Synchronous pyogenic liver abscess and acute cholecystitis: how to recognize it and what to do (emergency cholecystostomy followed by delayed laparoscopic cholecystectomy).

BACKGROUND: The treatment of synchronous pyogenic liver abscess (PLA) and acute cholecystitis (AC) may be challenging. Moreover, because of the similarity of symptoms and the suboptimal accuracy of ultrasound (US), PLA(s) may be undetected, unless a computer tomography (CT) scan is performed. The aims of this study were (1) to evaluate the results of emergency cholecystostomy (CS) and late laparoscopic cholecystectomy (LC) in such a population and (2) to identify the criteria for selecting patients with AC and a high risk of having synchronous PLA(s) for referral for a CT scan. METHODS: A retrospective analysis of the outcome of 12 patients with AC and PLA(s) treated by emergency CS followed by delayed LC from January 1996 through May 2010 at a tertiary-care university hospital was performed. Clinical, laboratory, and radiological data of patients with synchronous AC and PLA(s) are compared with those of 66 patients with "simple" AC. RESULTS: The association of age >55 years, temperature >38°C, WBC count >12,000/ml, and ASAT >50 UI/l and/or ALAT >75 UI/l allows for the selection of patients at high risk of PLA to undergo a CT scan (sensitivity: 100%; specificity: 86%). All treated patients had a sudden improvement within 24 h following CS. PLA was treated in 10/12 patients (83%). Hospital stay lasted 21.5 ± 3.5 days. Ten patients underwent elective LC 12 ± 4 weeks after CS with no conversion and 30% perioperative morbidity. Operating time was 91 min. Hospital stay was 1.7 days [7 patients (70%) underwent surgery as an outpatient]. CONCLUSIONS: A simple algorithm is presented for the selection of patients with AC to undergo a CT scan to identify synchronous PLA. Emergency CS followed by delayed LC is a viable, first-line treatment option for synchronous PLA and AC.

Laparoscopic liver resection for hepatocellular carcinoma.

BACKGROUND: Single, small hepatocarcinomas (HCC) are still an indication for partial liver resection in patients ineligible for transplantation. Anatomical resections are recommended for oncological reasons. The mini-invasive approach of laparoscopy should minimize hepatic and parietal injury, thereby decreasing the risk of liver failure and ascites. However, the oncological results of this approach and its presumed benefits remain undemonstrated. We evaluated the short- and midterm results of laparoscopic liver resections for HCC. METHODS: Between 1999 and 2006, we performed 32 laparoscopic liver resections for HCC. Mean tumor size was 3.8 +/- 2 cm and the mean age of the patients was 65 +/- 11 years. Twenty-two patients had cirrhosis (21 Child A and one Child C). Operative and postoperative results were analyzed, together with recurrence and survival rates. RESULTS: We carried out 13 unisegmentectomies, nine bisegmentectomies, one trisegmentectomy, two right hepatectomies, one left hepatectomy, and six atypical resections. The duration of the operation was 231 +/- 101 minutes. Conversion to laparotomy was required in three patients (9%), none in emergency situations. Mean blood loss was 461 ml, with five patients (15.6%) requiring blood transfusion. The mean surgical margin was 10.4 mm. One cirrhotic patient (Child C) underwent surgery for a partially ruptured tumor and died of liver failure. Two patients had ascites and no transient liver failure occurred in the other 19 cirrhotic patients. Mean hospital stay was 7.1 days. During a mean follow-up of 26 months, 10 patients (31%) presented recurrence within the liver. None of the patients had peritoneal carcinomatosis or trocar site recurrence. Three-year overall and disease-free survival rates were 71.9% and 54.5%, respectively. CONCLUSIONS: Laparoscopic liver resection for HCC is feasible and well tolerated. Midterm survival and recurrence rates are similar to those after laparotomy.

Day-case laparoscopic cholecystectomy: results of 211 consecutive patients.

OBJECTIVES: The purpose of this work was to evaluate the feasibility and outcome of elective laparoscopic cholecystectomy as a day-case procedure in a French university hospital. METHODS: Since the creation of a surgical day-care centre in 1999, patients without severe chronic disease and anticoagulant therapy were selected for elective laparoscopic cholecystectomy. They were admitted and operated on in the morning hours and discharged after a double check by the surgeon and an anaesthetist 4 to 6 hours later. They were contacted by telephone the day subsequent to surgery and were seen in the outpatient unit 8 to 10 days after. RESULTS: Two hundred eleven laparoscopic cholecystectomies were performed in day-care surgery from January 1999 to December 2005. The proportion of day-case management increased during the six-year period from 32% to 53%. Eighteen percent of patients had an overnight admission. The overall complication rate was 1.8%. None of the patients had an emergency readmission. Incapacity duration went from 1 to 15 days. CONCLUSION: These results suggest that laparoscopic cholecystectomy can be routinely performed as a day-case procedure.

[An exceptional and misleading case of choledochal cyst]. / Une forme anatomique exceptionnelle et trompeuse de kyste du cholédoque.

The authors report a case of choledocal cyst extended to left and right hepatic ducts. An heterogeneous intracystic fluid, partial calcification of cystic wall, a slight positivity of echinoccosis serology in a patient from a highly endemic country erroneously led to diagnosis of hydatid cyst invading the left hepatic duct. The diagnosis of choledocal cyst was done on the resection specimen after left hepatectomy. A small patch of cyst wall with terminations of both right sectorial hepatic ducts was used for cysto-jejunal Roux-en-Y loop anastomosis. Peculiarities of this type of choledocal cyst are discussed.

Endoscopic Internal Drainage with Enteral Nutrition (EDEN) for treatment of leaks following sleeve gastrectomy.

BACKGROUND: Endoscopic treatment of gastric leaks (GL) following sleeve gastrectomy (SG) involves different techniques; however, standard management is not yet established. We report our experience about endoscopic internal drainage of leaks using pigtail stents coupled with enteral nutrition (EDEN) for 4 to 6 weeks until healing is achieved. METHODS: In 21 pts (18 F, 41 years), one or two plastic pigtail stents were delivered across the leak 25.6 days (4-98) post-surgery. In all patients, nasojejunal tube was inserted. Check endoscopy was done at 4 to 6 weeks with either restenting if persistent leak, or removal if no extravasation of contrast in peritoneal cavity, or closure with an Over-the-Scope Clip® (OTSC®) if contrast opacifying the crossing stent without concomitant peritoneal extravasation. RESULTS: Twenty-one out of 21 (100 %) patients underwent check endoscopy at average of 30.15 days (26-45) from stenting. In 7/21 (33.3 %) patients leak sealed, 2/7 needed OTSC®. Second check endoscopy, 26.7 days (25-42) later, showed sealed leak in 10 out 14; 6/10 had OTSC®. Four required restenting. One patient, 28 days later, needed OTSC®. One healed at 135 days and another 180 days after four and seven changes, respectively. One patient is currently under treatment. In 20/21 (95.2 %), GL have healed with EID treatment of 55.5 days (26- 180); all are asymptomatic on a normal diet at average follow-up of 150.3 days (20-276). CONCLUSIONS: EDEN is a promising therapeutic approach for treating leaks following SG. Multiple endoscopic sessions may be required.

Laparoscopic liver resection for localized primary intrahepatic bile duct dilatation.

BACKGROUND: Primary intrahepatic bile duct dilatation (IHBD) may present as a localized form in which resection of the affected liver can prevent immediate and late complications. Laparoscopy has gained large interest in liver surgery. It also allows a safe and efficient exploration of the common bile duct. METHODS: We performed 10 laparoscopic liver resections for localized IHBD, on 7 women and 3 men (mean age 47 years). Resections were 2 right hepatectomies, 4 left hepatectomies, and 4 left lateral sectionectomies. Three patients had associated common bile duct stones that were treated through intraoperative cholangioscopy. RESULTS: The mean operative time was 303.9 minutes. The mean blood loss was 217 mL. None of these patients required hand assistance or conversion to open surgery. One patient suffered a residual collection that was drained percutaneously. The postoperative course was uneventful in the other patients. The mean hospital stay was 5.3 days. No recurrence of cholangitis was observed during the follow-up period. CONCLUSIONS: The laparoscopic treatment of IHBD is safe and should be performed by teams with expertise in both hepatobiliary surgery and laparoscopy.

Leiomyosarcoma of the inferior vena cava involving the renal veins: a simple method of right renal vein reimplantation.

In this report we describe a case of leiomyosarcoma of the inferior vena cava involving the renal veins. The abdominal computed tomography scan showed a tumor in the infrahepatic portion of the inferior vena cava and the confluence of the renal veins. After resection of the tumor, venous reconstruction involved the replacement of the inferior vena cava with a prosthetic graft and the implantation of the right renal vein into the portal vein. The left renal vein was ligated distally, with preservation of collateral pathways. To our knowledge, no other reports of such venous reconstruction have been published. After a follow-up of 30 months, the patient has shown no further symptoms, and the abdominal computed tomography scan demonstrates patency of the renal portal anastomosis. Tests indicated normal renal and hepatic function, suggesting good tolerance of the renal portal anastomosis. We believe that the technique described in this report should be adopted routinely for tumors located in the renal veins, provided complete resection of the tumor with a comfortable resection margin is possible.