How can recovery be enhanced after single-stage laparoscopic management of CBD stones? Endoscopic treatment versus laparoscopic surgery.

BACKGROUND: Single-stage management of CBD stones comprises simultaneous common bile duct (CBD) clearance and cholecystectomy. The CBD can be cleared by using endoscopic treatment (ET) or laparoscopic surgery (LS) alone. AIMS: To determine the most rapid recovery after the single-stage laparoscopic management of CBD stones. METHODS: Patients with CBD stones treated at either of two centers (one performing ET only and one performing LS only for single-stage treatment) were included. The primary endpoint was "the textbook outcome". RESULTS: The feasibility rate was 74% for ET and 100% for LS (p≤0.001). The proportion of cases with the textbook outcome was higher in the ET group than in the LS-only group (73% vs. 10%; p<0.001). The CBD clearance rate was similar in the ET and LS-only groups (100% vs. 96.6%, respectively; p=0.17). The overall morbidity rate was lower in the ET group than in the LS-only group (23% vs. 29%, p=0.05). CONCLUSION AND RELEVANCE: Both ET and LS are feasible, safe and effective for clearance of the CBD. ET was better than LS in terms of a less frequent requirement for drainage and a shorter length of hospital stay. LS was associated with a shorter operating time.

Does use of a metallic colon stent as a bridge to surgery modify the pathology data in patients with colonic obstruction? A case-matched study.

BACKGROUND: In a recent propensity score study, we established that overall- and disease-free survival were worse after use of a colonic stent (CS) than after emergency surgery for colonic obstruction. The present study sought to explain the association between CS use and poor survival by analyzing pathological specimens. METHODS: From January 1998 to December 2011, all patients with left obstructive colon cancer and having been operated on with curative intent were included in the study. The primary end point involved a comparison of pathological data from the CS- and the surgery-only groups in a case-matched analysis (with the groups matched for the T stage). In a series of secondary analyses, we studied a range of factors known to be associated with adverse outcomes (microscopic perforation, vascular embolism, perineural invasion, and lymph node invasion) in the study population as a whole (in order to evaluate stenting as an adverse factor) and in the CS group alone (in order to identify factors associated with a poor prognosis in this specific group of patients). RESULTS: A total of 84 patients were included in the study (50 in the CS group). Stenting was mentioned in only 70 % of the pathology lab reports (n = 35/50). Twenty-five patients in the CS group were matched with 25 patients of the surgery-only group. Tumor ulceration (p < 0.0001), peritumor ulceration (p < 0.0001), perineural invasion (p = 0.008), and lymph node invasion (p = 0.005) were significantly more frequent in the CS group. In a multivariate analysis of the CS group, T4 status and tumor size were significant risk factors for microscopic perforation, perineural invasion, and lymph node invasion. CONCLUSION: The CS- and surgery-only groups differed significantly in terms of ulceration at or near the tumor, perineural invasion, and lymph node invasion. Explanation of the adverse outcomes associated with CS use will probably require further investigation.

Feasibility of the Glissonian approach during right hepatectomy.

OBJECTIVE: The Glissonian approach during hepatectomy is a selective vascular clamping procedure associated with low rates of technical failure and complications. The aim of the present study was to assess the feasibility of a right Glissonian approach in relation to portal vein anatomy. METHODS: This was a prospective study conducted over a 12-month period, which included 32 patients for whom preoperative three-dimensional reconstruction using contrast-enhanced computed tomography in the portal venous phase and portography for right portal vein embolization were available, and in whom a right Glissonian approach was applied during right hepatectomy. Preoperative imaging data were correlated with intraoperative Doppler ultrasound findings (considered as the reference dataset). Causes of failures and complications specifically related to the Glissonian approach were identified. RESULTS: Right hepatectomy was performed for colorectal liver metastases (n = 25), hepatocellular carcinoma on cirrhosis (n = 6) and intrahepatic cholangiocarcinoma (n = 1). The Glissonian approach was effective in 24 (75%) patients. In the remaining eight (25%) patients, failure was caused by incomplete clamping (n = 2) or clamping of the left portal pedicle (n = 6). The portal anatomy was aberrant in six patients with failure, showing portal trifurcation (n = 1), right portal trifurcation (n = 1) and a common trunk between the right anterior and left portal branch (n = 4). An angle of less than 50° between the portal vein and left portal branch was reported in association with extended clamping to the left portal branch (selectivity = 72%, specificity = 71%). Intraoperative bleeding and biliary fistula occurred in two patients with non-normal portal anatomy. CONCLUSIONS: The right Glissonian approach was effective in 75% of patients. Failure of the procedure (including the extension of clamping to the left pedicle) mostly occurred in patients with portal vein variations, which can be accurately assessed using a combination of preoperative imaging and intraoperative Doppler ultrasound.

Is stenting as "a bridge to surgery" an oncologically safe strategy for the management of acute, left-sided, malignant, colonic obstruction? A comparative study with a propensity score analysis.

OBJECTIVE AND BACKGROUND: Self-expanding metallic stent (SEMS) insertion has been suggested as a promising alternative to emergency surgery for left-sided malignant colonic obstruction (LMCO). However, the literature on the long-term impact of SEMS as "a bridge to surgery" is limited and contradictory. METHODS: From January 1998 to June 2011, we retrospectively identified patients operated on for LMCO with curative intent. The primary outcome criterion was overall survival. Short-term secondary endpoints included the technical success rate and overall success rate and long-term secondary endpoints included 5-year overall survival, 5-year cancer-specific mortality, 5-year disease-free survival, the recurrence rate, and mean time to recurrence. Patients treated with SEMS were analyzed on an intention-to-treat basis. Overall survival was analyzed after using a propensity score to correct for selection bias. RESULTS: There were 48 patients in the SEMS group and 39 in the surgery-only group. In the overall population, overall survival (P = 0.001) and 5-year overall survival (P = 0.0003) were significantly lower in the SEMS group than in the surgery-only group, and 5-year cancer-specific mortality was significantly higher in the SEMS group (48% vs 21%, respectively (P = 0.02)). Five-year disease-free survival, the recurrence rate, and the mean time to recurrence were better in the surgery-only group (not significant). For patients with no metastases or perforations at hospital admission, overall survival (P = 0.003) and 5-year overall survival (30% vs 67%, respectively, P = 0.001) were significantly lower in the SEMS group than in the surgery-only group. CONCLUSIONS: Our study results suggest worse overall survival of patients with LMCO with SEMS insertion compared with immediate surgery.

The feasibility of short-stay laparoscopic appendectomy for acute appendicitis: a prospective cohort study.

BACKGROUND: Short-stay laparoscopic appendectomy for acute appendicitis (AA) has not yet been validated. This study was designed to prospectively evaluate the hospital length of stay (LOS) after laparoscopic appendectomy for AA and to determine predictive factors for successful short-stay surgery (LOS <24 h). METHODS: Between January and December 2010, all consecutive adults admitted for AA were prospectively treated with LOS <24 h as a patient management goal. The proportion of patients with LOS <24 h was analyzed for the intention-to-treat (ITT) population and for the population eligible for short-stay surgery. Predictive factors for LOS <24 h were analyzed. RESULTS: Of the 123 patients included in this study, 71.5 % (88/123) were eligible for short-stay surgery. The proportion of LOS <24 h cases was 52 % (64/123) in the ITT population and 72.7 % (64/88) in the eligible population. LOS <12 h was achieved in 17.8 % (22/123) in the ITT patients and 25 % (22/88) of the eligible patients. The main cause of unexpected readmission was postoperative pain (n = 10, 8.1 %). Age <23 years and a serum C-reactive protein level <18 mg/l had a positive predictive value of 100 % for LOS <24 h. Of the eligible patients, 27.2 % (24/88) were subject to unplanned overnight admissions and postsurgery readmissions. CONCLUSIONS: LOS <24 h was feasible for 52 % of patients admitted for AA and for 72.7 % of the patients eligible for short-term surgery. Low age and a low preoperative serum CRP level are predictive factors for the feasibility of short-stay laparoscopic appendectomy for AA.