Reoperative surgery after repair of postcholecystectomy bile duct injuries: is it worthwhile?

BACKGROUND: Repeat repair of bile duct injuries (BDIs) after cholecystectomy is technically challenging, and its success remains uncertain. We retrospectively evaluated the short- and long-term outcomes of patients requiring reoperative surgery for BDI at a major referral center for hepatobiliary surgery. METHODS: Between January 1991 and May 2011, we performed surgical BDI repairs in 46 patients. Among them, 22 patients had undergone a previous surgical repair elsewhere (group 1), and 24 patients had no previous repair (group 2). We compared the early and late outcomes in the two groups. RESULTS: The patients in group 1 were younger (48.6 vs. 54.8 years, p = 0.0001) and were referred after a longer interval (>1 month) from BDI (72.7 vs. 41.7%, p = 0.042). Intraoperative diagnosis of BDI (59.1 vs. 12.5%, p = 0.001), ongoing cholangitis (45.4 vs. 12.5%; p = 0.02), and delay of repair after referral to our institution (116 ± 34 days vs. 23 ± 9 days; p = 0.001) were significantly more frequent in group 1 than in group 2. No significant differences were found for postoperative mortality, morbidity, or length of stay between the groups. Patients with associated vascular injuries had a higher postoperative morbidity rate (p = 0.01) and associated hepatectomy rate (p = 0.045). After a mean follow-up of 96.6 ± 9.7 months (range 5-237.2 months, median 96 months), the rate of recurrent cholangitis (6.5%) was comparable in the two groups. CONCLUSIONS: This study demonstrates that short- and long-term outcomes after surgical repair of BDI are comparable regardless of whether the patient requires reoperative surgery for a failed primary repair. Associated vascular injuries increase postoperative morbidity and the need for liver resection.

What is a safe future liver remnant size in patients undergoing major hepatectomy for colorectal liver metastases and treated by intensive preoperative chemotherapy?

BACKGROUND: A multidisciplinary approach involving preoperative chemotherapy has become common practice in patients with colorectal liver metastases (CLM). The definition of a safe future liver remnant (FLR) volume based on preoperative clinical data in these patients is lacking. Our aim was to identify predictors of postoperative morbidities in patients undergoing major hepatectomy after intensive preoperative chemotherapy for CLM. METHODS: Between January 2000 and August 2010, a total of 101 consecutive patients with CLM underwent major hepatectomy after preoperative chemotherapy (≥6 cycles of oxaliplatin or irinotecan regimen with or without targeted therapies). The FLR ratio was calculated by two formulas: actual FLR (aFLR) ratio, and standardized FLR (sFLR) ratio. Predictors of postoperative overall morbidity, sepsis, and liver failure were identified by univariate and multivariate analyses. RESULTS: Fifty-eight patients (57.4%) had 95 postoperative complications. Sepsis and postoperative liver failure occurred in 23 (22.8%) and 16 patients (15.8%), respectively. On univariate analysis, small aFLR ratio was significantly associated with all complications, and sFLR ratio was associated with sepsis and liver failure. In receiver-operating characteristic analysis, the cutoff of aFLR ratio in predicting overall morbidity, sepsis, and liver failure was 44.8, 43.1, and 37.7%, respectively, and that of sFLR ratio in predicting sepsis and liver failure was 43.6 and 48.5%, respectively. On multivariate analysis, these aFLR and sFLR ratio cutoffs were independent predictors of all complications and of sepsis and liver failure, respectively. CONCLUSIONS: This study provides a cutoff FLR ratio for safe postoperative outcome after major hepatectomy in CLM patients receiving six or more cycles of preoperative chemotherapy.

Multivariate analysis of risk factors for pulmonary complications after hepatic resection.

OBJECTIVE: To generate the first evaluation of risk factors for postoperative pulmonary complications (PPCs) after hepatectomy. BACKGROUND: Postoperative pulmonary complications (PPCs) after surgery are associated with significant morbidity and have been shown to increase the length of hospital stays. Several studies have been conducted to identify the risk factors for PPCs after abdominal surgery. METHODS: Between January 2006 and December 2009, 555 patients underwent elective hepatectomy. We prospectively collected and retrospectively analyzed demographic data, pathological variables, associated pathological conditions, and preoperative, intraoperative, and postoperative variables. The dependent variables studied were the occurrence of PPCs, pleural effusion, pneumonia, and pulmonary embolism. RESULTS: Multivariate analysis identified 5 independent risk factors for global PPCs: prolonged surgery [odds ratio (OR) = 1], presence of a nasogastric tube (OR = 1.6), intraoperative blood transfusion (OR = 1.7), diabetes mellitus (OR = 2.7), and a transverse subcostal bilateral muscle cutting incision (OR = 3.4). There were 4 independent risk factors for pleural effusion: prolonged surgery (OR = 1), surgery on the right lobe of the liver (OR = 1.6), neoadjuvant chemotherapy (OR = 2), and a transverse subcostal bilateral muscle cutting incision (OR = 2.5). There were 3 independent risk factors for pneumonia: intraoperative blood transfusion (OR = 1.9), diabetes mellitus (OR = 2.2), and atrial fibrillation (OR = 3). For pulmonary embolism, history of previous thromboembolic events was identified as the only risk factor (OR = 8.8). CONCLUSIONS: The correction of modifiable risk factors among the identified factors could reduce the incidence of PPCs and, as a consequence, improve patient outcomes and reduce the length of hospital stays.

Robotic central pancreatectomy with stented pancreaticogastrostomy: operative details.

BACKGROUND: Central pancreatectomy (CP) is increasingly being used to treat selected lesions of the central pancreatic segment. A step-by-step technique for robotic CP is described and a literature review provided for this minimally invasive approach. METHODS: A 55-year-old woman was referred to the authors' center for the treatment of a single 4 cm lesion located at the proximal part of the pancreatic body. The da Vinci Robotic surgical system® with a five trocar technique was used. The pancreatic neck was transected using an endoscopic stapler. The pancreatic body was progressively dissected from the splenic vessels right to left and sectioned with an appropriate oncologic margin. A pancreaticogastrostomy protected by a transanastomotic external stent was constructed to the distal pancreatic stump. RESULTS: Surgery lasted 450 min (8 min docking time) with minimal blood loss. Pathology showed a 28 mm well-differentiated neuroendocrine pancreatic tumor with tumor-free resection margins. The patient was discharged home on postoperative day 15 in good condition. CONCLUSIONS: Robotic surgery can be safely used for complex pancreatic resection requiring pancreaticoenteric reconstruction. The experience reported so far is still limited but the results are encouraging; robotics shows the potential to bridge the gap between minimally invasive surgery and advanced pancreatic surgery.

Consecutive concomitant laparoscopic splenectomy and cholecystectomy: an Italian experience of 30 patients and proposition of a technique.

INTRODUCTION: With recent advancements in the field of minimally invasive surgery, combined laparoscopic procedure is now being performed for treating coexisting abdominal pathologies during the same surgery. In some patients, spleen disorders are associated with gallbladder stones. Conventional surgery requires a wide upper abdominal incision for correct exposure of both organs. The aim of this study was to assess the feasibility and outcomes of concomitant laparoscopic treatment for coexisting spleen and gallbladder diseases. MATERIALS AND METHODS: Thirty consecutive laparoscopic splenectomy (LS) plus laparoscopic cholecystectomy (LC) have been performed in our department between January 2000 and December 2009 (24% of 125 LS performed in this period). There were 11 female patients and 19 male patients, with a median age of 16.2 years (range: 4-55). Indications were hereditary spherocytosis for 22 cases, idiopathic thrombocytopenic purpura for 3 cases, thalassemia for 4 cases, and sickle cell disease for 1 case. Patients were operated on using right semilateral position, tilting the table from right to left, using a five-trocar technique in 25 cases and a four-trocar technique in the last 5 cases. Cholecystectomy was performed first, then splenectomy was achieved, and spleen was removed in an Endobag. RESULTS: One patient required conversion to open procedure (3.3%) because of splenomegaly. Average operative time was 150 minutes (range: 90-240). Average length of stay was 3.5 days (range: 3-11). Mean blood loss was 60 mL (range: 30-500). Transfusion rate was 3.3%. Mean spleen size and weight were, respectively, 16.5 cm and 410 g. No perioperative mortality occurred in the series. We reported 3 cases of hemoperitoneum, of which one managed conservatively. The results using four trocars were comparable to those with five trocars. CONCLUSION: With increasing institutional experience, concomitant laparoscopic splenectomy and cholecystectomy is a safe and feasible procedure and may be considered for coexisting spleen and gallbladder diseases. The four-trocar technique guarantees good results.

Risk factors for liver failure and mortality after hepatectomy associated with portal vein resection.

OBJECTIVE: To report the postoperative outcome of hepatectomy associated with portal vein resection (PVR) and to identify risk factors of clinical value for predicting postoperative liver failure and mortality. SUMMARY BACKGROUND DATA: Resection of the portal vein during hepatectomy allows an increase in the number of patients who may benefit from a potentially curative operation that is, however, technically difficult and may increase postoperative morbidity and mortality. Few data are available about risk factors for liver failure and mortality after such extensive operations. METHODS: Between July 1996 and July 2008, a total of 1348 patients were operated on for liver disease in our institution. Among them, 55 patients underwent liver resection associated with PVR. Medical records of these patients were prospectively collected and retrospectively analyzed. RESULTS: Overall mortality for this selected group of patients was 7.2%. Irreversible liver failure was the main cause of death. Overall morbidity was 58.1%. A total of 94% of the patients (n = 52) underwent a major (≥ 3 segments) or an extended > 4 segments) right or left hepatectomy. Univariate analysis showed that male gender (P = 0.004), extended liver resection (P = 0.028), and, particularly, extended right hepatectomy (P = 0.015) were significantly associated with an increased risk of postoperative liver failure. Male gender was the single independent risk factor for liver failure. Moreover, the presence of liver steatosis (P = 0.014), an extended right hepatectomy procedure (P = 0.047), and postoperative liver failure (P = 0.046) were significantly associated with an increased rate of postoperative mortality. CONCLUSION: The present study confirmed that major or extended hepatic resection with PVR can be performed with acceptable overall morbidity and mortality rates. Preoperative selection of the patients should take in consideration the gender and the extent of hepatic resection to avoid irreversible postoperative liver failure. Extended right hepatectomy with PVR should be carefully considered in patients with liver steatosis due to the high risk of postoperative mortality.

Right colon, left colon, and rectal surgeries are not similar for surgical site infection development. Analysis of 277 elective and urgent colorectal resections.

PURPOSE: Surgical site infections (SSIs) are the most common infections in colorectal surgery. Although some studies suggest that rectal surgery differs from colon surgery for SSI incidence and risk factors, the National Nosocomial Infection Surveillance system categorizes all colorectal surgeries into only one group. The aim of this study was to determine incidence, characteristics, and risk factors of SSIs according to the subclassification of colorectal surgery into right colon surgery (RCS), left colon surgery (LCS), and rectum surgery (RS). METHODS: From November 2005 to July 2009, all patients requiring colorectal resectioning were enrolled into our program. The outcome of interest was an SSI diagnosis. Univariate and multivariate analyses were performed to determine SSI predictors in each group. RESULTS: Two hundred seventy-seven consecutive colorectal resections were analyzed. SSI rates were 8% in RCS, 18.4% in LCS, and 17.6% in RS. LCS and RS showed significantly higher SSI incidences (p = 0.022) and greater rates of organ/space infections compared to RCS (p = 0.029). Predictors of SSI were steroid use among RCS, age greater than 70 years, multiple comorbidities, steroid use, non-neoplastic colonic disease, urgent operation, ostomy creation, postoperative intensive care among LCS, preoperative chemoradiation, heart disease, and prolonged operation among RS patients. On multivariate analysis, the coupled LCS and RS groups showed an increased risk for SSI compared to RCS (OR, 2.57). CONCLUSIONS: SSI incidences, characteristics, and risk factors seem to be different among RCS, LCS, and RS. A tailored SSI surveillance program should be applied for each of the three groups, leading to a more competent SSI recognition and reduction of SSI incidence and related costs.

Malignant rhabdoid tumour of the liver in the young adult: report of first two cases.

Few cases of malignant rhabdoid tumour (MRT) of the liver are reported in literature and always in paediatric patients. We report the first two cases of young adults submitted to hepatic resection for MRT of the liver. A major liver resection was performed in both cases. The histology showed round or fusiform, loosely cohesive cells. The cytoplasm contained abundant eosinophilic inclusions, which caused the nuclei to be located in eccentric locations, giving the characteristic rhabdoid appearance. The immunohistochemical study was performed, and characteristic lack of nuclear INI1 protein expression was found. In a case surgery was associated to chemoradiotherapy. One patient died at 48 months followup for tumour recurrence. The other is still alive at 25 months followup. MRTs are rare tumours of pediatric age with poor prognosis. Hypothetical less malignant behaviour in the young adults could be supposed. Therefore an aggressive surgical and oncological treatment seems justified.

Short-term preoperative IL-2 immunotherapy in operable pancreatic cancer: a randomized study.

BACKGROUND/AIMS: A cell-mediated immunodeficiency is demonstrated to occur in advanced cancer patients. Lymphocytopenia predicts a poor prognosis, moreover, the surgical trauma can worsen the impaired immune surveillance and favor disease recurrence. This study investigates the effectiveness of preoperative interleukin-2 administration to improve lymphocyte counts' postoperative recovery in pancreatic cancer. METHODOLOGY: 31 patients with pancreatic cancer who underwent radical surgery were randomized according to 3 different groups. Group A: 9 patients treated with human recombinant IL-2 subcutaneously at 9 million IU/day for 3 days before surgery; group B: 9 patients treated with IL-2 at 12 million IU/day for 3 days before surgery; group C: 13 patients treated with surgery alone. Assessment of total and T helper lymphocyte counts were studied at hospital admission and in 7th and 14th postoperative day. RESULTS: Toxicity of IL-2 treatment was mild in all groups. Postoperative lymphocytopenia was observed in group A and C, without statistical differences, whereas group B had mean lymphocyte levels within the normal values in the postoperative period. CONCLUSIONS: This preliminary result suggests that preoperative subcutaneously IL-2 immunotherapy at 12 million IU for 3 consecutive days before surgery is able to abrogate the effects of the surgical trauma and recover a normal immunofunction in pancreatic cancer patients.

Interleukin-2 immunotherapy action on innate immunity cells in peripheral blood and tumoral tissue of pancreatic adenocarcinoma patients.

BACKGROUND AND AIMS: Innate immunity cells play a crucial role in host anticancer defense: cancer patients with high levels of natural killer (NK) cells and eosinophils have a better prognosis. Recombinant interleukin-2 (rIL-2) immunotherapy stimulates innate immunity cells. This study aims to evaluate the toxicity of pre- and postoperative rIL-2 treatment and the effects on innate immunity both in peripheral blood and in cancer tissue of patients with resectable pancreatic adenocarcinoma. MATERIALS AND METHODS: Seventeen patients received high dose rIL-2 preoperative subcutaneous administration and two low dose postoperative cycles. We evaluated NK cell and eosinophil count in blood and in pancreatic surgical specimens. RESULTS: Toxicity was moderate. In the early postoperative period, blood NK cells and eosinophils significantly increased compared to basal values (p < 0.02). Histopathological analysis did not find significant intratumoral infiltration of NK cells nor of eosinophils. CONCLUSIONS: Preoperative high dose rIL-2 administration is able to counteract surgery-induced deficiency of NK cells and eosinophils in peripheral blood in the early postoperative period, although it cannot overcome local mechanisms of immune tumor escape in cancer tissue. The amplification of innate immunity, induced by immunotherapy, may improve the control of metastatic cells spreading in the perioperative period.

Challenging diagnosis of ileal gastrointestinal stromal tumor presenting with obscure digestive bleeding.

We report a case of a patient observed in emergency condition for recurrent episodes of massive obscure gastrointestinal bleeding that required surgical control. At laparotomy we found an ileal mass with the characteristics of a gastrointestinal stromal tumor (GIST) at histopathological analysis. GISTs should always be considered as a possible cause of obscure gastrointestinal bleeding, although they are often difficult to diagnose preoperatively. Laparotomy is sometimes the only way to obtain a diagnosis. Starting from this case, we reviewed the literature about GISTs, focusing our attention on their diagnosis and the possible surgical and nonsurgical therapies.

Prolonged survival of a patient affected by pancreatic adenocarcinoma with massive lymphocyte and dendritic cell infiltration after interleukin-2 immunotherapy. Report of a case.

Several studies have shown that there is a paucity of immune cells within the stroma of pancreatic adenocarcinoma, a very aggressive cancer with a median survival of about 18 months. A 65-year-old man presented with jaundice. Abdominal ultrasound revealed intra- and extrahepatic bile duct dilatation and a 45-mm diameter hypoechoic solid mass within the pancreatic head; a computed tomography scan excluded vascular infiltration and metastatic lesions. The patient received immunotherapy consisting of 6,000,000 IU human recombinant interleukin-2 administered subcutaneously twice a day for 3 consecutive days. Thirty-six hours after the last dose, he underwent a pylorus-preserving pancreatoduodenectomy. Because of the presence of high-grade dysplasia detected by intraoperative histological examination of a distal section, a spleen preserving total pancreatectomy was performed. The postoperative course was uneventful. The patient died 32 months after surgery because of local recurrence. Histopathology showed G3 pancreatic ductal adenocarcinoma infiltrating the anterior and posterior peripancreatic tissue, duodenal wall and intrapancreatic common bile duct, with sarcoma-like foci and a component of intraductal tumor involving the common bile duct. In the distal pancreas, widespread foci of pancreatic intraepithelial neoplasia (PanI2-3) were found. The Ki-67 proliferation index was 16%. TNM staging was pT3 pN1 R1. Sections were immunostained for the T-lymphocyte marker CD3 and for the dendritic cell marker CD1a. Intratumoral infiltration was high for CD1a+ cells and mild for CD3+ cells. Preoperative immunotherapy with interleukin-2 may contribute to massive stromal infiltration of immune cells in pancreatic adenocarcinoma. This may prolong the survival even in the presence of negative prognostic factors (age >65 years, tumor diameter >20 mm, R1, tumor grade G3).

A case of pancreatic heterotopy of duodenal wall, intraductal papillary mucinous tumor and intraepithelial neoplasm of pancreas, papillary carcinoma of kidney in a single patient.

We report a case of the contemporaneous presence of two histologically different pancreatic neoplasms, one renal cancer and one embryogenic duodenal anomaly in a single patient. A 66-year-old man underwent ultrasound examination because of urinary disorders; a solid neoformation within the inferior pole of the left kidney was observed. Computed tomography confirmed the renal lesion, but also a heterogeneous mass within the pancreatic head appeared without bile ducts dilatation. Abdominal magnetic resonance revealed a multiloculated cystic component of the pancreatic mass. A second CT scan confirmed the renal and biliary findings, but it revealed a modest enlargement of the pancreatic asymptomatic mass. A resection of the left kidney inferior pole and a pylorus-preserving pancreaticoduodenectomy were performed. Histopathologic analysis of the surgical specimen revealed mild differentiated papillary renal carcinoma, intraductal papillary mucinous adenoma of the pancreatic head, foci of intraepithelial pancreatic neoplasm and pancreatic heterotopy of duodenal muscular and submucosal layers. The coexistence of several primaries and anomalies in one patient led us to suppose a genetic predisposition to different lesions, even in the absence of known familial genetic syndromes. The study of such cases may help to improve the investigation of molecular correlations and etiological factors of different solid tumors. Nowadays, surgery is the only effective cure.