Feasibility of laparoscopic portal vein ligation prior to major hepatectomy.

BACKGROUND: Patients noted to have an inadequate future liver remnant on pre operative volumetric assessment are considered to be candidates for portal vein embolization (PVE). A subset of patients undergo laparoscopic intervention prior to PVE for staging purposes or to address the primary in Stage IV colon cancer. These patients usually undergo PVE as a subsequent additional procedure by the transhepatic route. The aim of this study was to assess the feasibility of portal vein ligation by the laparoscopic approach in suitable patients. MATERIALS AND METHODS: A retrospective review of a prospectively maintained database was performed to identify patients that underwent laparoscopic portal vein ligation (LPVL). The demographic, clinical, radiographic, operative and volumetric details were collected to determine the feasibility of portal vein ligation. RESULTS: A total of nine patients underwent LPVL as part of a two stage procedure in preparation for subsequent major hepatectomy. With a median age of 67 yrs, the diagnoses included: colorectal metastasis (five patients), cholangiocarcinoma (three patients) and hepatocellular carcinoma (one patient). The ligation involved the right portal vein in all and was performed with silk ligature (seven patients) and clips (two patients). Volumetric data was available in six patients which showed a mean increase from 209.1 cc+/-97.76 to 495.83 cc+/-310.91 (increase by 181.5%) In two patients, inadequate hypertrophy mandated later embolization by percutaneous technique. Five patients underwent subsequent major hepatic resection as planned. The remaining four patients were noted to have progression of disease that precluded the planned procedure. There were no complications associated with LPVL. CONCLUSIONS: LPVL is feasible and can be safely performed. In a select group of patients, it may be considered as an alternative to subsequent embolization and thereby potentially absolve the need for an additional procedure with its attendant complications.

Laparoscopic cholecystectomy by ultrasonic dissection without cystic duct and artery ligature.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the gold standard treatment of gallstones. Nevertheless, there are some pitfalls due to the limits of current technology and the use of inappropriate ligature material, with a relevant risk of injuries and postoperative, mainly biliary, complications. Ultrasonically activated scissors may divide both vessels and cystic duct, with no need of further ligature, and possibly reduce the risk of thermal injuries. METHODS: A prospective nonrandomized clinical trial was started in 1999 to test harmonic shears (Ultracision, Ethicon Endo-Surgery, Cincinnati, OH, USA) in 461 consecutive patients undergoing LC in order to evaluate the theoretical benefits of ultrasonic dissection and the possible reduction in intraoperative bile duct injuries (BDIs) and postoperative complications. Patients were divided in two groups: in group 1 (HS; 331 patients) the operation was performed by Ultracision (including coagulation-division of cystic duct and artery); in group 2 (LOOP; 130 patients) the cystic duct, after coagulation-division by harmonic scissors, was further secured with an endo-loop. Both groups were further divided into two subgroups: expert and surgeon-in-training. The following categories of data were collected and analyzed: individual patient data, indication for laparoscopic cholecystectomy, surgical procedure data (associated procedures, intraoperative cholangiography, intraoperative complications, length of surgery, and conversion to open), and postoperative course data (postoperative morbidity, postoperative mortality, reinterventions, and postoperative hospital stay). Furthermore, biliary complications were analyzed as a single parameter comparing the incidence within groups and subgroups. Cumulative complications (intraoperative and postoperative) were also analyzed as a single parameter comparing their incidence in the series of each surgeon within the surgeon-in-training subgroup to the average results of the expert subgroup. Finally, length of surgery, postoperative complication rate, and length of postoperative hospital stay within subgroups were analyzed to evaluate the learning curve. RESULTS: Overall conversion rate was 0.87%. The mean operating time was 76.8 min (median, 70 min) in group 1 and 97.5 min (median 90 min) in group 2. BDI occurred in 1 case (0.32%) in the surgeon-in-training subgroup. Overall BDI rate was 0.22% (1/461). The overall incidence of postoperative bile leak was 2.7% (9 patients of subgroup 1 and 1 patient of subgroup 2). Clinical observation with spontaneous resolution occurred in 4 patients, and in 1 case the management consisted in an endoscopic biliary drainage; surgery was requested in the remaining cases. A laparoscopic approach was successfully attempted in all cases. Overall morbidity rate was 8.76% in group 1 and 13.84% in group 2. Rates of major complications, overall biliary complication, and postoperative bile leaks within the expert and surgeon-in-training subgroup differ significantly (p = 0.026, p = 0.03, and p = 0.049, respectively). There was 1 death (0.22%) due to sepsis that resulted from a small bowel injury by trocar insertion. Mean postoperative stay was 4.28 days for group 1 and 5.05 days for group 2. CONCLUSION: No significant difference was found in both patient groups regarding postoperative mortality and complications, biliary complications, and especially cystic duct leaks. A retrospective comparison of literature data showed that use of ultrasonic dissection during LC seems to reduce the risk of BDI. Nevertheless, a learning curve in the use of ultrasonic-activated devices is required: a significant differences in postoperative major complications and biliary complications between the expert and the surgeon-in-training subgroups was shown. Furthermore, ultrasonic scissors misuse may cause bowel injuries in patients with severe adhesions, and this could represent a possible limitation for surgical safety.

Cholecystoenteric fistula (CF) is not a contraindication for laparoscopic surgery.

BACKGROUND: Cholecystoenteric fistula (CF) is a rare complication of cholelithiasis. The aim of this study was to evaluate the safety and risk of complications when the laparoscopic approach is applied in patients with CF. METHODS: A questionnaire was mailed to all surgeons with experience of >100 cholecystectomies working in Naples, Italy, and the neighboring area. RESULTS: Between February 1990 and May 1999, 34 patients presented with cholecystoenteric fistula (0.2% of >15,000 laparoscopic cholecystectomies performed in the same period). These patients were allocated into two groups: the LT group (those who underwent laparotomic conversion after the diagnosis of CF), which consisted of 20 patients, four men and 16 women, with a mean age of 66.5 +/- 9.3 years (range, 46-85) and the LS group (laparoscopically treated patients), which consisted of 14 patients, three men and 11 women, with a mean age of 65.6 +/- 8.8 years (range, 51-74). They types of CF observed were as follows: in the former group of patients, cholecystoduodenal fistulas (n = 11, 55%), cholecystocolic fistulas (n = 5, 25%), cholecystojejunal fistulas (n = 3, 15%), and cholecystogastric fistulas (n = 1, 5%); in the latter group, cholecystoduodenal fistulas (n = 8, 5.1%), and cholecystocolic fistulas (n = 4, 28.6) and cholecystojejunal fistulas (n = 2, 14.3%). Stapler closure of CF was done in four LT patients and three LS patients with cholecystoduodenal fistula; it was also done in three LT patients and three LS patients with cholecystocolic fistula. Hand-sutured fistulectomy was performed in six LT patients and three LS patients with cholecystoduodenal fistula, in two LT patients with cholecystocolic fistula, and in all patients with cholecystojejunal or cholecystogastric fistula. There were no deaths or intraoperative complications in either group. One patient in the LT group developed a bronchopneumonia postoperatively. Postoperative hospital stay was significantly longer in LT patients-17 +/- 4 vs 3+/-1 days (p < 0.001). CONCLUSION: Cholecystoenteric fistula is an occasional intraoperative finding during laparoscopic cholecystectomy. The results of this study, which are based on the collective experiences of 19 surgeons, illustrate the growing success of the laparoscopic approach to this condition, including a decreasing rate of conversion to open surgery over the last 3 years.

Laparoscopic gastric resections.

The impressive breakthrough in laparoscopic surgery has pushed surgeons to perform gastric resection through such an approach. Laparoscopy reduces the surgical stress and the postoperative pain and has a positive impact on the rehabilitation time, the hospital stay, and return to work and social activities. Laparoscopic partial gastrectomy for benign diseases and for palliation has been accepted as an effective surgical option: they are reproducible operations performed worldwide at a more and more rapid pace. Laparoscopic gastric resections and laparoscopically assisted gastric resections for malignancy deserve a word of caution. Nevertheless, the investigators report their series of laparoscopic subtotal and distal gastrectomies for cancer with medium and long-term results comparable with those of open surgery. Furthermore, new and less invasive surgical options have been recently introduced. Full and partial thickness local resections may be accomplished through intragastric procedures, for treatment of small benign tumors and early stage gastric cancer.

Normothermic ischemia induces major histocompatibility complex class I expression in hepatocytes.

The hepatic expression of major histocompatibility complex (MHC) antigens is normally limited. However aberrant expression may occur in cholestatic diseases or following liver transplantation. The aim of this work was to investigate the effect of normothermic ischemia on hepatocellular MHC expression. Temporary (90-min) normothermic ischemia of the liver was induced in inbred rats. There was a significant elevation of aspartate aminotransferase and alanine aminotransferase levels after ischemia, rising to their maximum by 6 h. Histologic findings showed large, confluent areas of necrosis, and preserved areas were seen with centrolobular congestion and macrovacuolar steatosis. Expression of MHC class I and II antigens was detected using the immunoperoxidase technique, 1 h, 12 h, 3 days, 7 days and 1 month after the end of intervention. A marked induction of the expression of class I, but not of class II, MHC antigens was observed on the hepatocyte membranes after ischemia. We suggest that normothermic ischemia can occur postoperatively in human liver transplantation and may cause increased expression of class I MHC antigens on hepatocytes, leading to increased sensitivity of liver allografts to rejection by cytotoxic T cells.

DNA flow cytometry in patients undergoing liver transplantation for hepatocellular carcinoma.

The purpose of the study was to analyse patterns of DNA content in hepatocellular carcinomas (HCC) submitted to orthotopic liver transplantation (OLT). Paraffin-embedded archival material from 15 patients (ten men, five women, mean age 51 +/- 1.78 years) transplanted in St-Roch Hospital between 1988 and 1991 was available for laboratory evaluation by flow cytometry. Five out of 15 were incidental HCC. The analysis was performed by a FACSscan flow cytometer coupled to a Hewlett-Packard computer. The cellular DNA content was defined as diploid or aneuploid in the presence of a single (DNA index of 1) or two distinct (DNA index different from 1) Gzero/G1 peaks, respectively. All incidental HCC (five patients) were diploid, the tumour size was 1.2 +/- 0.2 cm, the number of nodules was 1.4 +/- 0.24 and the mortality rate was 40%. No death in the incidental HCC group was related to neoplastic recurrence. In the remaining ten patients transplanted for HCC, we observed 50% diploid tumours, the tumour size was 5.2 +/- 1.55 cm and the number of nodules was 2.7 +/- 0.56. In this group six patients died of neoplastic recurrence (two were diploid and four aneuploid). The diameter of the neoplasm in diploid patients who died of neoplastic recurrence was over 5 cm and the number of nodules was over three. Moreover, in aneuploid patients who died of neoplastic recurrence, the diameter of the neoplasm was less than 5 cm in three cases and the number of nodules was less than three in two patients. This study indicates that incidental HCC may be a less aggressive malignancy and may have a better prognosis. In this group, no patient recurred after OLT and all tumours were diploid. Aneuploidy, tumour size (> 5 cm) and number of lesions (> 3) are prognostic indicators for neoplastic recurrence in patients transplanted for hepatocellular carcinoma.

[Laparoscopic treatment of appendiceal peritonitis in adults]. / Traitement par voie coelioscopique des péritonites appendiculaires chez l'adulte.

UNLABELLED: The aim of this study was to evaluate the results of laparoscopic treatment of appendicular peritonitis. PATIENTS AND METHODS: From January 1991 to December 1994, 32 patients (16 men and 16 women with a mean age of 43 years) underwent emergency laparoscopy for a clinical diagnosis of localized or generalized appendicular peritonitis. All patients had double antibiotic therapy for at least 7 days. The laparoscopic appendectomy technique consisted of:insufflation to 12 mmHg, introduction of 3 trocars, first peritoneal lavage, coagulation of the mesoappendix, ligature of the base of the appendix, no drainage. RESULTS: There were 4 conversions (12.5%). Nine of the 28 cases treated completely by laparoscopy, presented generalized peritonitis and 19 presented localized peritonitis (including 8 abscesses). The operations were performed by 7 surgeons and the mean operating time was 86 minutes. There were no deaths. The postoperative morbidity was 10.7%. The mean duration of postoperative ileus was 2.8 days. The mean hospital stay was 6.8 days. Histological examination concluded on acute suppurative appendicitis 96.4% of cases. There were no bowel obstructions or incisional hernias with a mean followup of 28.5 months. CONCLUSIONS: The laparoscopic treatment of appendicular peritonitis is possible, simple and reproducible, effective, without any specific complications. The advantages of laparoscopic techniques over the traditional large incisions are the absence of parietal complications, the quality of exploration and peritoneal lavage, and improvement of postoperative comfort.

Port-Site Recurrence of Cancer Associated With Laparoscopic Diagnosis and Resection: The European Experience.

Port-site recurrences of cancer have drawn attention to the potential risks of laparoscopy for the diagnosis and treatment of digestive cancers. The first observations concerned unsuspected gallbladder cancers shown by laparoscopic cholecystectomy for lithiasis. Seventeen cases in patients with advanced or early colon cancer followed. It eventually became clear that all cancers could be the origin of such recurrences, which present as apparently isolated nodules embedded in the wall. These parietal recurrences were well known in open surgery, having been reported for most cancers, but they drew little attention because they usually occur in the context of carcinosis. It must be remembered that digestive cancers in general have a high potential for dissemination and that nearly 30% of patients have micrometastases in the bloodstream, the lymph nodes, the peritoneum, or even the bone marrow. The mechanism of tumor implantation is analogous to development of an inflammatory reaction. Under these conditions, laparoscopic surgery is susceptible to cause neoplastic dissemination for a number of mechanical reasons: CO2 insufflation, tumor manipulation, failure to isolate the tumor, forceful extraction of the surgical specimen, and exsufflation. Multiinstitutional trials of well-defined laparoscopic protocols based on the same oncologic principles as in open surgery should reduce the frequency of tumor cell dissemination and the incidence of port-site recurrences.

Hyperacute rejection of liver allografts in sensitized rats: role of nonparenchymal liver cells.

Reasons why liver allografts are more resistant to antibody mediated rejection than other organ allografts are not fully understood. In order to define the role of nonparenchymal liver cells, we have compared the fate of liver allografts in two combinations of sensitized inbred rats. In the DA into LEW combination, hyperacute rejection of liver allografts was observed (mean survival time of liver grafted rats was 5.2 +/- 0.6 hr). A sharp decrease of the level of cytotoxic antibodies was observed after transplantation associated with deposits of IgG, IgM, C3, and fibrinogen on sinusoidal cells. Macroscopic and histological aspects of liver allografts were suggestive of an antibody-mediated rejection with congestion and portal hemorrhage. On the contrary, in the LEW into BN combination, survival time was significantly longer (259.2 +/- 25.2 hr), whereas histological studies demonstrated signs of cellular rejection. A decrease in the level of cytotoxic antibodies was present and deposits of IgG, IgM, C3, and fibrinogen were more significant. After blockade of the Kupffer cells of the LEW-transplanted liver, survival time of the BN rats was significantly reduced (38.8 +/- 8.0 hr). Macroscopic and histological aspects of the grafts were suggestive of antibody-mediated rejection and deposits of IgG, IgM, and C3 were reduced. The results suggest the hypothesis that resistance of liver allografts to antibody-mediated rejection is probably due to the ability of nonparenchymal liver cells to absorb preformed cytotoxic antibodies and complement.

Immunophenotyping and metastatic localization of breast cancer.

Monoclonal antibody SM 92 is involved in the immunophenotype of gastrointestinal and liver cells, SM 43 in ovarian cells, and SM 13 in lung cells. Based on a study of 61 breast adenocarcinoma patients, we found that tumors reacting with SM 92 appear associated with liver metastases, SM 43 with ovarian metastases, and SM 13 with lung metastases. These associations are highly significant. They lend some support to the concept that tumor cells that metastasize tend to go to sites where cells normally have the same surface antigens.

Role of non-parenchymal liver cells in ischaemia-reperfusion liver injury: protective effects of muramyl dipeptide.

It has been suggested that non-parenchymal liver cells play a central role after ischaemia and reperfusion of the liver. Male Lewis rats were subjected to 90 min of warm liver ischaemia. Four groups were constituted: group 1, no treatment; group 2, muramyl dipeptide treatment, activation of Kupffer cells; group 3, dextran sulphate injection, Kupffer cell blockade; and group 4, gadolinium chloride administration, Kupffer cell blockade. Dextran sulphate (4 mg/100 g) and gadolinium chloride (GdCl2, 0.7 mg/100 g) were given intravenously on day 2. MDP was injected intravenously (500 mg/250 g) 24 h before and 10 min after the intervention. Mortality rates were assessed and serum transaminases, histology of the liver and Kupffer cell phagocytic activity were evaluated 6 h after the end of ischaemia. MDP treatment significantly (P < 0.001) reduced mortality (30%) in comparison with the non-treated group (60%). The mortality rate was significantly higher in the dextran sulphate-treated (80%) and gadolinium chloride-treated (90%) groups in comparison with group 1. A significant reduction in transaminase levels was observed after MDP treatment, while blockade of Kupffer cells resulted in higher serum transaminase levels. The extent of necrosis and congestion was improved by MDP administration, while disruption of the vascular and sinusoidal integrity of the liver and extensive areas of necrosis were observed in dextran sulphate and gadolinium chloride-treated rats. Sheep red blood cell 51Cr liver uptake was deeply depressed 6 h after the end of ischaemia in group 1 (10 +/- 1.2%/g tissue). MDP injection restored the Kupffer cell activity (30.6 +/- 3.22%/g tissue) while dextran sulphate and gadolinium chloride administration markedly decreased SRBC 51Cr liver uptake. Our findings demonstrate that MDP in able to protect the liver from ischaemic insult while blockade of Kupffer cells was deleterious in rats subjected to liver ischaemia.

[Biliary complications after a liver transplant]. / Complicanze biliari dopo trapianto epatico.

Biliary tract complications are still an important source of morbidity and mortality after liver transplantation. Between March 1988 and September 1991 we performed 111 liver transplants in 109 patients (84 men and 25 women, mean age 44.5 +/- 1.1 year). Biliary tract reconstruction was via a choledocho-choledochostomy (n = 107) or via a Roux limb choledochojejunostomy (n = 4). Ten biliary complications (11.9%) occurred (6 biliary leakage, 3 biliary strictures, 1 biliary cast syndrome). Five patients (5.9%) necessitated operative repair (Roux limb choledochojejunostomy). No death was related to biliary tract complication.

Role of nonparenchymal liver cells in guinea pig to rat hepatic xenotransplantation.

This work was undertaken to investigate the role of nonparenchymal liver cells in a discordant model of hepatic xenografting. Three experimental groups were established: in group 1 guinea pig to Lew rat liver xenotransplantations were performed; in group 2 both donor and recipient were treated with dextran sulfate, a known inhibitor of the reticuloendothelial system phagocytic function; in group 3 both donor and recipient were injected with muramyl dipeptide, a synthetic immunomodulator stimulating the monocyte/macrophage axis. Survival time was assessed and xenoantibody titers 30 min before and after the intervention, Kupffer cell activity 30 min after transplantation, histology and immunoglobulin and complement deposits of the grafted liver were evaluated too. Survival time of the xenografted rats in group 1 was 6.4 +/- 0.31 h. Blockade of Kupffer cells by dextran sulfate administration significantly (p < 0.001) depressed the survival time (2.9 +/- 0.31 h) of the grafted rats, while a significant increase (p < 0.001) was observed in the muramyl dipeptide-treated group (9.3 +/- 0.52 h). A significant reduction of xenoantibody titers 30 min after intervention was observed in the muramyl dipeptide group while no reduction was observed in the dextran group. Thirty minutes after xenotransplantation sheep red blood cell 51Cr uptake was significantly depressed by dextran sulfate treatment while muramyl dipeptide administration restored the Kupffer cell activity. Histological changes worsened after dextran administration in comparison with the other groups. Immunoglobulins and complement deposits were diminished by dextran administration.(ABSTRACT TRUNCATED AT 250 WORDS)

[Orthotopic liver transplantation and hepatocellular carcinoma]. / Trapianto ortotopico di fegato e carcinoma epatocellulare.

Nineteen orthotopic liver transplantations (OLT) were performed in patients with hepatocellular carcinoma, between March 1988 and December 1990, in our Department. Thirteen patients (68.4%), 10 men and 3 women, mean age 48.2 +/- 2.8 years, were clear cut neoplastic disease, six patients (31.6%), 4 men and 2 women, mean age 48.6 +/- 4.2 years, were incidental tumors. Three years survival rate was 20% in clear cut neoplastic diseases (4 patients died for neoplastic recurrence) and 66% in incidental tumors. Our results demonstrate that liver transplantation for hepatobiliary malignancy is still justified, patient selection is important in predicting outcome.