Is Systemic Chemotherapy Useful in Patients Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Colorectal Peritoneal Metastases? A Propensity-Score Analysis.

PURPOSE: Multimodal treatment of colorectal (CRC) peritoneal metastases (PM) includes systemic chemotherapy (SC) and surgical cytoreduction (CRS), eventually with hyperthermic intraperitoneal chemotherapy (HIPEC), in select patients. Considering lack of clear guidelines, this study was designed to analyze the role of chemotherapy and its timing in patients treated with CRS-HIPEC. METHODS: Data from 13 Italian centers with PM expertise were collected by a collaborative group of the Italian Society of Surgical Oncology (SICO). Clinicopathological variables, SC use, and timing of administration were correlated with overall survival (OS), disease-free survival (DFS), and local (peritoneal) DFS (LDFS) after propensity-score (PS) weighting to reduce confounding factors. RESULTS: A total of 367 patients treated with CRS-HIPEC were included in the propensity-score weighting. Of the total patients, 19.9% did not receive chemotherapy within 6 months of surgery, 32.4% received chemotherapy before surgery (pregroup), 28.9% after (post), and 18.8% received both pre- and post-CRS-HIPEC treatment (peri). SC was preferentially administered to younger (p = 0.02) and node-positive (p = 0.010) patients. Preoperative SC is associated with increased rate of major complications (26.9 vs. 11.3%, p = 0.0009). After PS weighting, there were no differences in OS, DFS, or LDFS (p = 0.56, 0.50, and 0.17) between chemotherapy-treated and untreated patients. Considering SC timing, the post CRS-HIPEC group had a longer DFS and LDFS than the pre-group (median DFS 15.4 vs. 9.8 m, p = 0.003; median LDFS 26.3 vs. 15.8 m, p = 0.026). CONCLUSIONS: In patients with CRC-PM treated with CRS-HIPEC, systemic chemotherapy was not associated with overall survival benefit. The adjuvant schedule was related to prolonged disease-free intervals. Additional, randomized studies are required to clarify the role and timing of systemic chemotherapy in this patient subset.

Fluorescence Cholangiography Using Indocyanine Green Improves the Identification of Biliary Structures During Laparoscopic Cholecystectomy.

BACKGROUND: This cross-sectional survey aimed to determine whether fluorescence cholangiography using indocyanine green (ICG-FC) can improve the detection of the cystic duct and the main bile duct during laparoscopic cholecystectomy (LC). METHODS: The survey was distributed to 214 surgeons (residents/faculties) in 2021. The confidence in the identification of the cystic duct and of the main bile duct was elicited on a 10-point Likert scale before/after the use of ICG-FC. This was repeated for three LCs ranging from a procedure deemed easy to a LC for acute cholecystitis. RESULTS: There were 149 responses. ICG-FC increased the responders' confidence in identifying the cystic duct, raising the median value from 6 (IQR, 5-8) with white light up to 9 (IQR, 9-10) with ICG-FC (paired p < 0.001). This increase was even more evident when identifying the main bile duct, where the median confidence value increased from 5 (IQR, 4-7) with white light to 9 (IQR, 8-10) with the use of ICG-FC (p < 0.001). ICG-FC significantly increased the detection of residents of the main bile duct in case of intermediate difficulty LCs and in LCs for acute cholecystitis. CONCLUSIONS: The results support that the use of near-infrared imaging can ameliorate detection of biliary structures, especially of the main bile duct and this was particularly true for young surgeons and in more complex situations.

Microsatellite and RAS/RAF Mutational Status as Prognostic Factors in Colorectal Peritoneal Metastases Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC).

BACKGROUND: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) leads to prolonged survival for selected patients with colorectal (CRC) peritoneal metastases (PM). This study aimed to analyze the prognostic role of micro-satellite (MS) status and RAS/RAF mutations for patients treated with CRS. METHODS: Data were collected from 13 Italian centers with PM expertise within a collaborative group of the Italian Society of Surgical Oncology. Clinical and pathologic variables and KRAS/NRAS/BRAF mutational and MS status were correlated with overall survival (OS) and disease-free survival (DFS). RESULTS: The study enrolled 437 patients treated with CRS-HIPEC. The median OS was 42.3 months [95% confidence interval (CI), 33.4-51.2 months], and the median DFS was 13.6 months (95% CI, 12.3-14.9 months). The local (peritoneal) DFS was 20.5 months (95% CI, 16.4-24.6 months). In addition to the known clinical factors, KRAS mutations (p = 0.005), BRAF mutations (p = 0.01), and MS status (p = 0.04) were related to survival. The KRAS- and BRAF-mutated patients had a shorter survival than the wild-type (WT) patients (5-year OS, 29.4% and 26.8% vs 51.5%, respectively). The patients with micro-satellite instability (MSI) had a longer survival than the patients with micro-satellite stability (MSS) (5-year OS, 58.3% vs 36.7%). The MSI/WT patients had the best prognosis. The MSS/WT and MSI/mutated patients had similar survivals, whereas the MSS/mutated patients showed the worst prognosis (5-year OS, 70.6%, 48.1%, 23.4%; p = 0.0001). In the multivariable analysis, OS was related to the Peritoneal Cancer Index [hazard ratio (HR), 1.05 per point], completeness of cytoreduction (CC) score (HR, 2.8), N status (HR, 1.6), signet-ring (HR, 2.4), MSI/WT (HR, 0.5), and MSS/WT-MSI/mutation (HR, 0.4). Similar results were obtained for DFS. CONCLUSION: For patients affected by CRC-PM who are eligible for CRS, clinical and pathologic criteria need to be integrated with molecular features (KRAS/BRAF mutation). Micro-satellite status should be strongly considered because MSI confers a survival advantage over MSS, even for mutated patients.

Forecasting outcomes after cholecystectomy in octogenarian patients.

BACKGROUND: Although gallstone disease increases with aging, elderly patients are less likely to undergo cholecystectomy. This is because age itself is a negative predictor after cholecystectomy. The ACS-NSQIP risk calculator can therefore help surgeons decide whether to operate or not. However, little is known about the accuracy of this model outside the ACS National Surgical Quality Improvement Program. The aim of the present study is to evaluate the ability of the ACS-NSQIP model to predict the clinical outcomes of patients aged 80 years or older undergoing elective or emergency cholecystectomy. STUDY DESIGN: The study focused on 263 patients over 80 years of age operated on between 2010 and 2019: 174 were treated as emergencies because of acute cholecystitis (66.2%). Outcomes evaluated are those predicted by the ACS-NSQIP calculator within 30 days of surgery. The ACS-NSQIP model was tested for both discrimination and calibration. Differences among observed and expected outcomes were evaluated. RESULTS: When considering all patients, the discrimination of mortality was very high, as it was that of severe complications. Considering only the elective cholecystectomies, the discrimination capacity of ACS-NSQIP risk calculator has consistently worsened in each outcome while it remains high considering the emergency cholecystectomies. In the evaluation of the emergency cholecystectomy, the model showed a very high discriminatory ability and, more importantly, it showed an excellent calibration. Comparisons between main outcomes showed small or even negligible differences between observed and expected values. CONCLUSION: The results of the present study suggest that clinical decisions on cholecystectomy in a patient aged 80 years or older should be assisted through the ACS-NSQIP model.

First 100 minimally invasive liver resections in a new tertiary referral centre for liver surgery.

BACKGROUND: In the last decades, there has been an exponential diffusion of minimally invasive liver surgery (MILS) worldwide. The aim of this study was to evaluate our initial experience of 100 patients undergoing MILS resection comparing their outcomes with the standard open procedures. MATERIALS AND METHODS: One hundred consecutive MILS from 2016 to 2019 were included. Clinicopathological data were reviewed to evaluate outcomes. Standard open resections were used as the control group and compared exploiting propensity score matching. RESULTS: In total, 290 patients were included. The rate of MILS has been constantly increasing throughout years, representing the 48% in 2019. Of 100 (34.5%) MILS patients, 85 could be matched. After matching, the MILS conversion rate was 5.8% (n = 5). The post-operative complication rates were higher in the open group (45.9% vs. 31.8%, P = 0.004). Post-operative blood transfusions were less common in the MILS group (4.7% vs. 16.5%, P = 0.021). Biliary leak occurred in 2 (2.4) MILS versus 13 (15.3) open. The median comprehensive complication index was higher in the open group (8.7 [0-28.6] vs. 0 [0-10.4], P = 0.0009). The post-operative length of hospital stay was shorter after MILS (median 6 [5-8] vs 8 [7-13] days, P < 0.0001). CONCLUSIONS: The rate of MILS has been significantly increasing throughout the years. The benefits of MILS over the traditional open approach were confirmed. The main advantages include lower rates of post-operative complications, blood transfusions, bile leaks and a significantly decreased hospital stay.

Cytoreduction plus hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis in colorectal cancer patients: a single-center cohort study.

BACKGROUND: In this study, we report our experience of cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) in patients with peritoneal carcinomatosis (PC) from colorectal cancer (CRC), focusing on the factors affecting survival. METHODS: All patients with surgically treated PC from colorectal cancer and with no involvement of other organs referred to our institute from March 2005 to December 2017 were included in the analysis. RESULTS: Thirty-eight patients underwent CRS-HIPEC, and all had a completeness of cytoreduction score of 0 (CC0). The median operating time was 645 min (interquartile range [IQR] 565-710). Five patients (13.1%) had Clavien-Dindo grade > 2 postoperative complications. Median overall survival (OS) was 60 months. In the Cox regression for OS, calculated on the CRS-HIPEC group, the peritoneal cancer index (PCI) > 6 (hazard ratio [HR] 4.48, IQR 1.68-11.9, P = 0.003) and significant nodal involvement (N2) (HR 3.89, IQR 1.50-10.1, P = 0.005) were independent prognostic factors. Median disease-free survival (DFS) was 16 months. Only N2 (HR 2.44, IQR 1.11-5.36, P = 0.027) was a significantly negative prognostic factor for DFS in multivariate analysis. CONCLUSIONS: CRS-HIPEC can substantially improve survival. However, patients with high PCI (PCI > 6) and significant nodal involvement (N2) may not benefit from the procedure.

Laparoendoscopic rendezvous in the treatment of cholecysto-choledocholitiasis: a single series of 200 patients.

BACKGROUND AND AIM: Although the ideal management of cholecysto-choledocholitiasis is controversial, the two-stage approach, namely the common bile duct (CBD) clearance through endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy, remains the standard way of management. However, whenever feasible, the one-stage approach, using the so-called "laparoendoscopic rendezvous" (LERV) technique, offers some advantages, mainly reducing the hospital stay and the risk of post-ERCP pancreatitis. The aim of this study was to evaluate the safety and the efficacy of the one-stage approach, and to compare our results with data from available large studies. MATERIALS AND METHODS: We reviewed our series of consecutive patients with cholecysto-choledocholitiasis treated by LERV from January 2003, to October 2016. Both elective and emergency cases were included. The primary end-point was the efficacy to obtain the CBD stones clearance. Secondary end-points were morbidity and mortality, operative time, conversion rate, and in-hospital stay. RESULTS: A total of 200 patients underwent a LERV procedure for the intra-operative diagnosis by intra-operative cholangiogram of cholecysto-choledocholitiasis. In 187 patients (93.5%), it was possible to cannulate the cystic duct with the jag-wire. Success rate was 95%. Conversion rate was 3%. The mean operative time was 135 min and the mean in-hospital stay was 4 days. 29 (14.5%) were the early complications, six mild pancreatitis. Four patients required re-operation during the hospital stay. 11 patients (5.5%) developed late complications during a median follow-up of 57.7 months. CONCLUSIONS: Our results confirm that LERV technique is a safe procedure with high success rates for the treatment of cholecysto-choledocholitiasis. The major advantages include the single-stage treatment, the shorter hospital stay, and the lower incidence of post-ERCP pancreatitis.

Implementation of a patient blood management in an Italian City Hospital: is it effective in reducing the use of red blood cells?

To evaluate the effect of patient blood management (PBM) since its introduction, we analyzed the need for transfusion and the outcomes in patients undergoing abdominal surgery for different types of tumor pre- and post-PBM. Patients undergoing elective gastric, liver, pancreatic, and colorectal surgery between 2017 and 2020 were included. The implementation of the PBM program was completed on May 1, 2018. The patients were grouped as follows: those who underwent surgery before the implementation of the program (pre-PBM) versus after the implementation (post-PBM). A total of 1302 patients were included in the analysis (445 pre-PBM vs. 857 post-PBM). The number of transfused patients per year decreased significantly after the introduction of PBM. A strong tendency for a decreased incidence of transfusion was evident in gastric and pancreatic surgery and a similar decrease was statistically significant in liver surgery. With regard to gastric surgery, a single-unit transfusion scheme was used more frequently in the post-PBM group (7.7% vs. 55% after PBM; p = 0.049); this was similar in liver surgery (17.6% vs. 58.3% after PBM; p = 0.04). Within the subgroup of patients undergoing liver surgery, a significant reduction in the use of blood transfusion (20.5% vs. 6.7%; p = 0.002) and a decrease in the Hb trigger for transfusion (8.5, 8.2-9.5 vs. 8.2, 7.7-8.4 g/dl; p = 0.039) was reported after the PBM introduction. After the implementation of a PBM protocol, a significant reduction in the number of patients receiving blood transfusion was demonstrated, with a strong tendency to minimize the use of blood products for most types of oncologic surgery.

Which octogenarian patients are at higher risk after cholecystectomy for symptomatic gallstone disease? A single center cohort study.

BACKGROUND: Incidence of gallstones in those aged ≥ 80 years is as high as 38%-53%. The decision-making process to select those oldest old patients who could benefit from cholecystectomy is challenging. AIM: To assess the risk of morbidity of the "oldest-old" patients treated with cholecystectomy in order to provide useful data that could help surgeons in the decision-making process leading to surgery in this population. METHODS: A retrospective study was conducted between 2010 and 2019. Perioperative variables were collected and compared between patients who had postoperative complications. A model was created and tested to predict severe postoperative morbidity. RESULTS: The 269 patients were included in the study (193 complicated). The 9.7% of complications were grade 3 or 4 according to the Clavien-Dindo classification. Bilirubin levels were lower in patients who did not have any postoperative complications. American Society of Anesthesiologists scale 4 patients, performing a choledocholithotomy and bilirubin levels were associated with Clavien-Dindo > 2 complications (P < 0.001). The decision curve analysis showed that the proposed model had a higher net benefit than the treating all/none options between threshold probabilities of 11% and 32% of developing a severe complication. CONCLUSION: Patients with American Society of Anesthesiologists scale 4, higher level of bilirubin and need of choledocholithotomy are at the highest risk of a severely complicated postoperative course. Alternative endoscopic or percutaneous treatments should be considered in this subgroup of octogenarians.

The Impact of Postoperative Ascites on Survival After Surgery for Hepatocellular Carcinoma: a National Study.

BACKGROUND: Postoperative ascites (POA) is the most common complication after liver surgery for hepatocarcinoma (HCC), but its impact on survival is not reported. The aim of the study is to investigate its impact on overall survival (OS) and disease-free survival (DFS), and secondarily to identify the factors that may predict the occurrence. METHOD: Data were collected from 23 centers participating in the Italian Surgical HCC Register (HE.RC.O.LE.S. Group) between 2008 and 2018. POA was defined as ≥500 ml of ascites in the drainage after surgery. Survival analysis was conducted by the Kaplan Meier method. Risk adjustment analysis was conducted by Cox regression to investigate the risk factors for mortality and recurrence. RESULTS: Among 2144 patients resected for HCC, 1871(88.5%) patients did not experience POA while 243(11.5%) had the complication. Median OS for NO-POA group was not reached, while it was 50 months (95%CI = 41-71) for those with POA (p < 0.001). POA independently increased the risk of mortality (HR = 1.696, 95%CI = 1.352-2.129, p < 0.001). Relapse risk after surgery was not predicted by the occurrence of POA. Presence of varices (OR = 2.562, 95%CI = 0.921-1.822, p < 0.001) and bilobar disease (OR = 1.940, 95%CI = 0.921-1.822, p: 0.004) were predictors of POA, while laparoscopic surgery was protective (OR = 0.445, 95%CI = 0.295-0.668, p < 0.001). Ninety-day mortality was higher in the POA group (9.1% vs 1.9% in NO-POA group, p < 0.001). CONCLUSION: The occurrence of POA after surgery for HCC strongly increases the risk of long-term mortality and its occurrence is relatively frequent. More efforts in surgical planning should be made to limit its occurrence.

Benchmarking a new tertiary referral center for hepato-biliary surgery through a critical systematic review of available literature.

BACKGROUND: Studies reporting benchmark values for surgical procedures should provide instruments for comparison, gap analysis and adoption of corrective measures to improve the outcome. METHODS: A systematic search was performed to identify articles containing the MESH terms "benchmarking" AND "hepatectomy". An Institutional Review Board-approved database of all hepato-biliary surgical procedures, performed in a new tertiary referral surgical unit was used for benchmarking results with the values reported in the literature. RESULTS: Five articles were suitable for benchmarking: 3 based benchmark values (BMV) on the 75th percentiles of surgical outcomes among high-volume centers, one study provided BMV on the "Achievable Bench-mark of Care" and one study provided BMV on the 75th percentiles through a Bayesian prediction. When we benchmarked our surgical experience of 320 hepatic resections, we found margins for improvement for open major hepatectomies and for laparoscopic multiple resections/concomitant bowel resections but it was impossible to compare homogeneous sub-groups of patients for most of the procedures due to the lack of high-quality literature data. CONCLUSION: Benchmarking a surgical experience with the BMV provided in literature was attempted but unfortunately the lack of a standardized way for conducting benchmark analysis did not allow, at present, reliable quality comparison and improvement.

Is It Possible a Conservative Approach After Radiochemotherapy in Locally Advanced Rectal Cancer (LARC)? A Systematic Review of the Literature and Meta-analysis.

BACKGROUND: Locally advanced rectal cancer is usually treated with a preoperative approach with radiochemotherapy followed by surgery. Patients obtaining a pathologic complete response have a very favorable long-term prognosis. This study was intended to assess whether major surgery can reduce tumor recurrences and prolong survival of patients with a complete response after radiochemotherapy. METHODS: Computerized literature search was performed to identify relevant articles. Comparative studies reporting the outcomes of non-operative and operative management in patients after neoadjuvant treatment were reviewed. Data synthesis was performed using Review Manager 5.0 software. RESULTS: Twelve non-randomized comparative studies with a total of 1812 patients were suitable for analysis. There was no significant difference in overall survival at 3 and 5 years (odds ratio [OR] 1.31; 95% CI 0.64-2.69; p = 0.46 and 1.48; 95% CI 1.00-2.20; p = 0.50) and in disease-free survival at 3 and 5 years (odds ratio [OR] 1.20; 95% CI 0.68-2.14; p = 0.53 and 1.22; 95% CI 0.86-1.74; p = 0.26, respectively) between locally advanced rectal cancer patients treated with and without operative approach. CONCLUSIONS: Major surgery does not seem to improve prognosis in patients obtaining a complete response after radiochemotherapy. Clinical trials, using clear criteria to identify complete response patients, are needed to recommend non-operative approach.

Preoperative Chemotherapy and Resection Margin Status in Colorectal Liver Metastasis Patients: A Propensity Score-Matched Analysis.

In this article, we compared the early and long-term outcomes of patients with metastatic colorectal cancer treated with chemotherapy followed by resection with those of patients undergoing surgery first, focusing our analysis on resection margin status. Patients who underwent liver resection with curative intent for colorectal liver metastases from July 2001 to January 2018 were included in the analysis. Propensity score matching was used to reduce treatment allocation bias. The cohort comprised 164 patients; 117 (71.3%) underwent liver resection first, whereas the remaining 47 (28.7%) had preoperative chemotherapy. After a 1:1 ratio of propensity score matching, 47 patients per group were evaluated. A positive resection margin was found in 13 patients in the surgery-first group (25.5%) versus 4 (8.5%) in the preoperative chemotherapy group (P = 0.029). Postmatched logistic regression analysis showed that only preoperative chemotherapy was significantly associated with the rate of positive resection margin (odds ratio 0.24, 95% confidence interval 0.07-0.81; P = 0.022). Median follow-up was 41 months (interquartile range 8-69). Cox proportional hazard regression analysis revealed that only positive resection margin was a significant negative prognostic factor (hazard ratio 2.2, 95% CI 1.18-4.11; P = 0.014). Within the preoperative chemotherapy group, median overall survival was 40 months in R0 patients and 10 months in R1 patients (P = 0.016). Although preoperative chemotherapy in colorectal liver metastasis patients may affect the rate of positive resection margin, its impact on survival seems to be limited. In the present study, the most important prognostic factor was the resection margin status.

Robotic vs laparoscopic splenectomy for splenomegaly: A retrospective comparative cohort study.

BACKGROUND: The aim of this study was to evaluate the role of robotic total splenectomy for splenomegaly, comparing this approach with the laparoscopic technique. METHODS: We conducted a retrospective review of all patients who underwent minimally invasive splenectomy for splenomegaly (maximum splenic diameter>15 cm) at our institution between 2000 and 2017. RESULTS: A total of 39 patients (27 laparoscopic vs 12 robotic splenectomies) were included in the study. Operative time was significantly longer in the robotic group (270 min vs 180 min, p = 0.007). Median intraoperative blood loss was 350 ml for laparoscopic procedures while it was 100 ml for the robotic ones (p = 0.032). Conversion to open surgery was required in 4 cases of laparoscopic splenectomy while no conversion were registered in the robotic group. No significant differences were seen in postoperative morbidity and mortality between the two groups. CONCLUSIONS: Robotic splenectomy for splenomegaly is associated with less blood loss and longer operative times than the laparoscopic procedure.

Bile duct injury during laparoscopic cholecystectomy: results of an Italian national survey on 56 591 cholecystectomies.

HYPOTHESIS: Bile duct injury (BDI) remains the most serious complication of cholecystectomy. With laparoscopic cholecystectomy (LC), the incidence has become more frequent. This study verifies the current incidence, mechanism, presentation, and treatment of BDI occurring during LC in general surgical practice. DESIGN: Anonymous retrospective multicenter survey. SETTING: Department of surgery at a university referral center, collecting data from general surgical units. PATIENTS: Data from 56 591 patients who underwent LC between January 1, 1998, and December 31, 2000, in 184 hospitals in Italy were analyzed. MAIN OUTCOME MEASURES: Current incidence, mechanism, presentation, and treatment of BDI occurring during LC in general surgical practice. RESULTS: Two hundred thirty-five BDIs were reported, with an overall incidence of 0.42%. There were no risk factors in 80.0% of the patients. Poor identification of the anatomical features of the hepatic pedicle was the most frequently reported cause (36.8%), and technical problems accounted for 27.0% of causes. The incidence of BDI was higher during cholecystitis (P<.001) and decreased with increasing number of LCs performed by the surgical teams (P<.01). There was no difference in incidence according to technique (French or US) or to routine or selective intraoperative cholangiography. One hundred eight BDIs (46.0%) were recognized intraoperatively and immediately repaired in 89.8% of patients. One hundred twenty-seven BDIs (54.0%) were diagnosed postoperatively, the dominant manifestation being biliary fistula (44.1%). CONCLUSIONS: This study confirms a higher incidence of BDI during LC. It highlights the relevance of the number of previously performed LCs and of the correct surgical technique to avoid BDI. The need for correct procedures, adequate expertise of the repairing surgeon in BDI repairs, and a multidisciplinary approach in the management of BDI is emphasized.

Advantages of multidisciplinary management of bile duct injuries occurring during cholecystectomy.

BACKGROUND: The aim of the present study was to highlight the advantages of treatment of bile duct injury (BDI) occurring during cholecystectomy on the basis of a multidisciplinary cooperation of expert surgeons, radiologists, and endoscopists. METHODS: Sixty-six patients had major BDIs or short- or long-term failures of repair. BDI was diagnosed intraoperatively in 27 patients (40.9%) and postoperatively in 39 (59.1%) patients. Among referred patients, 30 had complications from bile leak, 15 from obstructive jaundice, and 20 from recurrent cholangitis. Two patients died from sepsis after delayed referral before repair was attempted. Eleven additional patients had minor BDIs with bile leak both with and without choleperitoneum. RESULTS: Of patients with major BDI, surgical repair was performed in 41 (64.1%). Postsurgical morbidity rate was 15.8%, and there was no mortality. The rate of excellent or good results after surgical repair was 78.0% (32 of 41 patients), and this increased to 87.8% (36 of 41 patients) by continuing treatment with stenting in postsurgical strictures. Biliary stenting alone was performed in 23 patients (35.9%), with excellent or good results in 17 (73.9%). More than 200 endoscopic and percutaneous procedures were performed for initial assessment, treatment of sepsis, nonsurgical repair, contribution to repair, and follow-up. Patients with minor BDIs underwent various combinations of surgical and endoscopic or percutaneous treatments, always with good results. CONCLUSIONS: A multidisciplinary approach was of paramount importance in many phases of treatment of BDI: initial assessment, treatment of secondary complications, resolution of sepsis, percutaneous stenting before surgical repair, dilatation of strictures after repair, final treatment in patients not repaired surgically, and follow-up.

Pedicle clamping with ischemic preconditioning in liver resection.

Hepatic pedicle clamping (HPC) is widely used to control intraoperative bleeding during hepatectomy; intermittent HPC is better tolerated but is associated with blood loss during each period of reperfusion. Recently, it has been shown that ischemic preconditioning (IP) reduces the ischemia-reperfusion damage for up to 30 minutes of continuous clamping in healthy liver. We evaluated the safety of IP for more prolonged periods of continuous clamping in 42 consecutive patients with healthy liver submitted to hepatectomy. IP was used in 21 patients (group A); mean +/- SD of liver ischemia was 54 +/- 19 minutes (range, 27-110; in 7 cases >60 minutes). In the other 21 patients, continuous clamping alone was used (Group B); liver ischemia lasted 36 +/- 14 minutes (range, 13-70; in 2 cases >60 minutes). Two patients in Group A (9.5%) and 3 in Group B (14.2%) received blood transfusions. In spite of the longer duration of ischemia (P=.001), patients with IP had lower aspartate aminotransferase (AST; P=.03) and alanine aminotransferase (ALT; P=not significant) at postoperative day 1, with a similar trend at postoperative day 3. This was reconfirmed by multiple regression analysis, which showed that although postoperative transaminases increased with increasing duration of ischemia and of the operation in both groups, the increases were significantly smaller (P<.001) with the use of preconditioning. In conclusion, the present study confirms that IP is safe and effective for liver resection in healthy liver and is also better tolerated than continuous clamping alone for prolonged periods of ischemia. This technique should be preferred to continuous clamping alone in healthy liver. Additional studies are needed to assess the role of IP in cirrhotic liver and to compare IP with intermittent clamping.