Safety and long-term outcome of a new concept for surgical adhesion-reduction strategies (Prevadh): a prospective, multicenter study.

BACKGROUND/AIMS: No agent has been consistently effective in preventing formation of peritoneal adhesions and postoperative bowel obstruction after abdominal surgery. The aim of this prospective multicenter study was to assess clinical safety and efficiency of a new adhesion-reduction barrier METHODOLOGY: Between September 2000 and April 2001, Prevadh was used in 78 patients. Operative procedures included 25 hepatic resections, 7 cholecystectomies, 32 colonic resections, 7 protectomies, 3 colostomy or recovery of continuity, 1 gynaecologic surgery and 3 others. Eleven patients were operated on by laparoscopy and 67 by laparotomy. RESULTS: The overall incidence of abscesses and wound complications was 2.4% and 9% respectively. After a mean follow-up of 36 months (range: 4-51 months), no patients experienced adverse events related to the adhesion barrier. Surgical reoperative procedures were performed in 10 patients for unrelated causes and no bowel obstruction occurred within the protected area. CONCLUSIONS: This study confirmed the safety of Prevadh adhesion barrier and suggested that this resorbable barrier might provide prevention from adhesion formation on peritoneal injured surfaces. However, a large randomized controlled trial remains necessary to prove the real effectiveness of adhesion barriers on clinical long-term outcome.

Stents for palliation of obstructive metastatic colon cancer: impact on management and chemotherapy administration.

HYPOTHESIS: The more rapid and less complicated recovery after palliative stent insertion compared with surgery may theoretically facilitate the early administration of chemotherapy. DESIGN: A retrospective study. SETTING: University tertiary care referral center. PATIENTS: From January 1, 1996, to September 15, 2005, 58 patients with obstructing colon cancer and nonresectable synchronous metastases were treated with self-expanding colonic metallic stent (SEMS) (n = 31) or surgery (n = 27). MAIN OUTCOME MEASURES: Comparison of the use of SEMS and emergency surgery as palliative measures to treat obstructing colon cancer with special reference to time to chemotherapy administration and survival. RESULTS: Mortality and morbidity were comparable between the 2 groups. Median hospital stay was shorter after SEMS insertion than after surgery (median, 8.0 vs 13.5 days, respectively; P < .01). Incidence of stoma creation was lower in patients treated with SEMS than in patients treated with surgery (6% vs 37%, respectively; P = .02). The median time to chemotherapy administration was shorter after SEMS insertion than after surgery (14.0 vs 28.5 days, respectively; P = .002). Three patients with SEMS and 0 patients in the surgical group underwent a curative colonic and hepatic resection after downstaging by chemotherapy (P = .27). Two patients (6%) with SEMS and undergoing chemotherapy had a tumor perforation requiring emergency surgery. There was no difference in survival between the 2 groups (median survival, 13.7 months for SEMS vs 11.4 months for surgery; P = .19). CONCLUSIONS: Insertion of SEMS should be the first step to treat obstructing colon cancer with nonresectable synchronous metastases because it allows chemotherapy to be administered earlier, may increase the resectability rate of metastases, and favorably impacts survival. The risk of tumor perforation while receiving chemotherapy requires attention.

Risk factors for mortality and intra-abdominal complications after pancreatoduodenectomy: multivariate analysis in 300 patients.

BACKGROUND: Studies of risk factors after pancreatoduodenectomy are few: some concern restricted populations and others are based on administrative data. METHODS: Multicenter clinical data were collected for 300 patients undergoing pancreatoduodenectomy to determine (by univariate and multivariate analysis) preoperative and intraoperative risk factors for mortality and intra-abdominal complications (IACs), including pancreatic fistula. Fourteen factors including the center and volume effect were analyzed. RESULTS: In univariate analysis, mortality was increased with age 70 years or more, extended resection(s), and volume and center effects. IACs occurred more often with main pancreatic duct diameter of 3 mm or less, normal parenchyma texture, extended resection(s), and the center effect. Pancreatic fistula was more frequent with main pancreatic duct diameter of 3 mm or less, normal parenchyma texture, and the center effect. In multivariate analysis, independent risk factor(s) for mortality were age greater than 70 years (odds ratio [OR], 3; 95% confidence interval [CI], 1.3-8) and extended resection (OR, 5; 95% CI, 1.2-22), risk factors for IACs were extended resection (OR, 5; 95% CI, 1.2-22) and main pancreatic duct diameter of 3 mm or less (OR, 2; 95% CI, 1.1-3), and the risk factor for pancreatic fistula was main pancreatic duct diameter of 3 mm or less (OR, 2.5; 95% CI, 1.2-4.6). CONCLUSIONS: Age more than 70 years, extended resections, and main pancreatic duct diameter less than 3 mm are independent risk factors that should be considered in indications for and techniques of pancreatoduodenectomy.

Povidone-iodine vs sodium hypochlorite enema for mechanical preparation before elective open colonic or rectal resection with primary anastomosis: a multicenter randomized controlled trial.

HYPOTHESIS: The anti-infective actions of povidone-iodine (PVI) and sodium hypochlorite enemas are different. DESIGN: Prospective, randomized, single-blind study. SETTING: Multicenter. PATIENTS: Five hundred seventeen consecutive patients with colorectal carcinoma or sigmoid diverticular disease undergoing elective open colorectal resection, followed by primary anastomosis. INTERVENTION: All patients received senna (1-2 packages diluted in a glass of water) at 6 pm the evening before surgery. Patients were administered two 2-L aqueous enemas of 5% PVI (n = 277) or 0.3% sodium hypochlorite (n = 240) at 9 pm the evening before surgery and at 3 hours before operation. Intravenous ceftriaxone sodium (1 g) and metronidazole (1 g) were administered at anesthetic induction. MAIN OUTCOME MEASURE: Rate of patients with 1 infective parietoabdominal complication or more. RESULTS: The percentages of patients with 1 infective parietoabdominal complication or more did not differ between the 2 groups (13.7% in the PVI-treated group vs 15.0% in the sodium hypochlorite-treated group). Tolerance was better in the PVI-treated group than in the sodium hypochlorite-treated group (79.4% vs 67.9%), with fewer patients experiencing abdominal pain (13.0% vs 24.6%) or discontinuing their preparation (3.0% vs 9.0%) (P=.02 for all). There were more patients with malaise in the PVI-treated group than in the sodium hypochlorite-treated group (9.1% vs 4.9%, P<.05). Three patients in the sodium hypochlorite-treated group had necrotic ulcerative colitis. CONCLUSION: When antiseptic enemas are chosen for mechanical preparation before colorectal surgery, PVI should be preferred over sodium hypochlorite because of better tolerance and avoidance of necrotic ulcerative colitis.

A controlled randomized multicenter trial of pancreatogastrostomy or pancreatojejunostomy after pancreatoduodenectomy.

BACKGROUND: Only 2 large (more than 100 patients) prospective trials comparing pancreatogastrostomy (PG) with pancreatojejunostomy (PJ) after pancreatoduodenectomy (PD) have been reported until now. One nonrandomized study showed that there were less pancreatic and digestive tract fistula with PG, whereas the other, a randomized trial from a single high-volume center, found no significant differences between the two techniques. METHODS: Single blind, controlled randomized, multicenter trial. The main endpoint was intra-abdominal complications (IACs). RESULTS: Of 149 randomized patients, 81 underwent PG and 68 PJ. No significant difference was found between the two groups concerning pre- or intraoperative patient characteristics. The rate of patients with one or more IACs was 34% in each group. Twenty-seven patients sustained a pancreatoenteric fistula (18%), 13 in PG (16%; 95% confidence interval [CI] 8-24%) and 14 in PJ (20%; 95% CI 10.5-29.5%). No statistically significant difference was found between the 2 groups concerning the mortality rate (11% overall), the rate of reoperations and/or postoperative interventional radiology drainages (23%), or the length of hospital stay (median 20.5 days). Univariate analysis found the following risk factors: (1) age > or =70 years old, (2) extrapancreatic disease, (3) normal consistency of pancreas, (4) diameter of main pancreatic duct <3 mm, (5) duration of operation >6 hours, and (6) a center effect. Significantly more IAC, pancreatoenteric fistula, and deaths occurred in one center (that included the most patients) (P = .05), but there were significantly more high-risk patients in this center (normal pancreas consistency, extrapancreatic pathology, small pancreatic duct, higher transfusion requirements, and duration of operation >6 hours) compared with the other centers. In multivariate analysis, the center effect disappeared. Independent risk factors included duration of operation >6 hours for IAC and for pancreatoenteric fistula (P = .01), extrapancreatic disease for pancreatoenteric fistulas (P < .04), and age > or =70 years for mortality (P < .02). CONCLUSIONS: The type of pancreatoenteric anastomosis (PJ or PG) after PD does not significantly influence the rate of patients with one or more IAC and/or pancreatic fistula or the severity of complications.

Medial pancreatectomy: a multi-institutional retrospective study of 53 patients by the French Pancreas Club.

BACKGROUND: The results of medial pancreatectomy have been previously reported anecdotally. The purpose of the study was to provide short- and long-term results of MP in a large multicenter collective series. METHODS: From 1990 to 1998, 53 patients (mean age +/- SD = 49 +/- 15 years) underwent medial pancreatectomy for primary cystic neoplasms of pancreas (n = 19), endocrine neoplasms (n = 17), intraductal papillary mucinous neoplasms (IPMN) (n = 6), fibrotic stenosis of the Wirsung's duct (n = 4), or other benign (n = 4) or malignant (n = 3) diseases. The proximal (right) pancreatic remnant was sutured (n = 53), and the distal (left) remnant was either anastomosed to a jejunal loop (n = 26), to the stomach (n = 25), or oversewn (n = 2). Medial pancreatectomy was indicated in 3 patients (6%) because of failed enucleation, in 3 (6%) to prevent worsening of preexisting diabetes, or to prevent de novo diabetes in a patient with chronic pancreatitis, and deliberately in the 47 others. RESULTS: The length of the resected pancreas was 5.0+/- 2.2 cm (range, 2-15). One patient (2%) died from a pancreatic fistula and portal thrombosis. Three patients were reoperated on because of complications related to the left pancreas, which was partially or totally resected. Pancreatic fistula developed in 16 patients (30%). Mean delay for the return of oral feeding was related to the presence of a pancreatic fistula. At follow-up (median = 26 months, range, 12-131), 1 pancreatic recurrence and 1 de novo diabetes occurred in patients without IPMN. In patients with IPMN, the rates of pancreatic recurrence and diabetes were 40% (2/5), respectively. CONCLUSIONS: Medial pancreatectomy effectively preserves long-term endocrine function and is associated with a low risk of local recurrence, except in patients with IPMN. However, there is a high risk (30%) of PF after medial pancreatectomy.

Laparoscopic liver resection for subcapsular hepatocellular carcinoma complicating chronic liver disease.

HYPOTHESIS: Laparoscopic liver resection for subcapsular hepatocellular carcinoma in patients with chronic liver disease is associated with lower morbidity than open resections. DESIGN: A case-comparison study. SETTING: A tertiary referral center. PATIENTS AND INTERVENTION: From December 1, 1998, to November 30, 2000, 13 patients with chronic liver disease who underwent laparoscopic resection of hepatocellular carcinoma formed the laparoscopic group (LG). Tumors were 5 cm or smaller, subcapsular, and located in anterolateral segments (segments II-VI). A control group was created by matching each laparoscopic case with patients identical for liver disease, tumor size, and location and type of hepatectomy who underwent open liver resection. Fourteen patients fulfilled the criteria and formed the open group (OG). MAIN OUTCOME MEASURES: Postoperative mortality and morbidity. RESULTS: One segment or less was resected in 21 patients and 2 in 6 patients. Operative duration and cumulative portal triad clamping times were longer in the LG (267 +/- 79 minutes vs 182 +/- 57 minutes, P =.006; 68 +/- 24 minutes vs 25 +/- 19 minutes, P =.006, respectively). Mortality rates were 0% in the LG and 14% (2/14) in the OG (P =.2). Postoperative liver failure and ascites occurred in 8% (1/13) in the LG and 36% (5/14) in the OG (P =.15). Surgical margin was not different in the 2 groups. Three-year survival was significantly higher in the LG (89% vs 55%; P =.04), but 3-year recurrence rates were similar (46% vs 44%). CONCLUSION: Our study suggests that, despite longer operative and clamping times without clinical consequences, the rate of decompensation of liver disease could be lower after laparoscopy.

Octreotide in the prevention of intra-abdominal complications following elective pancreatic resection: a prospective, multicenter randomized controlled trial.

HYPOTHESIS: Prophylactic administration of octreotide acetate decreases the rate of postoperative intra-abdominal complications (IACs) after elective pancreatic resection. DESIGN: Single-blind, controlled, randomized trial. SETTING: Multicenter (N = 20) trial in France. PATIENTS: Of 230 randomized patients undergoing pancreatoduodenectomy and pancreatic enteric anastomosis or distal pancreatectomy for either malignant or benign tumor or chronic pancreatitis, 122 were allotted intraoperatively to receive octreotide; 108 served as controls. RESULTS: All 230 patients were analyzed. Both groups were comparable except that significantly more patients in the octreotide group had biological glue injected into the main pancreatic duct alone (P<.001) or reinforcing the pancreatic enteric anastomosis (68% [83/122] vs 39% [42/108]; P =.002). Fewer patients (P =.08) in the octreotide group sustained 1 or more IACs (22% vs 32%). In subgroup analysis, octreotide significantly reduced the rate of patients sustaining 1 or more IACs when the main pancreatic duct diameter was less than 3 mm (P<.02), when pancreatojejunostomy was performed (P<.02), or both (P<.02). No significant differences were found regarding IAC severity. Twenty-three patients (10%) died postoperatively, 16 (70% of deaths) of whom had 1 or more IACs. The only independent risk factor for IACs found on multivariate analysis was pancreatoduodenectomy compared with distal pancreatectomy (P<.01) (odds ratio, 3.54 [95% confidence interval, 1.44-8.65]). CONCLUSIONS: Our results suggest that octreotide is not necessary for all patients undergoing pancreatic resection; it could be useful when the main pancreatic duct is less than 3 mm in diameter and when pancreatoduodenectomy is completed by pancreatojejunostomy.

Laparoscopic versus open left lateral hepatic lobectomy: a case-control study.

BACKGROUND: After technical advances in hepatic surgery and laparoscopic surgery, some teams evaluated the possibilities of laparoscopic liver resections. The aim of our study was to assess the results of laparoscopic left lateral lobectomy (bisegmentectomy 2-3) and to perform a case-control comparison with the same operation performed by open surgery. STUDY DESIGN: From 1996 to 2002, 60 laparoscopic resections were performed in selected patients, including 18 left lateral lobectomies. The resected lesions were benign tumors, hepatocellular carcinomas with compensated cirrhosis, and metastases. Surgical procedures were performed with a harmonic scalpel, an ultrasonic dissector, linear staplers, and portal pedicule clamping when necessary. Results were compared with those of patients who underwent open left lateral lobectomies selected from our liver resection database in a case-control analysis. Both groups were similar for age, type and size of the tumor, and presence of underlying liver disease. RESULTS: Compared with laparotomy, laparoscopic left lateral lobectomies were associated with a longer surgical time (202 versus 145 minutes, p < 0.01), a longer portal triad clamping (39 versus 23 minutes, p < 0.05), and a decreased blood loss (236 versus 429 mL, p < 0.05). There were no deaths in either group, and the morbidity rates were 11% in the laparoscopic group and 15% in the open group. There were no specific complications of hepatic resection after laparoscopy (no hemorrhage, subphrenic collection, or biliary leak), but some were observed in the open group. CONCLUSIONS: This study demonstrates the safety of laparoscopic left lateral lobectomy. Despite longer operation and clamping time, without any clinical consequences, the laparoscopic approach was associated with decreased blood loss and absence of specific complications of the hepatic resection.

Randomized trial of adjuvant chemotherapy after curative resection for gastric cancer.

BACKGROUND: The aim of the study was to evaluate the efficacy of adjuvant chemotherapy on survival after resection for gastric cancer. METHODS: Patients were enrolled if they underwent resection of gastric cancer but had lymph node or serosal involvement or both. Surgical resection was either total or partial gastrectomy according to the site of the tumor, and surgeons were allowed to perform either D1 or D2 gastrectomy. The subjects were random assigned in two treatment groups as follows: surgery alone as the control group, or surgery and adjuvant chemotherapy. Nine cycles of 5 days protocol every 4 weeks was proposed to the patients of the chemotherapy group. The protocol included a daily administration of 200 mg/m(2) of folinic acid, 5-fluorouracil (375 mg/m(2) during the first session increasing 25 mg by session until reaching 500 mg/m(2)) and CDDP 15 mg/m(2). Two hundred patients were required. Kaplan-Meier survival curves were compared according to the log-rank and the Mantel-Haenszel methods. RESULTS: In all, 205 patients were enrolled in the study; 104 had surgery alone and 101 had surgery and adjuvant chemotherapy. The patients' characteristics were similar except for the mean age, which was 4 years less in the control group. Because of toxicity, 54% of the patients stopped the protocol before the end of the nine courses, and 46% of the patients received the nine courses including 32% with a decreased dose and 14% with a full dose. The 5-year survival rate was 39% in the control group and 39% in the chemotherapy group. CONCLUSIONS: This protocol of adjuvant chemotherapy failed to improve the 5-year survival after resection for gastric cancer.

[Laparoscopic resection of benign submucosal stomach tumors. A report of 65 cases]. / Exérèse laparoscopique des tumeurs sous-muqueuses bénignes de l'estomac. A propos de 65 cas.

AIM OF THE STUDY: The aim of this retrospective multicenter study was to evaluate the feasibility and the results of laparoscopic resection of benign submucosal gastric tumors. PATIENTS AND METHODS: We reviewed the cases of 65 patients (20 centers) who have been operated on laparoscopically for benign submucosal gastric tumors. The tumor was symptomatic in 56 cases, located on the posterior wall in 23 cases. The mean size of the tumor was 3.8 cm (1.5-10). RESULTS: A laparoscopic wedge resection was performed in 53 cases. In 1 case a laparoscopic-assisted gastrectomy was done. A conversion to laparotomy was mandatory in 11 cases because of difficulties in localization of the tumor (n=5), in excision (n=5) or for safety reasons (n=1). There was no mortality. Two patients required reoperation because of bleeding. During follow-up, one patient developed recurrence requiring a second laparoscopic excision. CONCLUSION: Most submucosal benign gastric tumors can be removed by laparoscopy. The location of the tumor (posterior wall or closed to the lesser curvature) or the size of the tumor (large or very small) can make the laparoscopic approach difficult.

Dysphagia after Laparoscopic 360 Repair for Gastroesophageal Reflux Disease.

In comparison to medical treatment, antireflux surgery is recognized as an effective, efficient and longlasting therapy, as well as the only treatment that is able to modify the natural history of gastroesophageal reflux disease (GERD). The 360 fundoplication is the most widely used surgical procedure for GERD. Although performed in the era of H2-blockers and open surgery, comparison of the so-called Nissen repair to both symptomatic and continuous medical therapies concluded that surgery was superior to medical therapy in every outcome measure used.

Laparoscopic liver resection for peripheral hepatocellular carcinoma in patients with chronic liver disease: midterm results and perspectives.

OBJECTIVE: Report the midterm results of laparoscopic resection for hepatocellular in chronic liver disease (CLD). SUMMARY BACKGROUND DATA: Surgical resection for hepatocellular carcinoma (HCC) in chronic liver disease (CLD) remains controversial because of high morbidity and recurrence rates. Laparoscopic resection of liver tumors has recently been developed and could reduce morbidity. METHODS: From 1998 to 2003, patients with HCC and CLD were considered for laparoscopic liver resection. Inclusion criteria were chronic hepatitis or Child's A cirrhosis, solitary tumor < or =5 cm in size, and location in peripheral segments of the liver. Mortality, morbidity, recurrence rates, and survival were analyzed. RESULTS: A total of 27 patients were included. Liver resections included anatomic resection in 17 cases and non anatomic resection in 10. Seven conversions to laparotomy (26%) occurred for moderate hemorrhage in 5 cases and technical difficulties in 2 cases. Mortality and morbidity rates were 0% and 33%, respectively. Postoperative ascites and encephalopathy occurred in 2 patients (7%) who both had undergone conversion to laparotomy. Mean surgical margin was 11 mm (range, 1-47 mm). After a mean follow-up of 2 years (range, 1.1-4.7), 8 patients (30%) developed intrahepatic tumor recurrence of which one died. Treatment of recurrence was possible in 4 patients (50%), including orthotopic liver transplantation, right hepatectomy, radiofrequency ablation, and chemoembolization in 1 case each. There were no adhesions in the 2 reoperated patients. Overall and disease-free 3-year survival rates were 93% and 64%, respectively. CONCLUSION: Our study shows that laparoscopic liver resection for HCC in selected patients is a safe procedure with very good midterm results. This approach could have an impact on the therapeutic strategy of HCC complicating CLD as a treatment with curative intent or as a bridge to liver transplantation.

Anatomical bi- and trisegmentectomies as alternatives to extensive liver resections.

OBJECTIVE: To assess the technical and oncologic results of anatomic hepatic bi- and trisegmentectomies. SUMMARY BACKGROUND DATA: Regardless of their size, some tumors require extensive hepatectomy only because they are located centrally or in the vicinity of major portal pedicles or hepatic veins. Anatomic bi- and trisegmentectomy might represent an alternative to extensive hepatectomies in such cases. METHODS: Of 435 liver resections, 32 cases (7%) included 2 or 3 adjacent segments (left lateral sectionectomies, ie, bisegmentectomies 2-3, excluded). There were 16 central hepatectomies (segments 4, 5, and 8), 7 right posterior sectionectomies (segments 6 and 7) and 2 central anterior (segments 4b and 5), 1 central posterior (segments 4a and 8), 2 right superior (segments 7 and 8), 3 right inferior (segments 5 and 6), and 1 left anterior (segments 3 and 4b) bisegmentectomies. Indications were malignant disease in 29 patients, including 15 with cirrhosis and 2 with benign tumors. External landmarks, selective devascularization, and intraoperative ultrasound were used to achieve anatomic resection. RESULTS: Mortality, transfusion, and morbidity rates were 0%, 26%, and 19%, respectively. Mean section margin was 9 mm (range, 1-40 mm). Isolated intrahepatic recurrence occurred in 7 patients (24%) and 3 (43%) underwent repeat hepatectomy. CONCLUSION: Anatomic bi- or trisegmentectomy is a safe alternative to extensive liver resection in selected patients, avoiding unnecessary sacrifice of functional parenchyma and enhancing the opportunity to perform repeat resections in cases of recurrence.

Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra-abdominal complications after pancreatic resection: prospective randomized trial.

OBJECTIVE: To determine whether temporary occlusion of the main pancreatic duct with human fibrin glue decreases the incidence of intra-abdominal complications after pancreatoduodenectomy (PD) or distal pancreatectomy (DP). SUMMARY BACKGROUND DATA: To the authors' knowledge, there are no randomized studies comparing outcomes after pancreatic resection with or without main pancreatic duct occlusion by injection of fibrin glue. Of three nonrandomized studies, two reported no fistulas after intracanal injection and ductal occlusion with fibrin glue after PD with immediate pancreatodigestive anastomosis, while another study reported no protective effect of glue injection. METHODS: This prospective, randomized, single-blinded, multicenter study, conducted between January 1995 and January 1999, included 182 consecutive patients undergoing PD followed by immediate pancreatic anastomosis or DP, whether for benign or malignant tumor or for chronic pancreatitis. One hundred two underwent pancreatic resection followed by ductal occlusion with fibrin glue (made slowly resorbable by the addition of aprotinin); 80 underwent resection without ductal occlusion. The main end point was the number of patients with one or more of the following intra-abdominal complications: pancreatic or other digestive tract fistula, intra-abdominal collections (infected or not), acute pancreatitis, or intra-abdominal or digestive tract hemorrhage. Severity factors included postoperative mortality, repeat operations, and length of hospital stay. RESULTS: The two groups were similar in pre- and intraoperative characteristics except that there were significantly more patients in the ductal occlusion group who were receiving octreotide, who had reinforcement of their anastomosis by fibrin glue, and who had fibrotic pancreatic stumps. However, the rate of patients with one or more intra-abdominal complications, and notably with pancreatic fistula, did not differ significantly between the two groups. There was still no significant difference found after statistical adjustment for these patient characteristic discrepancies, confirming the inefficacy of fibrin glue. The rate of intra-abdominal complications was significantly higher in the presence of a normal, nonfibrotic pancreatic stump and main pancreatic duct diameter less than 3 mm, whereas reinforcement of the anastomosis with fibrin glue or use of octreotide did not influence outcome. In multivariate analysis, however, normal pancreatic parenchyma was the only independent risk factor for intra-abdominal complications. No significant differences were found in the severity of complications between the two groups. CONCLUSIONS: Ductal occlusion by intracanal injection of fibrin glue decreases neither the rate nor the severity of intra-abdominal complications after pancreatic resection.

Laparoscopic living donor hepatectomy for liver transplantation in children.

BACKGROUND: Because cadaveric organ donors are in short supply, living donors are increasingly being used in transplantations. We have developed a safe and reproducible method for laparoscopic liver resection. METHODS: Left hepatic lobectomy (resection of segments 2 and 3) was done by laparoscopy in one woman aged 27 years and one man aged 31 years. The grafts were prepared under laparoscopy, without any vascular clamping, and were externalised through a suprapubic Pfannenstiel incision. Both grafts were transplanted conventionally to the patients' respective sons, who were both aged 1 year and had biliary atresia. FINDINGS: Donor operations lasted 7 h for the woman and 6 h for the man, and warm ischaemia times were 4 and 10 min, respectively. Blood loss was 150 and 450 mL, respectively, and no transfusions were required. Neither patient had complications during or after surgery; and hospital stay was 7 and 5 days, respectively. Both recipients are alive and have excellent graft function. INTERPRETATION: We have shown the feasibility of laparoscopic living donor hepatectomy from parent to child. If the safety and feasibility of this procedure can be shown in larger series, laparoscopic donor left lobectomy could become a new option for paediatric living donor liver transplantation.