Extra-Glissonian approach in liver resection.

BACKGROUND: In this study we analyzed our most recent experience in the use of the extraglissonian approach to the hilar structures in two circumstances: pedicle transection during major liver resections, and selective clamping in minor hepatectomies. METHODS: The major liver resections study group consisted of 89 cases. Extraglissonian approach and stapler transection of hilar structures was used in 61 (69%). The study group of minor liver resections consisted of 103 cases. Extraglissonian approach and selective clamping was used in 27 cases (26%). RESULTS: In major hepatectomies pedicle stapling and hilar dissection demonstrated a similar operative time (240 vs. 260 min; P = 0.230); no differences were observed in the amount of haemorrhage (800 ml vs. 730 ml; P = 0.699), number of patients transfused (16 vs. 6; P = 0.418) and volume of blood transfused (4 PRC vs. 4 PRC; P = 0.521). Duration of vascular pedicle occlusion was 35 vs. 30 min respectively (P = 0.293). Major complications (grade >or=3a) occurred in 18 (20%) patients and mortality rates (4.9% vs. 3.5%; P = 0.882) were similar for both group. In minor liver resections there were no differences between Pringle and selective clamping in operative time (240 vs. 240 min; P = 0.321), haemorrhage (435 ml vs. 310 ml; P = 0.575), number of patients transfused (18 vs. 7; P = 0.505) and volume blood transfused (4 PRC vs. 3 PRC; P = 0.423). Major complications (grade >or=3a) occurred in 14 (14%) patients, and mortality (2.6% vs. 3.7%; P = 0.719) were similar for both groups. However, the duration of pedicle clamping was significantly longer in the selective clamping group (26 +/- 21 minutes vs. 44 +/- 18 minutes) (P = 0.001). CONCLUSIONS: The extraglissonian approach can be extremely useful in liver surgery. Selective clamping with extraglissonian approach avoids ischemia to the other hemiliver. Selective clamping it is also important from the homodynamic point of view because there is no splanchnic stasis and low fluid replacement.

Las hepatectomías mayores en pacientes con colangiocarcinoma e ictericia son seguras / Major hepatectomies are safe in patients with cholangiocarcinoma and jaundice

Introducción En el tumor de Klatskin la única posibilidad de cura es la extirpación quirúrgica radical. No obstante, la resección quirúrgica es difícil. Objetivo El objetivo de este trabajo es valorar la necesidad de drenaje biliar preoperatorio, el índice de resecabilidad, el porcentaje de hepatectomías, la morbimortalidad y la supervivencia a largo plazo. Material y métodos Desde el año 2005 hasta el año 2008, se estudió a 26 pacientes con tumor de Klatskin mediante tomografía computarizada helicoidal con multidetectores y colangiorresonancia magnética en casos especiales. Siete pacientes se consideraron irresecables (27%). A los restantes 19 pacientes se les realizaron 8 hepatectomías izquierdas, 5 derechas y 6 resecciones exclusivamente de la vía biliar con linfadenectomía y hepático yeyunostomía a todos ellos. La resecabilidad fue del 73%, la transfusión del 53% y el drenaje biliar preoperatorio se utilizó en 7 casos (37%). La morbilidad fue del 58% y la mortalidad del 10%. La supervivencia y la recidiva a los 48 meses fueron respectivamente del 63 y del 37%.Al comparar la evolución de los 9 pacientes con bilirrubina inferior a 15mg/dl y los 10 pacientes con bilirrubina superior a 15mg/dl, no hubo diferencias en los datos epidemiológicos. Seis pacientes (67%) con bilirrubina baja frente a un paciente (10%) del grupo de bilirrubina alta habían recibido un drenaje biliar preoperatorio (p=0,02). La bilirrubina del grupo no ictérico era de 4,7±4,3 frente a 22,1±3,9 del grupo con ictericia (p<0,001). No hubo diferencias en la evolución postoperatoria. En conclusión, la resecabilidad y la supervivencia postoperatoria de los pacientes con tumor de Klatskin han mejorado sensiblemente en los últimos años. En casos seleccionados, las hepatectomías mayores en pacientes con ictericia sin desnutrición ni colangitis preoperatoria son seguras (AU)

Background Surgical resection is the only possibility of long term survival in patients with Klatskin tumours. However, surgical resection is a challenging problem and hepatic resection is often necessary. Objective The aim of our study was to assess the need for biliary drainage, resection rate and outcome of hilar cholangiocarcinoma in a single tertiary referral centre. Patients and methods From 2005 to 2008, 26 patients with Klatskin tumours were identified and assessed prospectively with multidetector CT and MR cholangiography in special cases. Seven patients (27%) were deemed to be unresectable in pre-operative staging. A total of 19 surgical procedures were performed, 8 left hepatectomies, 5 right hepatectomies and 6 resections exclusively of the biliary tree. Resection rate was 73%, transfusion rate 53% and preoperative biliary drainage was performed only in 7 cases (37%). Major complications occurred in 11 (58%), including two post-operative deaths (10%).There were no differences in the epidemiological data, when we separately analysed the outcomes of the 9 patients with bilirubin <15mg/dL and the 10 patients with bilirubin >15mg/dL. Biliary drainage was required in 6 (67%) patients in the group with low bilirubin levels vs. 1(10%) in the other group (P=0.02). The mean bilirubin level in the jaundiced group was 22.1±3.9 vs. 4.7±4.3 (P<0.001) in the other group. There were no differences in the postoperative outcome between both groups. Conclusion Resection and survival rates have increased recently but still carries the risk of significant morbidity and mortality. Major hepatectomies in selected patients without percutaneous biliary drainage are safe (AU)

[Major hepatectomies are safe in patients with cholangiocarcinoma and jaundice]. / Las hepatectomías mayores en pacientes con colangiocarcinoma e ictericia son seguras.

BACKGROUND: Surgical resection is the only possibility of long term survival in patients with Klatskin tumours. However, surgical resection is a challenging problem and hepatic resection is often necessary. OBJECTIVE: The aim of our study was to assess the need for biliary drainage, resection rate and outcome of hilar cholangiocarcinoma in a single tertiary referral centre. PATIENTS AND METHODS: From 2005 to 2008, 26 patients with Klatskin tumours were identified and assessed prospectively with multidetector CT and MR cholangiography in special cases. Seven patients (27%) were deemed to be unresectable in pre-operative staging. A total of 19 surgical procedures were performed, 8 left hepatectomies, 5 right hepatectomies and 6 resections exclusively of the biliary tree. RESULTS: Resection rate was 73%, transfusion rate 53% and preoperative biliary drainage was performed only in 7 cases (37%). Major complications occurred in 11 (58%), including two post-operative deaths (10%). There were no differences in the epidemiological data, when we separately analysed the outcomes of the 9 patients with bilirubin<15 mg/dL and the 10 patients with bilirubin>15 mg/dL. Biliary drainage was required in 6 (67%) patients in the group with low bilirubin levels vs. 1(10%) in the other group (P=0.02). The mean bilirubin level in the jaundiced group was 22.1+/-3.9 vs. 4.7+/-4.3 (P<0.001) in the other group. There were no differences in the postoperative outcome between both groups. CONCLUSION: Resection and survival rates have increased recently but still carries the risk of significant morbidity and mortality. Major hepatectomies in selected patients without percutaneous biliary drainage are safe.

[Results of hepatobiliary and pancreatic surgery according to DRG in a level 2 hospital surgery department during the years 2005-2006]. / Resultados de la cirugía hepatobiliopancreática en un servicio de cirugía de un hospital de segundo nivel según los GRD durante el bienio 2005-2006.

OBJECTIVE: To assess the results of the hepatobiliary and pancreatic surgery of a surgery department during 2005-2006 using the diagnostic related groups. MATERIALS AND METHOD: The data were obtained from the CMBD-HA of the Catalan Health Service. We assessed the frequency, hospital stay and mortality of the surgical procedures. The results were compared with the 63 public hospitals, and the 8 of them belonging to the Catalan Health Institute. RESULTS: In our area, a clear trend is observed in referrals for certain types of complex procedures on the liver, pancreas and biliary system excluding cholecystectomy with or without associated morbidities (7-11%) without exceeding the population percentage (12%). In our centre, the impact on hospital stay is more evident in complex procedures. The total savings in our centre during the years 2005-2006 compared with the XHUP hospitals group were 2212 days of hospital stay with an equivalent cost saving of more than one million euro. The frequency and the results of hospital stay and mortality of laparoscopic and open cholecystectomy were those expected for the population covered by a general hospital. The mortality in complex procedures was half of that of the whole public network or the ICS centres. CONCLUSIONS: In the complex hepatobiliary-pancreatic pathology, the mortality, and cost savings in our centre appear to be the result of, not only the high volume of procedures, but also to specialisation and factors related to the structure of the department, and surgeon training.

Resultados de la cirugía hepatobiliopancreática en un servicio de cirugía de un hospital de segundo nivel según los GRD durante el bienio 2005-2006 / Results of hepatobiliary and pancreatic surgery according to DRG in a level 2 hospital surgery department during the years 2005-2006

Objetivo. Evaluar los resultados de la cirugía hepatobiliopancreática de un servicio de cirugía durante el bienio 2005-2006, mediante los grupos relacionados por el diagnóstico. Materiales y método. Los datos se han obtenido del Registro del Conjunto Mínimo Básico de Datos de los Hospitales de Agudos del CatSalut. Se ha valorado la frecuencia, la estancia y la mortalidad. Los resultados han sido comparados con los 63 hospitales públicos de Cataluña (XHUP) y con los 8 de ellos que pertenecen al Instituto Catalán de la Salud (ICS). Resultados. Se observa, en nuestra área de influencia, una clara tendencia a la referencia para cierto tipo de procedimientos complejos (7-11%), sin superarla proporción poblacional (12%). En nuestro centro, el impacto en las estancias hospitalarias es más evidente en los procedimientos complejos. El ahorro total de recursos de nuestro servicio en el bienio2005-2006 en relación con el grupo de hospitales de la XHUP fue de 2.212 días de estancia hospitalaria, cuyo coste equivale a más de un millón de euros. La frecuencia y los resultados sobre las estancias hospitalarias y la mortalidad de la colecistectomía son los esperados para la población que se atiende como hospital general. La mortalidad en los procedimientos complejos fue la mitad que la observada para el conjunto de hospitales de la XHUP o del ICS. Conclusiones. En la patología hepatobiliopancreática compleja, creemos que la mortalidad y el ahorro de recursos en nuestro centro se deben no sólo al volumen, sino a la especialización y los factores relacionados con la estructura del servicio y el entrenamiento de los cirujanos (AU)

Objective. To assess the results of the hepatobiliary and pancreatic surgery of a surgery department during2005-2006 using the diagnostic related groups. Materials and method. The data were obtained from the CMBD-HA of the Catalan Health Service. We assessed the frequency, hospital stay and mortality of the surgical procedures. The results were compared with the 63 public hospitals, and the 8 of them belonging to the Catalan Health Institute. Results. In our area, a clear trend is observed in referrals for certain types of complex procedures on the liver, pancreas and biliary system excluding cholecystectomy with or without associated morbidities(7-11%) without exceeding the population percentage(12%). In our centre, the impact on hospital stay is more evident in complex procedures. The total savings in our centre during the years 2005-2006 compared with the XHUP hospitals group were 2212 days of hospital stay with an equivalent cost saving of more than one million euro. The frequency and the results of hospital stay and mortality of laparoscopic and open cholecystectomy were those expected for the population covered by a general hospital. The mortality in complex procedures was half of that of the whole public network or the ICS centres. Conclusions. In the complex hepatobiliary-pancreatic pathology, the mortality, and cost savings in our centre appear to be the result of, not only the high volume of procedures, but also to specialization and factors related to the structure of the department, and surgeon training (AU)

Duodenopancreatectomía cefálica en tumores periampulares. Disección de la arteria mesentérica superior como abordaje inicial. Descripción de la técnica y evaluación de nuestra experiencia inicial / Cephalic duodenopancreatectomy in periampullary tumours. Dissection of the superior mesenteric artery as aninitial approach. Description of the technique and an assessment of our initial experience

Introducción. La duodenopancreatectomía cefálica (DPC) con abordaje inicial de la arteria mesentérica superior (AMS) ha sido descrita como una técnica útil para reducir las pérdidas de sangre y evitar una intervención inútil si hay afectación arterial. Objetivos. Analizar los resultados de dos modificaciones recientes en la técnica quirúrgica de la DPC introducidas en nuestro grupo: disección primaria de la AMS y la gastroenterostomía antecólica. Pacientes y método. Se dividió a los pacientes en 2 grupos, según hayan recibido o no disección inicial de la AMS. También se analizaron los resultados según el tipo de reconstrucción gástrica. Se comparan los resultados perioperatorios y a largo plazo. Resultados. La mortalidad general fue del 5% sin diferencias entre la DPC con abordaje inicial de la AMS y la técnica convencional. La tasa de transfusión (p < 0,001), el volumen transfundido (p = 0,001) y la incidencia general de complicaciones fue menor (p = 0,01) en el grupo con disección de la AMS. La estancia postoperatoria también fue significativamente menor (p # 0,001). A pesar de que la afectación ganglionar fue más frecuente en los pacientes operados con abordaje inicial de la AMS (p = 0,001), la tasa de recidiva fue la misma que con la técnica convencional. Dentro del grupo con disección inicial de la AMS, aquellos con reconstrucción antecólica presentaron con menor frecuencia retraso en el vaciamiento gástrico (p = 0,008). Conclusiones. La DPC con abordaje inicial de la AMS es una técnica segura. La transfusión, las complicaciones y la estancia hospitalaria son mejores. Cuando se asocia a reconstrucción duodenoyeyunal antecólica, los retrasos de vaciamiento gástrico son menos frecuentes (AU)

Introduction. Pancreatoduodenectomy (PD) with initial dissection of the superior mesenteric artery (SMA) has been described as a useful technical variant to reduce blood loss and to avoid an unnecessary intervention in those cases with arterial involvement. Objectives. To analyse the results of two recent technical modifications of PD introduced by our group: initial dissection of SMA and antecolic gastroenterostomy. Patients and method. Patients were divided into two groups: with and without initial dissection of the SMA. The results were also analysed according to the type of gastric reconstruction. Perioperative and long-term results are compared. Results. The overall mortality was 5%, with no significant differences between the initial SMA dissection and conventional PD. The transfusion rate (p < 0.001), the volume of blood products transfused (p = 0.001), and the overall complication rate were lower (p = 0.01) in the initial SMA dissection group. Also the postoperative hospital stay was significantly lower (p # 0.001). Despite a higher frequency of lymph node involvement in patients treated with initial SMA dissection (p = 0.001), the recurrence rate was similar between both groups. Among patients with initial SMA dissection, those who received antecolic reconstruction had a lower rate of delayed gastric emptying (p = 0.008). Conclusions. Initial SMA dissection PD is a safe technique. The transfusion rate, morbidity and postoperative hospital stay are better when compared with conventional CPD. When an antecolic duodenal-jejunal reconstruction is associated, delayed gastric emptying cases are less frequent (AU)

[Role of intra-operative echography and computed tomography with multiple detectors in the surgery of hepatic metastases: a prospective study]. / Papel de la ecografía intraoperatoria y la tomografía computarizada con multidetectores en la cirugía de las metástasis hepáticas: estudio prospectivo.

OBJECTIVES: To study the performance of the intraoperative ecography in the diagnosis of new liver metastases in the era of computerized tomography (CT) with multidetectors and its impact on the surgical operation. PATIENTS AND METHOD: Between February 2005 and April 2006 patients with resectable liver metastases where studied prospectively in a multidisciplinary meeting (surgeons, radiologist, oncologist). The preoperative CT findings were compared with the intraoperative findings and ultrasound study and the results of the surgical operation. RESULTS: Forty-five candidates for curative surgery had a total of 171 hepatic lesions. CT correctly detected 115 lesions with a sensitivity of 67%, and a positive predictive value of 97%, with a false negative rate of 33% and false positive rate of 2%. In 5 patients intraoperative findings were the cause of changing the surgical procedure, three patients were unresectable (rate of resectability of 93%) and two patients needed a larger hepatic resection. CONCLUSIONS: CT with multidetectors and multidisciplinary meetings are the most important factors in the decision making of surgery of liver metastases with a high resectability rate. Intraoperative ecography is useful for the detection of 10% more liver metastases, but rarely involves a change in the surgical procedure.

[Cephalic duodenopancreatectomy in periampullary tumours. Dissection of the superior mesenteric artery as aninitial approach. Description of the technique and an assessment of our initial experience]. / Duodenopancreatectomía cefálica en tumores periampulares. Disección de la arteria mesentérica superior como abordaje inicial. Descripción de la técnica y evaluación de nuestra experiencia inicial.

INTRODUCTION: Pancreatoduodenectomy (PD) with initial dissection of the superior mesenteric artery (SMA) has been described as a useful technical variant to reduce blood loss and to avoid an unnecessary intervention in those cases with arterial involvement. OBJECTIVES: To analyse the results of two recent technical modifications of PD introduced by our group: initial dissection of SMA and antecolic gastroenterostomy. PATIENTS AND METHOD: Patients were divided into two groups: with and without initial dissection of the SMA. The results were also analysed according to the type of gastric reconstruction. Perioperative and long-term results are compared. RESULTS: The overall mortality was 5%, with no significant differences between the initial SMA dissection and conventional PD. The transfusion rate (p < 0.001), the volume of blood products transfused (p = 0.001), and the overall complication rate were lower (p = 0.01) in the initial SMA dissection group. Also the postoperative hospital stay was significantly lower (p

Papel de la ecografía intraoperatoria y la tomografía computarizada con multidetectores en la cirugía de las metástasis hepáticas: estudio prospectivo / Role of intra-operative echography and computed tomography with multiple detectors in the surgery of hepatic metastases: a prospective study

Objetivos. Estudiar el papel de la ecografía intraoperatoria en el diagnóstico de nuevas metástasis hepáticas en la era de la tomografía computarizada (TC) con multidetectores y su impacto en el acto quirúrgico. Pacientes y método. Entre febrero de 2005 y abril de 2006 se estudió de forma prospectiva, en sesiones multidisciplinarias (cirujanos, radiólogos y oncólogos), a los pacientes con metástasis hepáticas resecables de cáncer colorrectal. Los hallazgos preoperatorios de la TC se compararon con los de la ecografía intraoperatoria, su correlación histológica y el resultado final de la intervención quirúrgica. Resultados. Se estudió a 45 pacientes candidatos a cirugía curativa, con un total de 171 metástasis hepáticas. La TC detectó correctamente 115 lesiones con una sensibilidad del 67%, un valor predictivo positivo del 97%, una tasa de falsos negativos del 33% y una tasa de falsos positivos del 2%. En 5 ocasiones los hallazgos intraoperatorios condicionaron un cambio en el acto quirúrgico programado: en 3 pacientes eran irresecables (tasa de resecabilidad del 93%) y 2 pacientes precisaron de resecciones más amplias de las previamente programadas. Conclusiones. La TC con multidetectores como prueba de imagen preoperatoria y las sesiones multidisciplinarias son el factor más importante en la toma de decisiones en la cirugía de las metástasis hepáticas y nos permiten obtener una alta tasa de resecabilidad. La ecografía intraoperatoria hepática nos permite encontrar un mayor número de metástasis y realizar una correcta delimitación anatómica y, en ocasiones, condiciona un cambio en el acto quirúrgico programado (AU)

Objectives. To study the performance of the intraoperative ecography in the diagnosis of new liver metastases in the era of computerized tomography (CT) with multidetectors and its impact on the surgical operation. Patients and method. Between February 2005 and April 2006 patients with resectable liver metastases where studied prospectively in a multidisciplinary meeting (surgeons, radiologist, oncologist). The preoperative CT findings were compared with the intraoperative findings and ultrasound study and the results of the surgical operation. Results. Forty-five candidates for curative surgery had a total of 171 hepatic lesions. CT correctly detected 115 lesions with a sensitivity of 67%, and a positive predictive value of 97%, with a false negative rate of 33% and false positive rate of 2%. In 5 patients intraoperative findings were the cause of changing the surgical procedure, three patients were unresectable (rate of resectability of 93%) and two patients needed a larger hepatic resection. Conclusions. CT with multidetectors and multidisciplinary meetings are the most important factors in the decision making of surgery of liver metastases with a high resectability rate. Intraoperative ecography is useful for the detection of 10% more liver metastases, but rarely involves a change in the surgical procedure (AU)

A comparison of a triple-injection axillary brachial plexus block with the humeral approach.

BACKGROUND AND OBJECTIVES: This prospective, randomized, and single-blind study compared effectiveness, performance, onset, and total anesthetic time and complications of the multiple axillary block (median, radial, and musculocutaneous nerves) with the humeral approach. METHODS: One hundred patients were randomly assigned to 2 groups. In group A (axillary) median, radial, and musculocutaneus nerves were located by a nerve stimulator and injections were made. In group H (humeral) all 4 terminal nerves of the brachial plexus were located and injections were made. A total of 40 mL mepivacaine of 1% was used. RESULTS: Complete sensory block of all 6 peripheral nerves occurred in 94% and 79% of patients in groups A and H, respectively (P < .05). The time to perform the block was shorter in group A (8 +/- 4 minutes v 11 +/- 4 minutes; P < .001); onset time was shorter in group A (16 +/- 8 minutes v 21 +/- 9 minutes; P < .05); total anesthetic time was shorter in group A (24 +/- 8 minutes v 33 +/- 10 minutes; P < .0001). Complete motor block was greater in group A (88% v 66%; P < .05). More vascular punctures occurred in group A (22% v 8%, P < .05). CONCLUSION: The triple-injection axillary block was more effective than the humeral approach as it was associated with more cases of sensory and complete motor block and gave shorter performance and onset times.