría favorecer un entorno en el que células tumorales residuales viables presentes en el lecho quirúrgico, torrente sanguíneo o micrometástasis ocultas puedan sobrevivir y progresar para producir una recurrencia local o a distancia. En este sentido, una infección del sitio quirúrgico (ISQ) podría ser un factor de riesgo de progresión de la enfermedad. Este estudio tuvo como objetivo investigar el impacto de la ISQ en la supervivencia y recurrencia del cáncer colorrectal. MÉTODO: Todos los pacientes con carcinoma colorrectal sometidos a resección con intención curativa entre 2011 y 2013 fueron analizados retrospectivamente. Se analizó supervivencia global y libre de enfermedad y la tasa de recurrencia local en pacientes con cáncer colorrectal con y sin ISQ. RESULTADOS: Se incluyeron 138 pacientes. 51 (37%) sufrieron ISQ pero no mostraron diferencias en la tasa de recurrencia y supervivencia global respecto a los pacientes no infectados. Sin embargo, el análisis estratificado reveló que los pacientes con un absceso intraabdominal o una infección órgano-espacio mostraron una tasa de recurrencia más alta y una disminución en la supervivencia global y libre de enfermedad. CONCLUSIONES: La ISQ, en función de la gravedad y la respuesta inflamatoria que genera, puede influir en el pronóstico oncológico y, por lo tanto, podría considerarse un factor de recurrencia. Futuros estudios multicéntricos son necesarios para demostrar una posible asociación.

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.

Effect of Alprostadil on Colorectal Anastomoses Under Relative Ischemia.

BACKGROUND: Anastomotic leak after colorectal surgery, which remains a serious clinical problem that causes augmented morbidity and mortality, is usually favored by ischemia. The aim of this study was to determine whether alprostadil may improve anastomotic wound healing under ischemic condition. METHODS: Ninety-three adult Wistar rats were randomized into three groups: control, ischemia (by devascularization along the first 2 cm at each anastomotic end), and ischemia plus alprostadil. Resection of a colonic segment at the colorectal junction and an anastomosis was performed. Animals were euthanized at 8 d. Surgical site infection, anastomotic leak, and grade of intra-abdominal adhesions using a validated scale were determined. Bursting pressure and tension were calculated and histologic examination of the anastomosis was performed. RESULTS: The ischemic group revealed an increased anastomotic leak rate (14/31 versus 3/31) and a lower bursting pressure and tension when compared to control group, validating therefore the experimental model. After intraperitoneal injection of alprostadil, anastomotic leak rate was significantly lower (5/31) and the bursting pressure and tension were significantly increased. Histologic examination revealed a lower presence of inflammatory cells, and a significantly higher neovascularization and a higher presence of fibroblasts in treated animals when compared with the ischemic group. CONCLUSIONS: Alprostadil may have a positive effect on colonic anastomotic wound healing under relative ischemic condition. Alprostadil administration increases anastomotic bursting pressure, decreases leak rate, and reverses most of the histological changes caused by blood flow decrease. These protective effects could be caused by vasodilation, stimulation of neovascularization, and immunomodulatory properties.

Efficacy of fibrin-sealants in reducing biliary leakage following laparoscopic common bile duct exploration. / Eficacia del sellante de fibrina-colágeno para reducir la incidencia de fístulas biliares tras la exploración laparoscópica de la vía biliar.

INTRODUCTION: In spite of the acquired experience with laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis management, there is still a risk of biliary leakage of 5% to 15% following choledochotomy closure. We evaluate the usefulness of fibrin-collagen sealants to reduce the incidence of biliary fistula after laparoscopic choledochorrhaphy. METHODS: We report a retrospective analysis of 96 patients undergoing LCBDE from March 2009 to March 2017, whose closure of the bile duct was completed by antegrade stenting and choledochorraphy or by performing a primary suture. The study population was divided into two groups according to whether they received a collagen-fibrin sealant covering the choledochorrhaphy or not, analyzing the incidence of postoperative biliary fistula in each group. RESULTS: Thirty-nine patients (41%) received a fibrin-collagen sponge while the bile duct closure was not covered in the remaining 57 patients (59%). The incidence of biliary fistula was 7.7% (3 patients) in the first group and 14% (8 patients) in the second group (P=.338). In patients who underwent primary choledochorraphy, the fibrin-collagen sealant reduced the incidence of biliary leakage significantly (4.5% vs. 33%, P=.020), which was a protective factor with an odds ratio of 10.5. CONCLUSION: Fibrin-collagen sealants may decrease the incidence of biliary fistula in patients who have undergone primary bile duct closure following LCBDE.

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.

Late Biliary Complications after Pancreaticoduodenectomy.

Since morbidity of pancreaticoduodenectomy (PD) has been improved, concerns about late complications have raised. We present a review of long-term biliary complications after PD attended at our institution. The data of 86 patients operated on from January 2001 to May 2014 were examined and incidence of late biliary complications was recorded. The preoperative features of the patients, timing of symptoms appearance, results of diagnostic imaging test, and the management strategies were analyzed. Late biliary complications occurred in 14 patients (16.3%). The median time to diagnosis was 9.50 months. The preoperative peak bilirubin level, need for preoperative drainage and intraoperative blood loss were not significantly different for patients with long-term biliary events. Eight patients (57.14%) developed true biliary strictures. Three of them (37.5%) had experienced a postoperative biliary leak (P < 0.0005) and resulted in benign strictures. The remaining five patients revealed tumor recurrence. Six patients had no biliary obstruction and cholangitis could only be explained through afferent-limb stasis. Late biliary strictures appear predominantly in the first postoperative year and develop more likely if a bile leak occurred in the postoperative period. However, biliary strictures are not always responsible for late biliary symptoms and afferent limb stasis may also be included in the differential diagnosis.

Laparoscopic common bile duct exploration in elderly patients: is there still a difference?

PURPOSE: Although surgery is frequently not the first treatment option in elderly patients diagnosed with common bile duct stones (CBDS) because of the fear of high morbidity and mortality rates, there are few data about the safety and efficacy of laparoscopic common bile duct exploration (LCBDE) in the elderly. METHODS: From February 2004 to January 2012, 94 patients underwent LCBDE at our center. Data about sex, age, comorbidity, American Society of Anesthesiologists (ASA) score, conversion to open surgery and bile duct clearance rate, postoperative complications, need for reoperation, and mortality were analyzed comparing patients of age 70 or older (group A, n=38) with patients aged under 70 (group B, n=56). RESULTS: Elderly patients had significantly more preoperative risk factors. Stone extraction was equally successful in both groups (89.5% in group A vs. 96.4% in group B, P=0.176). Six patients developed medical complications (7.9% in group A vs. 5.4% in group B, P=0.621). Surgical morbidity was equivalent for both groups (13.2% in group A vs. 10.7% in group B, P=0.718). Four patients in each group experienced some grade of bile leakage. Three patients were reoperated (1 patient in group A because of a biliary peritonitis and 2 in group B after an intra-abdominal hemorrhage). There were no mortality cases directly related to surgery. CONCLUSIONS: This study reveals that LCBDE is safe in the elderly patients and results are not different from those described in the general population. Patients with choledocholithiasis should be offered to undergo an LCBDE irrespective of their age at diagnosis.

Flu-like symptoms following radiofrequency liver transection: a new variety of the post-radiofrequency syndrome.

BACKGROUND/AIMS: The aim of our study was to determine whether post-radiofrequency syndrome may also develop following hepatectomy using saline-cooled radiofrequency coagulation. METHODS: We retrospectively reviewed 95 consecutive patients who underwent 110 liver resections between May 2000 and September 2012. We stated that 80.9% of the resections were carried out employing the saline-cooled radiofrequency device. All medical records were searched for the occurrence of flu-like symptoms, without evidence of sepsis or infection, in the first two postoperative weeks. RESULTS: Eleven patients (11.5%) developed flu-like symptoms after hepatectomy without evidence of sepsis or infection. All their hepatectomies were performed employing the saline-cooled radiofrequency probe (p = .089), and all cases but one appeared following colorectal liver metastases surgery (p = .042). Eight of them were readmitted to the hospital because of their symptoms. In all 11 cases, a fluid collection was present, 8 of them with gas presence. Nine patients underwent a percutaneous drainage whose cultures were negative. Ten patients recovered without treatment or with the intake of nonsteroidal anti-inflammatory drugs within 1 week, but one patient developed a secondary infection with gram-positive bacteria after percutaneous drainages that prolonged his hospital stay. CONCLUSION: Liver splitting using saline-cooled radiofrequency coagulation may cause postoperative symptoms that may mimic surgical site infection. Surgeons employing this device should keep this in mind to avoid potentially unwarranted treatments that may be unnecessary, expensive, and even harmful.