Evaluation of a patient referring GERD after sleeve gastrectomy should start with a detailed history and physical examination; the presence or absence of GERD-related symptoms should be thoroughly documented as well as any prior treatments or therapy used to treat it. Obtaining preoperative and operative records is of paramount importance particularly in those patients who had their index procedure performed elsewhere. Any endoscopic findings and prior imaging available are important to determine what the best course of action would be. If the patient had preoperative and postoperative imaging such as UGI, it is useful to compare those with a recent study to look for anatomical problems that may have been not addressed at the time of the index operation or developed over time. After this information is obtained, we can classify the GERD after sleeve as:
1. De novo GERD
2. Preexisting GERD without improvement
3. Preexisting GERD with worsening/complication
Regardless of how we classify the GERD, an initial evaluation with imaging
studies such as UGI and EGD is recommended. Comparison with any prior films if available is of significant value. Based on the UGI, we can determine if the shape of the sleeve falls into one of the following categories: tubular, dilated bottom, dilated upper, or dumbbell-shaped sleeve; we will also be able to evaluate esophageal peristalsis in real time and if there is associated hiatal hernias. We believe UGI under fluoroscopy provides important physiologic and anatomic information that can help guide our management approach, and therefore we offer it to all patients. We follow the radiologic evaluation with endoscopy, and during endoscopy, we look for objective signs of reflux such as esophagitis, presence of bile in the stomach or esophagus, as well as missed or recurrent hiatal hernias. In patients with evidence of esophagitis or metaplasia, multiple biopsies are taken. During the endoscopy, subtle findings that suggest a kink or a stricture may be present. In the absence of objective signs of gastroesophageal reflux disease on both endoscopy and upper GI series, we pursue physiologic testing followed by highresolution manometry and pH monitoring. In those patients where clear reflux esophagitis is seen, this additional testing may not be necessary or may be performed in selected cases depending on what the surgical or endoscopic therapy would be.
While it is true that most sleeve-related GERD will be effectively treated with a conversion to Roux-en-Y gastric bypass, not every patient with GERD after reflux will require a bypass or would agree to have one. First key step in addressing the patient is to evaluate whether the patient was selected appropriately to have a sleeve and second is to determine the exact sleeve anatomy; are there anatomical factors that will make it more likely for this patient to experience reflux; is there dilated fundus? Is there a kink or stricture in the sleeve or is it an anatomically appropriate operation? We should pay important attention to the weight loss the patient has experienced with the sleeve. Patients who do not have adequate weight loss and have GERD symptoms should not undergo other therapies and should probably undergo a bypass; however it is our unpublished experience that patients with the association of poor weight loss after sleeve and difficult to treat GERD will correct their GERD after conversion, but their weight loss results are still marginal even with a well-constructed bypass.
“At the University of Chicago, members of the Department of Surgery decided to investigate this issue more precisely. As stay-at-home restrictions in some states are easing, and as non-emergency medical care is being reconsidered, how does one possibly triage the thousands upon thousands of patients whose surgeries were postponed? Instead of the term “elective,” the University of Chicago’s Department of Surgery chose the phrase “Medically-Necessary, Time Sensitive” (MeNTS). This concept can be utilized to better assess the acuity and safety when determining which patients can get to the operating room in as high benefit/low risk manner as possible. And unlike in any recent time in history, risks to healthcare staff as well as risks to the patient from healthcare staff, are now thrown into the equation. The work was published in the April issue of the Journal of the American College of Surgeons.
On March 17, 2020, the American College of Surgeons recommended that all “elective” surgeries be canceled indefinitely. These guidelines were published, stating that only patients with “high acuity” surgical issues, which would include aggressive cancers and severely symptomatic disease, should proceed. Based on the Elective Surgery Acuity Scale (ESAS), most hospitals were strongly encouraged to cancel any surgery that was not high acuity, including slow-growing cancers, orthopedic and spine surgeries, airway surgeries, and any other surgeries for non-cancerous tumors. Heart surgeries for stable cardiac issues were also put on hold. Patients and surgeons waited. Some patients did, indeed undergo non-Covid-19-related surgeries. But most did not. Redeployment is gradually turning to re-entry.
The re-entry process for non-urgent (yet necessary) surgeries is a complicated one. Decisions and timing, based on a given hospital’s number and severity of Covid-19 patients, combined with a given city or state’s current and projected number of Covid-19 cases, how sick those patients will be, and whether or not a second surge may come, involves a fair amount of guesswork. As we have all seen, data manipulation has become a daily sparring match in many arenas. The authors of the study created an objective surgical risk scoring system, in order to help hospitals across this country, as well as others across the world, better identify appropriate timing regarding which surgeries can go ahead sooner rather than later, and why. They factored several variables into their equation, to account for the multiple potential barriers to care, including health and safety of hospital personnel. They created scoring systems based on three factors: Procedure, Disease and Patient Issues.
The authors of the study created an objective surgical risk scoring system, in order to help hospitals across this country, as well as others across the world, better identify appropriate timing regarding which surgeries can go ahead sooner rather than later, and why. They factored several variables into their equation, to account for the multiple potential barriers to care, including health and safety of hospital personnel. Each patient would receive an overall conglomerate score, based on all of these factors, with the lower risks giving them more favorable scores to proceed with surgery soon, and the higher risks giving patients a higher score, or higher risk regarding proceeding with surgery, meaning it may be safest, for now, to wait.
Dr. Jeffrey Matthews, senior author of the paper, and Department Chair at the University of Chicago, stated that this model is reproducible across hospital systems, in urban, rural, and academic settings. And in the event of potential unpredictable surges of Covid-19 cases, the scoring system “helps prioritize cases not only from the procedure/disease standpoint but also from the pandemic standpoint with respect to available hospital resources such as PPE, blood, ICU beds, and [regular hospital] beds.”
The scoring system is extremely new, and the coming weeks will reveal how patients, surgeons and hospitals are faring as patients without life-and-death emergencies and/or Covid-19 complications gradually begin filling the operating rooms and hospital beds. In addition, and perhaps just as important, the study authors note that creating systems whereby healthcare resources, safety, and impact on outcomes need to be considered more carefully for each patient intervention, the larger impact of each intervention on public health will be better understood: not only for today’s pandemic, but also in future, as yet unknown, global events.”
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The current world Covid-19 pandemic has been the most discussed topic in the media and scientific journals. Fear, uncertainty, and lack of knowledge about the disease may be the significant factors that justify such reality. It has been known that the disease presents with a rapidly spreading, it is significantly more severe among the elderly, and it has a substantial global socioeconomic impact. Besides the challenges associated with the unknown, there are other factors, such as the deluge of information. In this regard, the high number of scientific publications, encompassing in vitro, case studies, observational and randomized clinical studies, and even systematic reviews add up to the uncertainty. Such a situation is even worse when considering that most healthcare professionals lack adequate knowledge to critically appraise the scientific method, something that has been previously addressed by some authors. Therefore, it is of utmost importance that expert societies supported by data provided by the World Health Organization and the National Health Department take the lead in spreading trustworthy and reliable information.
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Coronavirus disease 2019 (COVID-19) emerged in Wuhan City and rapidly spread throughout China and around the world since December 2019. The World Health Organization (WHO) declared the COVID-19 outbreak a global pandemic on 11 March 2020. Patients with metabolic disorders like cardiovascular diseases, diabetes and obesity may face a greater risk of infection of COVID-19 and it can also greatly affect the development and prognosis of pneumonia.
“A higher cumulative MeNTS score, which can range from 21 to 105, is associated with poorer perioperative patient outcome, increased risk of COVID-19 transmission to the health care team, and/or increased hospital resource utilization. Given the need to maintain OR capacity for trauma, emergency, and highly urgent cases, an upper threshold MeNTS score can be designated by surgical and perioperative leadership based on the immediately anticipated conditions and resources at each institution.”
All elective surgical and endoscopic cases for metabolic and bariatric surgery should be postponed during the pandemic. This minimises risks to both patient and healthcare team, as well as reducing the utilisation of unnecessary resources, such as beds, ventilators and personal protective equipment (PPE). In addition, postponing these services will minimise potential exposure of the COVID-19 virus to unsuspecting healthcare providers and patients. As the long-term effects or complications of COVID-19 are still unknown, metabolic and bariatric surgeries for patients who were diagnosed and recovered from COVID-19 should be evaluated by a multidisciplinary team. Diet and lifestyle modifications should be advised before surgical treatment.
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Many oncological patients with upper gastrointestinal (GI) tract tumours, apart from other symptoms, are malnourished or cachectic at the time of presentation. In these patients feeding plays a crucial role, including as part of palliative treatment. Many studies have proved the benefits of enteral feeding over parenteral if feasible. Depending on the tumour’s location and clinical stage there are several options of enteral feeding aids available. Since the introduction of percutaneous endoscopic gastrostomy (PEG) and its relatively easy application in most patients, older techniques such as open gastrostomy or jejunostomy have rather few indications.
The majority of non-PEG techniques are used in patients with upper digestive tract, head and neck tumours or trauma that renders the PEG technique unfeasible or unsafe for the patient. In these patients, especially with advanced disease requiring neoadjuvant chemotherapy or palliative treatment, open gastrostomy and jejunostomy were the only options of enteral access. Since the first report of laparoscopic jejunostomy by O’Regan et al. in 1990 there have been several publications presenting techniques and outcomes of laparoscopic feeding jejunostomy. Laparoscopic jejunostomy can accompany staging or diagnostic laparoscopy for upper GI malignancy when the disease appears advanced, hence avoiding additional anaesthesia and an operation in the near future.
In this video the author describe the technique of laparoscopic feeding jejunostomy applied during the staging laparoscopy in patient with advanced upper gastrointestinal tract cancer with co-morbid cachexy, requiring enteral feeding and neoadjuvant chemotherapy.
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Basicamente, existem quatro situações que indicam a realização de traqueostomia: prevenção de lesões laringotraqueais pela intubação translaríngea prolongada; desobstrução da via aérea superior, em casos de tumores, corpo estranho ou infecção; acesso à via aérea inferior para aspiração e remoção de secreções; e aquisição de via aérea estável em paciente que necessita de suporte ventilatório prolongado.
A substituição do tubo endotraqueal pela cânula de traqueostomia ainda acrescenta benefícios, proporcionando conforto e segurança do paciente. Algumas sociedades americanas sugerem que a traqueostomia deva ser sempre considerada para pacientes que necessitarão de ventilação mecânica prolongada, ou seja, por mais de 14 dias.
Muitas vezes, a decisão de se realizar uma traqueostomia é tomada pelo julgamento clínico de médicos, principalmente aqueles que trabalham em unidades de terapia intensiva. Isso envolve a análise de múltiplos fatores, tais como as características de cada paciente, o motivo pelo qual ocorreu a intubação, doenças associadas, resposta ao trata-mento e prognóstico individualizado. Embora haja uma tendência de indicação de traqueostomia precoce em pacientes neurocríticos e com trauma grave.
- Diminuição do trabalho respiratório
- Melhora da aspiração das vias aéreas
- Permitir a fonação
- Permitir a alimentação por via oral
- Menor necessidade de sedação
- Redução do risco de pneumonia associada à ventilação
- Diminuição do tempo de ventilação mecânica
- Diminuição do tempo de internação em unidades de terapia
- Redução da mortalidade
Pyogenic liver abscess (PLA), a suppurating infection of the hepatic parenchyma, remains a mortality associated condition and nowadays develops as a complication of biliary tract diseases for about 40% of cases. Recently, the etiologies of PLA have shifted from intra-abdominal infections such as acute appendicitis and trauma to pathologic conditions of the biliary tract; however, up to 60% of patients with PLA have no clear risk factors and these cases are called cryptogenic.
The incidence of PLA varies from 8 to 22 patients per 1,000,000 people belonging to a geographical area with substantially higher rates having been reported in Taiwan. Early diagnosis and treatment is a crucial step in the management of these patients, since the presentation may be subtle and not specific (abdominal pain, fever, nausea, and vomiting), so currently constitutes a challenge for physicians: a high index of suspicion is the cornerstone of prevention for misdiagnosis and improvement of prognosis.
In recent decades, combined antibiotic therapy and percutaneous drainage have become the first-line treatment in most cases and has greatly improved patients’ prognosis: the mortality rate has dropped from 70% to 5%. In terms of causative pathogens, bacteria most frequently associated with PLA are Escherichia coli, Enterobacteriaceae, anaerobes, and other members of the gastrointestinal flora. Over the past 2 decades Klebsiella pneumoniae has been emerging as the predominant pathogen responsible for 50% to 90% of PLA in the Asian population and it has been reported with increasing frequency in South Africa, Europe, and the United States.
Because such experiences have not yet been reported in Maranhão, we reviewed the cases of PLA seen at our institution and the present study is a retrospective analysis of demographic characteristics, etiological factors, presentation patterns, microbiological etiology, and the treatment of PLA cases which were presented in an Brazilian hospital over a 25-year-period.
The American College of Surgeons (ACS) and SAGES has developed COVID-19 and Surgery as an online resource for the surgical community facing the impact of Coronavirus Disease 2019 (COVID-19). Content has been developed or curated under the auspices of ACS and SAGES Regents and Officers to bring surgeons trusted information, including best practices and guidance that specifically target the concerns and challenges surgeons face. As the COVID-19 landscape is rapidly changing, this website is updated several times weekly and houses current and past editions of our electronic newsletter.
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Os conceitos fundamentais da Anatomia Topográfica Humana através do estudo das regiões anatômicas com maior relevância Médico-Cirúrgica. Agora com amplo material multimídia disponibilizado através de acesso on-line dentro do livro e com isso creditamos que este trabalho será útil como mais uma ferramenta didática na preparação profissional dos estudantes de Medicina.
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The first postoperative fast-track protocols, also called “enhanced recovery after surgery” (ERAS), were instituted by colorectal surgeons almost three decades ago in order to modulate surgical stress and hasten recovery. Since then, the implementation of enhanced recovery programs has had an exponential expansion across most surgical specialties, including gynecology, urology, breast, vascular, and orthopedic surgery.
“Enhanced recovery after liver surgery” (ERLS) was first introduced in 2008 and has incrementally gained acceptance as being an integral part of perioperative care for hepatectomy patients. Several outcome metrics have shown to be improved with the adoption of a multimodal evidencebased strategy in liver surgery, many of which are also shared by other surgical specialties practicing in an enhanced recovery framework.
Improved clinical outcomes such as length of stay, morbidity rates, and hospital costs tend to support implementation of fast-track programs in general, but other metrics specific to liver surgery and to patients with colorectal liver metastases (CLM) further endorse this strategy when managing CLM. The implementation of an ERLS program represents a collaborative approach in which the different team players, including anesthesia, surgery, nutrition, pharmacy, nursing, and most importantly the patient and his/her family, engage actively in the perioperative pathway, in an evidence-based, patient-centered approach. The development of such programs also requires dedicated continuing education for the team members, flexibility in terms of perioperative management and decisionmaking by the health-care providers, support from the hospital administration, and systematic quality control measures to ensure implementation and accurate reporting. This review study the different core elements of ERLS and discuss different outcomes associated with this system-based approach, with an emphasis on oncological patients.
Interference with oncological treatment plans can negatively affect patients’ longterm outcomes but can also be detrimental to quality of life and overall functional status. Patient-reported outcomes (PROs) attempt to capture the patients’ perspective for a given intervention or treatment strategy, which are particularly important in oncological patients. Day et al. reported that the implementation of ERLS was beneficial for patients in terms of functional recovery, and although no significant differences were detected in terms of symptom burden, the impact of ERLS was shown to accelerate functional recovery by returning to baseline interference earlier. This positive effect from ERLS seems more pronounced in patients undergoing open hepatectomy over those already benefiting from minimally invasive surgery.
Over 50% to 60% of patients diagnosed with colorectal cancer will develop hepatic metastases during their lifetime. Resection for hepatic metastases has been a routine part of treatment for colorectal cancer since the publication of a large single-center experience demonstrating its safety and efficacy.
Predictors of poor outcome in that study included node-positive primary, disease-free interval <12 months, more than one tumor, tumor size >5 cm, and carcinoembryonic antigen level >200 ng/mL.
Traditional teaching suggested that hepatic resection for metastatic colorectal cancer to the liver, if technically feasible,should be performed only for fewer than four metastases. However, later studies challenged this paradigm. In a series of 235 patients who underwent hepatic resection for metastatic colorectal cancer, the 10-year survival rate of patients with four or more nodules was 29%, nearly comparable to the 32% survival rate of patients with only a solitary tumor metastasis.
In the Memorial Sloan-Kettering Cancer Center series of 98 patients with four or more colorectal hepatic metastases who underwent resection between 1998 and 2002, the 5-year actuarial survival was 33%. Furthermore, improved chemotherapeutic regimens and surgical techniques have produced aggressive strategies for the management of this disease.
Many groups now consider volume of future liver remnant and the health of the background liver, and not actual tumor number, as the primary determinants in selection for an operative approach. Hence, resectability is no longer defined by what is actually removed, but indications for hepatic resection now center on what will remain after resection.
Use of neoadjuvant chemotherapy, portal vein embolization, twostage hepatectomy, simultaneous ablation, and resection of extrahepatic tumor in select patients have increased the number of patients eligible for a surgical approach.
Good surgery for gastric cancer can be summarized in the mnemonic “OPERATIONS”: Oncologic Principles, Good Exposure, Understanding Anatomy, Comprehensive Total Approach, Meticulous Lymph Node Dissection, and Patients’ Safety. Surgery is as much an art as a technique, and the surgeon’s philosophy is an important component of practice. The surgeon should see the surgery, first and foremost, as for the patient’s benefit and have the same concern and regard for the patient as for a family member. The patient with gastric cancer has only one chance to be cured by surgery. Often this requires innovation and the adaptation of new technology by the surgeon. However, innovations must always honor accepted oncologic principles and practices a nd be based on sound scientific rationale.
There are fundamental differences between surgery performed in patients with cancer and in patients with other benign conditions. Protocols based on oncological principles must be followed throughout surgical procedures on cancer patients to prevent contamination with, or dissemination of, the cancer cells. The fundamental goal of cancer surgery is complete surgical resection of tumor, en bloc lymph node dissection, and careful hemostasis. If this goal is not achieved, cancer cells can be disseminated through broken lymphatics and vessels. The extent of gastric resection should be decided upon based on the location of tumor in the stomach and the safety resection margin so that microscopic tumors are not left in remaining stomach. The “no-touch” technique should be used during the entire procedure. The no-touch technique entails wrapping the primary tumor. This is especially important in cases of serosa-positive gastric cancer, in which it is of utmost importance to prevent iatrogenic peritoneal seeding through the surgeon’s hands. Unnecessary manipulation and dissection should be avoided as mitogenic factors for wound healing could be produced in response to the surgery; these could stimulate the proliferation of undetected micrometastatic tumors that remained after surgery.
The absence of oxygen and nutrients during ischaemia affects all tissues with aerobic metabolism. Ischaemia of these tissues creates a condition which upon the restoration of circulation results in further inflammation and oxidative damage (reperfusion injury). Restoration of blood flow to an ischaemic organ is essential to prevent irreversible tissue injury, however reperfusion of the organ or tissues may result in a local and systemic inflammatory response augmenting tissue injury in excess of that produced by ischaemia alone. This process of organ damage with ischaemia being exacerbated by reperfusion is called ischaemia-reperfusion (IR). Regardless of the disease process, severity of IR injury depends on the length of ischaemic time as well as size and pre-ischaemic condition of the affected tissue. The liver is the largest solid organ in the body, hence liver IR injury can have profound local and systemic consequences, particularly in those with pre-existing liver disease. Liver IR injury is common following liver surgery and transplantation and remains the main cause of morbidity and mortality.
The liver has a dual blood supply from the hepatic artery (20%) and the portal vein (80%). A temporary reduction in blood supply to the liver causes IR injury. This can be due to a systemic reduction or local cessation and restoration of blood flow. Liver resections are performed for primary or secondary tumours of the liver and carry a substantial risk of bleeding especially in patients with chronic liver disease. Significant blood loss is associated with increased transfusion requirements, tumour recurrence, complications and increased morbidity and mortality. Several methods of hepatic vascular control have been described in order to minimise blood loss during elective liver resection. The simplest and most common method is inflow occlusion by applying a tape or vascular clamp across the hepatoduodenal ligament (Pringle Manoeuvre). This occludes both the arterial and portal vein inflow to the liver and leads to a period of warm ischaemia (37 °C) to the liver parenchyma resulting in ‘warm’ IR injury when the temporary inflow occlusion is relieved. In major liver surgery, extensive mobilisation of the liver itself without inflow occlusion results in a significant reduction in hepatic oxygenation.
3. PATOPHYSIOLOGY and RISK FACTORS
A complex cellular and molecular network of hepatocytes, Kupffer cells, liver sinusoidal endothelial cells (LSEC), leukocytes and cytokines play a role in the pathogenesis of IR injury. In general, both warm and cold ischaemia share similar mechanisms of injury. Hepatocyte injury is a predominant feature of warm ischaemia, whilst endothelial cells are more susceptible to cold ischaemic injury. There are currently no proven treatments for liver IR injury. Understanding this complex network is essential in developing therapeutic strategies in prevention and treatment of IR injury. Identifying risk factors for IR injury are extremely important in patient selection for liver surgery and transplantation. The main factors are the donor or patient age, the duration of organ ischaemia, presence or absence of liver steatosis and in transplantation whether the donor organ has been retrieved from a brain dead or cardiac death donor.
4. PREVENTION and TREATMENT
There is currently no accepted treatment for liver IR injury. Several pharmacological agents and surgical techniques have been beneficial in reducing markers of hepatocyte injury in experimental liver IR, however, they are yet to show clinical benefit in human trials. The following is an outline of current and future strategies which may be effective in reducing the detrimental effects of liver IR injury in liver surgery and transplantation.
4.1 SURGICAL STRATEGIES
Inflow occlusion or portal triad clamping (PTC) can be continuous or intermittent; alternating between short periods of inflow occlusion and reperfusion. Intermittent clamping (IC) increases parenchymal tolerance to ischaemia. Hence, prolonged continuous inflow occlusion rather than short intermittent periods results in greater degree of post-operative liver dysfunction. IC permits longer total ischaemia times for more complex resections. Alternating between 15 min of inflow occlusion and 5 min reperfusion cycles can be performed safely for up to 120 min total ischaemia time. There is a potential risk of increased blood loss during the periods of no inflow occlusion. However, these intervals provide an opportunity for the surgeon to check for haemostasis and control small bleeding areas from the cut surface of the liver. The optimal IC cycle times are not clear, although intermittent cycles of up to 30 min inflow occlusion have also been reported with no increase in morbidity, blood loss or liver dysfunction compared to 15 min cycles. IC is particularly beneficial in reducing post-operative liver dysfunction in patients with liver cirrhosis or steatosis.
In liver surgery, IPC ( Ischaemic Preconditioning) involves a short period of ischaemia (10 min) and reperfusion (10 min) intraoperatively by portal triad clamping prior to parenchymal transection during which a longer continuous inflow occlusion is applied to minimise blood loss. It allows continuous ischaemia times of up to 40 min without significant liver dysfunction. However, the protective effect of IPC decreases with increasing age above 60 years old and compared to IC it is less effective in steatotic livers. Moreover, IPC may impair liver regeneration capacity and may not be tolerated by the small remnant liver in those with more complex and extensive liver resections increasing the risk of post-operative hepatic insufficiency.
In order to avoid direct ischaemic insult to the liver by inflow occlusion, remote ischaemic preconditioning (RIPC) has been used. RIPC involves preconditioning a remote organ prior to ischaemia of the target organ. It has been shown to be reduce warm IR injury to the liver in experimental studies. A recent pilot randomised trial of RIPC in patients undergoing major liver resection for colorectal liver metastasis used a tourniquet applied to the right thigh with 10 min cycles of inflation-deflation to induce IR injury to the leg for 60 min. This was performed after general anaesthesia prior to skin incision. A reduction in post-operative transaminases and improved liver function was shown without the use of liver inflow occlusion. These results are promising but require validation in a larger trial addressing clinical outcomes.
5. FUTURE PERSPECTIVES
Hepatic IR injury remains the main cause of morbidity and mortality in liver surgery and transplantation. Despite over two decades of research in this area, therapeutic options to treat or prevent liver IR are limited. This is primarily due to the difficulties in translation of promising agents into human clinical studies. Recent advances in our understanding of the immunological responses and endothelial dysfunction in the pathogenesis of liver IR injury may pave the way for the development of new and more effective and targeted pharmacological agents.
Chronic pancreatitis (CP) is a progressive, destructive, inflammatory process that ends in total destruction of the pâncreas and results in malabsorption, diabetes mellitus, and severe pain. The incidence and prevalence of CP are increasing in the worldwide and incidence is between 1.6 and 23 per 100 000 with increasing prevalence. The treatment of CP is complex; in the majority of cases na interdisciplinary approach is indicated that includes conservative, endoscopic, and surgical therapy. The surgical treatment of CP is based on two main concepts:preservation of tissue via drainage aims to protect against further loss of pancreatic function, and pancreatic resection is performed for nondilated pancreatic ducts, pancreatic head enlargement,or if a pancreatic carcinoma is suspected in the setting of CP.
The vast majority of patients are seen with a ductal obstruction in the pancreatic head, frequently associated with an inflammatory mass. In these patients, pancreatic head resection is the procedure of choice; The partial pancreatoduodenectomy (PD) or Kausch-Whipple procedure, in its classic or pylorus-preserving variant, has been the procedure of choice for pancreatic head resection in CP for many years (Jimenez et al, 2003). The duodenum-preserving pancreatic head resections and its variants—the Beger (1985), Frey (1987), and Bern procedures (Gloor et al, 2001)—represent less invasive, organsparing techniques with equal long-term results. Only very few patients come to medical attention with smallduct disease (diameter of the pancreatic duct ❤ mm) and no mass in the pancreatic head. Possibly, a large majority of those patients from former series had unknown autoimmune pancreatitis. In these cases, a V-shaped excision of the anterior aspect of the pancreas is a safe approach, with effective pain management (Yekebas et al, 2006). In the rare case of a patient seen with segmental CP in the pancreatic body or tail, such as that seen as a result of posttraumatic ductal stenosis, a middle segment pancreatectomy or a pancreatic left resection may be the best approach.
The adequate therapy of CP is adjusted to the symptoms of the patient, the stage of the disease, and the morphology of pathologic changes of the pancreas. The surgical technique must be adjusted to the pathomorphologic changes of the pancreas. For patients with CP and an inflammatory mass in the head of the pancreas, the DPPHR is less invasive than a PD and is associated with comparable long-term results. The Bern modification of the DPPHR represents a technical variation that is equally effective but technically less demanding. Whether total pancreatectomy with islet cell transplantation is a viable therapy of CP remains to be proved by further studies. Surgical therapy provides effective long-term pain relief and improvement of quality of life, but it may not stop the decline of endocrine or exocrine pancreatic function. Strategies to improve or maintain endocrine and exocrine function in CP remain an interesting field of research.
Laparoscopic distal pancreatectomy has become a relatively standard operation and has been approached by a similar technique by multiple groups since its original description. Generally, four or five trocars are used to gain entrance to the abdominal cavity, but three-trocar LPD has been described. A “clockwise” technique results in an efficient, reliable, and uniform approach for removing the vast majority of lesions that are located to the left of the neck of the pancreas (Asbun & Stauffer, 2011). The technique begins with the positioning of the patient in a modified right lateral decubitus position. The degree of lateral positioning depends on the patient’s body habitus and the location of the lesion, as well as the tilting capabilities of the operative bed. The use of gravity assisted retraction with the patient in a reverse Trendelenburg position with the left flank elevated is a key component to successful exposure of the tail of the pancreas and the spleen. Four mid- to left-sided abdominal trocars are placed in a semicircle around the body and tail of the pancreas, including two 12 mm and two 5 mm trocars, and a five step clockwise method is used.
Step 1: Mobilization of the splenic flexure of the colon
and exposure of the pancreas
The first step is mobilization of the splenic flexure of the colon. The lateral attachments, splenocolic ligament, and gastrocolic ligament are succes-sively transected to allow access to the lesser sac. If the spleen is to be removed, the dissection proceeds cranially, and the short gastric vessels are transected up to the superior pole of the spleen. Sufficient mobilization of the colon allows for gravity-assisted retraction of the colon, and the stomach is completely freed from the anterior aspect of the body and tail of the pancreas. Infrequently, an additional trocar or tacking stitch is required to elevate the stomach to the anterior abdominal wall off the pancreas and out of the operative field.
Step 2: Dissection along the inferior edge of the pancreas
and choosing the site for pancreatic division
The second step is to identify the inferior border of the pancreas and create a window in the fibroadipose tissue plane between the retroperitoneum and the pancreas. This dissection is carried medially toward the lesion of interest. Intraoperative ultrasound is performed to clearly identify the lesion and the planned site of division of the pancreas.
Step 3: Pancreatic parenchymal division and ligation
of the splenic vein and artery
The third step is pancreatic parenchymal division and ligation of the splenic artery and vein. After dissecting around the pancreas in 360 degrees, a Penrose drain or suture is placed around the proposed site of division of the pancreas and is used to elevate the pancreas from the retroperitoneum. A band passer instrument is helpful for this part of the procedure. For distal pancreatectomy, the splenic vessels will often be dissected, ligated, and divided en bloc with the parenchyma. For subtotal resections with division of the pancreas at the neck, the underlying superior mesenteric vein and splenic vein are dissected away from the posterior aspect of the pancreas, and the celiac trunk is identified individually and dissected free from the neck and proximal body of the pancreas. Parenchymal transection is performed with a linear stapling device by using a slow, gradual, and stepwise compression technique. Thick tissue staples (open staple height of approximately 4 mm) with staple line reinforcement is preferred for almost any pancreas consistency, and the stapler is gradually closed in a stepwise manner over the course of several minutes to allow for parenchymal compression. Parenchymal transection and splenic vessel division are done individually for subtotal pancreatectomy for lesions located between the gastroduodenal artery and the celiac trunk.
Step 4: Dissection along the superior edge of the pancreas
The fourth step is to sweep the pancreas inferiorly and anteriorly off the retroperitoneum toward the splenic hilum. A deeper dissection plane that includes Gerota fascia and the left adrenal gland may be chosen for malig-nancies that appear to have posterior invasion from the pancreas.
Step 5: Mobilization of the spleen and specimen removal
The fifth step is the mobilization of the spleen from its diaphragmatic and retroperitoneal attachments and placement of the specimen within a bag for exteriorization. Major complications were seen in less than 10% of patients, and both the conversion rate and the clinically significant pancreatic fistula (grade B/C) rate by using the gradual stepwise compression stapled technique was seen in fewer than 5%. Operative drains were rarely placed.
The minimally invasive approach to resection of the left-sided pancreas by distal or subtotal pancreatectomy has gained acceptance and been used with an increasing frequency worldwide during the past decade. Multiple systematic reviews have demonstrated the safety of LDP and its superiority versus open distal pancreatectomy (ODP) for selected outcomes, such as blood loss, transfusion rates, and hospital stays; it must be remembered, however, that all these studies are retrospective in nature and therefore severely limited by significant selection bias. All studies showed similar reoperation rates and mortality, but most found a lower overall morbidity for the laparoscopic approach. Some studies identified lower rates of specific complications, such as wound infection and even pancreatic fistula. Although oncologic clearance was similar, most studies have shown that ODP is often the surgery of choice for larger tumors.
Femoral hernia is not as common as inguinal hernia. It is often associated with incarceration or strangulation, resulting in peritonitis and mortality.
The pelvicrural interval (the opening from the abdomen to the thigh) is divided into two spaces: a lateral space, the lacuna musculosa, through which the iliopsoas muscles pass; and a medial space, the lacuna vasculosa, for the femoral vessels. The external iliac vessels run along the anterior surface of the iliopsoas muscle in the pelvis, pass between the iliopubic tract and Cooper’s ligament, and finally course beneath the inguinal ligament to become the femoral vessels. Where the external iliac vessels run down into the lacuna vasculosa, transversalis fascia covers the vessels to form the femoral sheath. It extends approximately 4 cm caudally and ends as the adventitia of the femoral vessels. The medial compartment of the femoral sheath is called the femoral canal, which is ordinarily less than 2 cm in diameter and contains lymphatic vessels and glands. The true opening of the femoral canal is a musculoaponeurotic ring, consisting of Cooper’s ligament inferiorly, the femoral vein laterally, and iliopubic tract superiorly and medially. In the past, the medial border of the femoral ring was for the lacunar ligament. The lacunar ligament is an attachment of the inguinal ligament to the pubic bone, however, and lies in the outer layer of the transversalis fascia.
McVay demonstrated that the medial boundary of the femoral ring is the lateral edge of the aponeurosis of the insertion of the transversus abdominis muscle with transversalis fascia onto the pectin of the pubis, not the lacunar ligament. Condon also demonstrated that the iliopubic tract bridges the femoral canal and then curves posteriorly and inferiorly, its fibers spreading fanwise to insert adjacent to Cooper’s ligament into a broad area of the superior ramus of the pubis. Thus, the true inner ring of the femoral canal is bounded by the iliopubic tract anteriorly and medially, and by Cooper’s ligament posteriorly. If a surgeon incises the inguinal ligament in a tightly incarcerated femoral hernia, he or she will find that the hernia cannot be reduced because of the more deeply placed ring. The distal orifice has a rigid boundary—surrounded by the lacunar ligament medially; the inguinal ligament superiorly; and the fascia of the pectineal muscle—and is usually less than 1 cm in diameter. The rigidity of these structures is the reason why strangulation often occurs in femoral hernias.
Currently, the ‘‘acquired’’ theory is widely accepted; however, the true cause of femoral hernia is not known. McVay demonstrated that the width of the femoral ring, which is determined by the length of the fanwise insertion of the iliopubic tract to Cooper’ ligament, is the main etiologic factor of the femoral hernia. Considering that the femoral hernia is very rare in children and most common in elderly women, however, McVay’s concept cannot be the only reason for the occurrence of femoral hernia. Nyhus noted the presence of a relatively large femoral defect without an accompanying femoral hernia during the preperitoneal approach. This may be caused by the acquired weakness of the transversalis fascia and a consequent predisposition to the development of the femoral hernia.
The ratio of femoral hernia relative to all groin hernias is reported to be 2% to 8% in adults . Femoral hernias are very rare in children, and most commonly observed between the ages of 40 and 70. The peak distribution is in the 50s, with a slight decrease in the 60s and 70s. As for sex distribution, femoral hernia is 4 to 5 times more common in female than in male; however, there are some reports that it is more common in men than in women. A right-sided presentation is more common than left, but the reason is not known.
Finally, femoral hernia is usually thought of as requiring emergency surgical treatment. Only 30% of our cases were treated as emergency operations, however, whereas 70% were elective. Unless patients complain of severe abdominal pain or ileus, surgeons need not perform emergency operations. In summary, the mesh plug hernia repair for femoral hernia has resulted in a reduced recurrence rate, shortened hospital stay, and a low rate of postoperative complications.
INTRODUCTION: Few other surgical procedures adversely affect a patient’s quality of life as much as a poorly functioning stoma. An ideal stoma meets two criteria: (1) The site is optimally matched to a patient’s variability in body form, physical ability and activities. (2) The construction minimises complications that relate to the use of stomal appliances and minimises technical failings such as parastomal hernia or prolapse.
1.The Skin and Subcutaneous Incision
A circular stomal opening is generally preferred, though for temporary stomata a linear incision minimises skin loss and may improve cosmesis after closure. We favour making a cruciate incision with cutting electrocautery, each quadrant being excised in a curved fashion with electrocautery or curved (Mayo) scissors to prevent charring.
A cruciate incision of the muscle fascia is generally used, mirroring that for the skin incision but without excision. It is common practice during laparotomy to align the muscle fasciotomy and skin incision by medial retraction of the rectus sheath using tissue-grasping forceps (e.g. Lanes’). This may reduce angulation of the bowel through the abdominal wall, though is unlikely to affect the duration of paralytic ileus in the post-operative phase and has little effect on eventual function.
A muscle-splitting incision through rectus abdominis is advocated, though this may simply be a necessary anatomical consequence reflecting the preference for an anterior stoma distant from the umbilicus, iliac crest and midline wounds. Stomal formation lateral to rectus abdominis does not actually seem to increase the risk of para-stomal hernia formation. This is unsurprising, since muscle division and correct closure at apppendicectomy rarely leads to hernia formation.
4.Choice of Bowel for the Construction of a Stoma
The principles of good anastamotic healing apply equally to stomal construction. Attention to tissue handling, vascularity and lack of tension encourage primary healing at the muco-cutaneous junction. Poor technique risks separation of the muco-cutaneous junction and prolonged healing by granulation, leading to stenosis. Tension may worsen stomal or spout retraction and can lead to difficulties in attaching stomal appliances to a concave stoma, particularly if a tight limb of the stoma gives a skin fold crease. Similarly, impaired vascularity can turn stomata a worrying colour, particularly if inotropes are required for a critically ill patient, and although frank necrosis is rare, stenosis may result in the longer term.
“Patients often judge a surgeon’s technical ability by the external appearance of scars, and may also judge a surgeon’s care and precision by the appearance and function of an abdominal stoma.”
The “ideal” tumor marker is economical, easy to estimate in easily accessible body fluids like blood or urine, has high sensitivity and specificity, can be used to screen for a cancer, has prognostic and predictive value at diagnosis, and is reliable during treatment and follow-up. It does not exist as of now. Commonly used tumor markers in gastrointestinal, liver, biliary tract, and pancreatic cancers are alpha fetoprotein (AFP), CA19.9, carcinoembryonic antigen (CEA), and chromogranin A (CgA).
Alpha Fetoprotein (AFP)
Alpha fetoprotein (AFP) is a glycoprotein that is produced in the yolk sac and the fetal liver. It is the most commonly used tumor marker for hepatocellular carcinoma (HCC). AFP may be raised in gonadal tumors, gastric cancer, and benign states like pregnancy, viral hepatitis, and cirrhosis caused by hepatitis C. The normal range is 10–20 ng/ml. Values above 400 ng/ml or a steady rise in serial estimation (even if lower than 400 ng/ml) is highly suggestive of HCC in a patient at risk of developing HCC. Persistent elevation of AFP is more significant than fluctuating levels. AFP levels are usually normal in the fibrolamellar variety of HCC. AFP is a heterogeneous molecule with respect to the carbohydrate moiety. Different AFP glycoforms can be separated and characterized by their affinity for lectins. Lectins are carbohydrate-binding proteins.
AFP level >500 ng/ml predicts high recurrence rate after transplantation, and such patients are not listed in the USA. Rise of AFP while on the wait list is also a poor prognostic factor. AFP >1000 ng/ml appears to be related to poor prognostic factors like microvascular invasion, portal vein invasion, bile duct invasion, and intrahepatic metastasis. In 2012 a French paper reported a model that added AFP to Milan criteria which improved prediction of recurrence and survival after liver transplantation for HCC.
CA 19-9 is the abbreviation for carbohydrate antigen or cancer antigen 19-9. This tumor marker belongs to the family of mucinous markers. These have a transmembrane protein skeleton and an extracellular side that has glycosylated oligosaccharides. It is a sialylated Lewis blood group antigen. Mucus glands in the pancreas, biliary tree, salivary glands, stomach, colon, and endometrium physiologically secrete CA 19-9, and this is present in small quantities in serum. Higher levels are observed in inflammatory conditions of the pancreas and biliary tree like acute pancreatitis, biliary obstruction, and cholangitis. Overall mean sensitivity and specificity of serum CA 19-9 for diagnosis of pancreatic cancer are 81% and 90% according to one recent review. This study reported these results using 37 KU/l as cutoff of CA 19-9. Serum CA 19-9 seems to fare very poorly and is unsuitable as a screening modality for pancreatic cancer.
In one of the largest reviews of data, positive predictive value for diagnosis of pancreatic cancer was only 0.9%. Another study from Mumbai used CA 19-9 to predict operability in 49 patients with pancreatic cancer. When CA 19-9 was more than twice the normal (37 U/l), 88% were unresectable. Out of the 29 patients considered resectable after contrast-enhanced CT scan of abdomen, 5 patients were found unresectable at operation due to subcentimeter liver or peritoneal metastasis. All these five patients had CA 19-9 level more than three times the normal limit. These investigators suggest that diagnostic/ staging laparoscopy should be used to avoid a non-therapeutic laparotomy if CA 19-9 is more than thrice the normal limit.
Chromogranin A (CgA)
CgA is an acidic glycoprotein that is ubiquitously present in almost all endocrine and neuroendocrine cells of the human body. They are synthesized in these cells, stored along with other hormones /neurotransmitters in vesicles and released from the cells by exocytosis along with other hormones. The granin family consists of eight different substances of which chromogranin A is the best known and the one in clinical use for several decades now. CgA is thus a universal marker for neuroendocrine cell differentiation and activity. Testing its serum level is a marker of neuroendocrine secretory activity in the body. There are numerous limitations for the use of serum chromogranin A for diagnosis or follow-up of gastroenteropancreatic neuroendocrine tumors (GEP-NETs). However, it still remains the preferred tumor marker in these conditions, as it is widely available and less cumbersome to perform and retains a reasonable sensitivity and specificity provided the clinician applies all necessary recommended precautions in performance of the test and interpretation of the results.
Highest levels of CgA in GEP-NETs are obtained in midgut neuroendocrine tumors, previously termed as “carcinoid tumors.” In ileal carcinoids with liver metastasis, level as high as 200 times upper normal limit is reported. GEP-NETs in MEN-1 syndrome could result in chromogranin A values of about 150 times the upper normal limit. CgA levels in pancreatic NETs are about 60–80 times upper normal limit. CgA is elevated in 100% of gastrinomas and 70% of pancreatic NETs. In gastrinoma, very high levels are reported even in the absence of liver metastasis. CgA level of more than 5000 μg/l was found to be an independent prognostic factor for midgut NETs. Median survival was 33 and 57 months below and above the 5000 μg/l cutoff, respectively. This interpretation of CgA level cannot be generalized to all GEP-NETs. Typical exception of high level without any metastatic disease is gastrinoma as mentioned earlier. CgA level does not correlate with the degree of differentiation of GEP-NETs. Diagnostic accuracy of CgA was 73% in well-differentiated NETs and 50% in poorly differentiated NETs. This is probably related to loss of secretory function of poorly differentiated NETs, where this tumor marker is less reliable. CgA level has been reported to fall after all forms of therapy for GEP-NETs. This could be resection of the tumor, liver transplantation for metastatic disease, radionuclide therapy, or treatment with receptor blockade like everolimus.
In the setting of a normal ejection fraction, fluid is only administered when the expectation is that cardiac output will increase, and vasopressors are utilized if the aforementioned devices show fluid will not increase cardiac output. Excess fluid in certain general surgical cases can cause ileus and bowel edema, and in cardiac cases, it can cause hemodilution. Patients randomized to restricted and liberal fluid resuscitation strategies found a clear linear relationship between total fluids administered (and weight gain) and complications following colorectal surgery including pulmonary edema and tissue-healing complications. Further multiple studies exist demonstrating fewer complications with normovolemia than with liberal strategies of fluid resuscitation.
It must be understood that goal-directed therapy does, in no way, mean reduction in fluid administration. For some procedures, it may be necessary to administer more than anticipated fluid volumes (orthopedics), while for others, the opposite may be true (abdominal). Normovolemia is important to maintain perfusion without volume overload. Thus, the idea behind goaldirected therapy is to maintain zero fluid balance coupled with minimal weight gain or loss. Hypovolemia is associated with reduced circulating blood volume, decreased renal perfusion, altered coagulation, microcirculation compromise, and endothelial dysfunction, among other processes. Hypervolemia is associated with splanchnic edema, decreased pulmonary gas exchange secondary to pulmonary edema, impaired wound healing, anastomotic dehiscence, decreased mobility, altered coagulation, and endothelial dysfunction, amidst others processes.
From a recent Cochrane review, there is no evidence that colloids are superior to crystalloid for resuscitation in patients. Therefore, crystalloid fluids should generally be the primary intravenous fluid during the perioperative course. In cardiac surgery, the utilization of 0.9% normal saline solution was associated with hyperchloremia and poor postoperative outcomes, including higher length of stay and increased mortality.118 Further, a more balanced crystalloid, such as Plasma-Lyte, was associated with improved outcomes in 22,851 surgical patients. In this study, there was a 2.05 odds ratio predictor of mortality with normal saline. Other complications such as acute kidney injury, gastrointestinal complications, major hemorrhage, and major infection were also increased in the group of
patients that were hyperchloremic after normal saline administration. Based on such evidence, it would seem prudent to proceed with a more balanced solution, such as PlasmaLyte, to reduce complications.
The purpose of this review is to evaluate the incidence and management of internal hernias (with or without SBO) after LGBP.
Laparoscopic Roux-en-Y gastric bypass (LGBP) has been shown to be an effective treatment for morbid obesity, both in terms of weight loss and improvement in multiple comorbidities. While the laparoscopic approach offers many advantages to the patient in terms of fewer wound complications, decreased length of hospital stay, and decreased postoperative pain, certain complications of this operation continue to pose difficult clinical problems as the number of procedures performed increases. One such complication is internal hernia through one of the mesenteric defects, which can result in small bowel obstruction, ischemia, or infarction and often requires reoperation.
An internal hernia is defined as a protrusion of intestine through a defect within the peritoneal cavity, as opposed to an external (or incisional) hernia that protrudes through all layers of the abdominal wall. Internal hernias almost always occur through iatrogenic defects created surgically.
Incisional hernias occur at a higher incidence after open gastric bypass (GBP) at a rate of about 20 percent. LGBP has a lower rate of incisional hernias. A recent study by Rosenthal, et al., showed a 0.2-percent rate of port site hernias in 849 patients using blunt-tip trocars at 3,744 port sites. Internal hernias, on the other hand, occur more frequently in LGBP than in the open procedure. This is a significant clinical problem, since internal hernia is the most common cause of small bowel obstruction (SBO) after LGBP. Retrospective reviews have found the incidence of SBO after LGBP to be between 1.8 and 9.7 percent. The incidence of internal hernia after LGBP is between 0.2 and 8.6 percent based on multiple studies.
This incidence is higher than that seen with open GBP, and this is presumably due to decreased adhesion formation after laparoscopic surgery compared to open surgery. The creation of potential space as a result of weight loss may also be a contributing factor in the etiology of internal hernias, which often present in a delayed fashion. In addition, the particular case of pregnancy— with the mass effect of an enlarging uterus—may predispose to this condition, as there have been three case reports in the literature of internal hernia during pregnancy, one of which resulted in intestinal ischemia and fetal demise. Due to the increasing scope of this problem and its potentially devastating consequences, surgeons should have a high clinical suspicion for internal hernia after LGBP.
An internal hernia can potentially occur through either two or three defects, depending on whether a retrocolic or antecolic technique is used for the Roux limb. Petersen’s defect is defined as the space between the Roux limb and the transverse mesocolon. A defect is also present between the biliopancreatic and Roux limbs at the jejunojejunostomy. If a retrocolic approach is used, a third defect in the transverse mesocolon is created. This is the most common site of internal hernia in most reports, which has prompted many surgeons to adopt an antecolic technique in order to eliminate this defect. Higa’s study of 2,000 patients showed an internal hernia distribution of 67 percent mesocolic, 21 percent jejunal, and 7.5 percent Petersen. However, some centers experience a higher rate of hernia in the jejunal or Petersen’s defects, despite the use of a retrocolic approach.
Patients with internal hernia most commonly present with abdominal pain, and may also have symptoms of small bowel obstruction. The time of presentation varies greatly and may occur within one week of the initial operation or up to three years postoperatively. However, the majority of cases occur between 6 and 24 months postoperative. Radiographic diagnosis of internal hernia presents a challenge since the characteristic findings on computed tomography (CT) scan are often missed.
Features suggestive of an internal hernia include small bowel loops in the upper quadrants; evidence of small bowel mesentery crossing the transverse mesocolon; presence of the jejunojejunostomy superior to the transverse colon; signs of small bowel obstruction; or twisting, swirling, crowding, stretching, or engorgement of the main mesenteric trunk and according to one study, the sensitivity and specificity of CT is 63 percent and 76 percent, respectively.
Another study showed that although the diagnosis was only made prospectively by CT scan in 64 percent of cases, a retrospective review of the images showed that diagnostic abnormalities were present in 97 percent of cases. A report of five cases of internal hernia by Onopchenko found that only one was diagnosed preoperatively by radiological reading, even though all five had findings suggestive of internal hernia to the bariatric surgeon. These findings emphasize the need for communication with the radiologist, careful attention to patient history, and high clinical suspicion for internal hernias. In rare cases, closed loop obstruction and extensive bowel ischemia and infarction can occur. This dreaded complication underscores the necessity of making a rapid diagnosis. If the patient has significant symptoms but radiologic studies are negative, a diagnostic laparoscopy is warranted to rule out internal hernia.
PREVENTION AND TREATMENT
Given the prevalence of internal hernias and the increasing popularity of bariatric surgery, it is important to prevent or minimize this complication at the time of the initial operation. Although there have been no randomized, controlled trials comparing different techniques of LGBP, some authors have anecdotally reported lower rates of internal hernia after modifying their technique from a retrocolic to antecolic approach. Champion and Williams reported a significant decrease in small bowel obstruction after changing to an antecolic position, and Felsher and colleagues found no internal hernias in their study after adopting the antecolic approach.
However, other studies support careful defect closure as the most important factor in reducing hernia rates. Dresel and colleagues report no internal hernias after modifying their technique to include closure of Petersen’s defect. Carmody and colleagues report a decreased hernia incidence when closing all defects, even with a retrocolic approach. DeMaria’s study reports anecdotal improvement after closing mesenteric defects in two layers, on the medial and lateral aspects of the defect.
The majority of internal hernias can be successfully treated laparoscopically, with reduction and defect closure. The laparoscopic approach is usually successful; however, because of the lack of adhesion formation after laparoscopy, Capella, et al., suggest laparotomy for patients who experience a second episode of bowel obstruction due to recurrent internal hernia after laparoscopic repair. The greater adhesion formation after laparotomy may help prevent future internal hernia formation.
One of the benefits of laparoscopy, decreased adhesion formation, is likely also responsible for the increasing prevalence of internal hernia as a complication following laparoscopic gastric bypass. Although it has not been borne out in randomized clinical trials, anecdotal evidence and expert opinion suggest that Roux limb position and mesenteric defect closure at the time of initial operation are important factors in ultimate rates of hernia formation. Careful attention must be paid to individual surgical techniques in order to prevent this potentially devastating complication. The benefits of LGBP are maximized when there is a low incidence of postoperative hernias and resultant obstruction.
Severe gastrointestinal bleeding has historically been a clinical problem primarily under the purview of the general surgeon. Diagnostic advances made as the result of newer technologies, such as fiberoptic and video endoscopy, selective visceral arteriography, and nuclear scintigraphy, have permitted more accurate and targeted operations. More importantly, they have led to safe, effective nonoperative therapeutic interventions that have obviated the need for surgery in many patients. Today, most gastrointestinal bleeding episodes are initially managed by endoscopic or angiographic control measures. Such interventions are often definitive in obtaining hemostasis. Even temporary cessation or attenuation of massive bleeding in an unstable patient permits a safer, more controlled operative procedure by allowing an adequate period of preoperative resuscitation. Despite the less frequent need for surgical intervention, traditional operative approaches, such as suture ligation, lesion or organ excision, vagotomy, portasystemic anastomosis, and devascularization procedures, continue to be life-saving in many instances. The proliferation of laparoscopic surgery has fostered the application of minimally invasive techniques to highly selected patients with gastrointestinal bleeding. Intraoperative endoscopy has greatly facilitated the accuracy of laparoscopic surgery by endoscopic localization of bleeding lesions requiring excision. It is anticipated that the evolving technologies pertinent to the diagnosis and management of gastrointestinal bleeding will continue to promote collaboration and cooperation between gastroenterologists, radiologists, and surgeons.
The role of surgery in acute peptic ulcer bleeding has markedly changed over the past two decades. The widespread use of endoscopic treatment has reduced the number of patients requiring surgery. Therefore, the need for routine early surgical consultation in all patients presenting with acute UGIB is now obviated (Gralnek et al., 2008). Emergency surgery should not be delayed, even if the patient is in haemodynamic shock, as this may lead to mortality (Schoenberg, 2001). Failure to stop bleeding with endoscopic haemostasis and/or interventional radiology is the most important and definite indication. The surgical procedures under these circumstances should be limited to achieve haemostasis. The widespread use of PPIs obviated further surgical procedures to reduce acid secretion. Rebleeding tends to necessitate emergency surgery in approximately 60% of cases with an increase in morbidity and mortality (Schoenberg et al.; 2001). The reported mortality rates after emergency surgery range from 2 – 36%. Whether to consider endoscopic retreatment or surgery for bleeding after initial endoscopic control is controversial (Cheung et al., 2009). A second attempt at endoscopic haemostasis is often effective (Cheung et al., 2009), with fewer complications avoiding some surgery without increasing mortality (Lau et al., 1999). Therefore, most patients with evidence of rebleeding can be offered a second attempt at endoscopic haemostasis. This is often effective, may result in fewer complications than surgery, and is the current recommended management approach. Available data suggest that early elective surgery for selected high-risk patients with bleeding peptic ulcer might decrease the overall mortality rate. It is a reasonable approach in ulcers measuring ≥2 cm or patients with hypotension at rebleeding that independently predicts endoscopic retreatment failure (Lau et al., 1999). Early elective surgery in patients presenting with arterial bleeding or a visible vessel of ≥2 mm is superior to endoscopic retreatment and has a relatively low overall mortality rate of 5% (Imhof et al., 1998 & 2003). Additional indications for early elective surgery include age >65 years, previous admission for ulcer plication, blood transfusion of more than 6 units in the first 24 hours and rebleeding within 48 hours (Bender et al., 1994; Mueller et al., 1994). This approach is associated with a low 30–day mortality rate as low as 7%.
Neuroendocrine tumours (NETs) are neoplasia that can exhibit a range of features such as the production of neuropeptides, the presence of large dense-core secretory vesicles, and the lack of neural structures. NETs can be found in many body regions including the head, neck, lungs, and abdomen. Gastroenteropancreatic (GEP) NETs can be functioning or nonfunctioning, depending on whether hormones are secreted. While the majority of NETs are sporadic, a smaller portion can be related to genetic syndromes such as multiple endocrine neoplasia (MEN), von Hippel-Lindau (VHL), and neurofibromatosis (NF). Compared with their epithelial counterparts, NETs have usually better outcomes. Surgical resections, ranging from enucleation to standard pancreatectomy and lymphadenectomy, play a key role in the management of these lesions, even in advanced disease. Long-term outcomes are correlated with the grading of the disease. Among GEP-NETs, small intestinal NETs (Si-NETs) have a higher incidence than pancreatic neuroendocrine tumours (PanNETs).
Along with incidental diagnosis, tumour size and tumour grading are the most powerful predictors of long-term survival and recurrence. Based on this data, the ENETS guidelines suggested active surveillance rather than surgery for patients with incidental NF-PanNETs that are <2 cm. A recent systematic review demonstrated that surveillance of asymptomatic small NF-PanNETs is safe at least in selected patients although the quality of available studies is still too low to draw firm conclusions. Regardless the size of the primary tumour and the absence of symptoms, a G2 or G3 PanNET/Cs should be treated with resection. Surgery still remains the gold standard in patients with NF-PanNET >2 cm.
The type of resection depends on the location of the lesion. In the presence of head lesions, Whipple’s procedure is the treatment of choice, while distal pancreatectomy and splenectomy is recommended in body-tail lesions. Regardless the type of surgery, a standard lymphadenectomy should be performed. The role of lymphadenectomy during surgical resection for PanNETs is still unclear; however, several authors have shown that the presence of lymph node metastases is associated with poor prognosis; therefore, lymphadenectomy is very helpful in the staging of the disease, but there is no evidence to support an extended lymphadenectomy. The risk of lymph node metastases increases with the increasing size of the primary lesion. Therefore, a standard lymphadenectomy which consists of peripancreatic lymph node dissection along major pancreatic vessels, should always be performed. Recent evidence on the role of conservative management of small PanNETs and the risk of node involvement in PanNETs >2 cm have now significantly limited the role of PSP in NF-PanNETs. These procedures that include enucleation and MP are now limited to patients with small, asymptomatic PanNETs in whom a conservative approach is contraindicated because of young age or for patient’s willingness. Despite a clear benefit in terms of long-term risk of developing pancreatic insufficiency, PSP has a similar morbidity and mortality to standard pancreatic resections.
Liver resection offers the only chance of cure in patients with a variety of primary and secondary liver tumors. For breast cancer, the natural history of this condition is poorly defined and the management remains controversial. Most physicians view liver metastases from breast cancer with resignation or attempt palliation with hormones and chemotherapy. Proper patient selection is crucial to ensure favorable long-term results. Although results of hepatic resection for metastatic colorectal cancer have been reported extensively, the experience with liver resection of metastases from breast cancer is limited. In 1991, the first series reporting hepatectomy for breast cancer patients was published.
A large series by Adam et al. reported the experience of 41 French centers regarding liver resection for noncolorectal, nonendocrine liver metastases. Among the 1452 patients who were studied, 454 (32%) were breast cancer patients. Mean age was 52 years (range 27–80 years). Most patients received adjuvant chemotherapy (58%), as few were downstaged by neoadjuvant chemotherapy. Delay between the treatment of the primary breast tumor and metastases was 54 months, with metachronous metastases in more than 90% of cases. There was a single metastasis in 56% of cases and less than three metastases in 84%. Only 8% were nonresectable. Most patients (77% of cases) underwent anatomical major resections (>3 segments). Negative margins were obtained in 82% of cases. Operative mortality was 0.2% during the 2 months following surgery. Fewer than 10% of the patients developed a local or systemic complication. With a median follow-up of 31 months, the overall survival was 41% at 5 years and 22% at 10 years, with a median of 45 months. Five- and 10-year recurrencefree survival rates were 14% and 10%, respectively.
Poor survival was associated with four factors determined by multivariate analysis: time to metastases, extrahepatic location, progression under chemotherapy treatment, and incomplete resection. At the UTMDACC, breast cancer patients who present with isolated synchronous liver metastases are treated initially with systemic chemotherapy. In responders,
hepatic resection is only contemplated if no other disease becomes evident during initial systemic treatment. Most candidates for hepatic resection undergo treatment for metachronous disease and only undergo resection for metastatic disease confined to the liver.
The association between GERD and obesity has generated great interest, because obesity has been indicated as a potential risk factor for reflux disease. A directly dependent relationship has been reported because an increase in body mass index has mirrored an increase in the risk of GERD. The incidence of reflux in the obese population has been cited as high as 61%. The pathophysiologic mechanism underlying the link between obesity and GERD has not been fully elucidated and seems to be multifaceted. As the number of obese patients is increasing, so is the volume and variety of bariatric procedures. The effect of bariatric surgery on preexisting GERD or newly developed GERD differs by procedure.
GERD AFTER ROUX-EN-Y GASTRIC BYPASS
Roux-en-Y gastric bypass (RYGB) has been used as a standalone reflux procedure. Mechanisms of the antireflux effect of RYGB include diverting bile from the Roux limb, promoting weight loss, lowering acid production in the gastric pouch, rapid pouch emptying, and decreasing abdominal pressure over the LES. Several studies have examined the relationship between GERD and RYGB. Studies have also analyzed symptomatic relief by using questionnaires before and after the procedure. One study has examined further the incidence of esophagitis postoperatively on endoscopy. Merrouche and colleagues showed a 6% incidence of esophagitis on endoscopy after RYGB; however, the preoperative incidence was not mentioned.
Pallati and colleagues also examined the GERD symptoms after several bariatric procedures by using the Bariatric Outcomes Longitudinal Database. GERD score improvement was highest in the RYGB group; 56.5% of patients showed improvement of symptoms. The study concluded that RYGB was superior to all other procedures in improving GERD. The proposed but unproven mechanisms included a greater weight loss and a decrease in the amount of gastric juice in the proximal pouch. The study, however, did not show any objective measures of GERD improvement. Another study by Frezza and colleagues showed a significant decrease in GERD-related symptoms over the 3-year study after laparoscopic RYGB, with decrease in reported heartburn from 87% to 22% (P<.001). The authors proposed that, in addition to volume reduction and rapid egress, the mechanism of how this procedure affects symptoms of GERD is through weight loss and elimination of acid production in the gastric pouch. The gastric pouch lacks parietal cells; thus, there is minimal to no acid production and also, owing to its small size, it minimizes any reservoir capacity to promote regurgitation.
Varban and colleagues examined the utilization of acid-reducing medications (proton pump inhibitor and H2-blockers) at 1 year after various bariatric procedures. The groups reported that at 1 year after RYGB, 56.2% of patients would discontinue an acid-reducing medication that they had been using at baseline. Interestingly, the group also showed that 19.2% of patients would also start a new acid-reducing medication after RYGB. Given the number of studies that have reported improvement in GERD symptoms after RYGB, this procedure is now widely accepted as the procedure of choice for treatment of GERD in the morbidly obese patient. Although no increased risk is conferred to patients with a body mass index of 35 kg/m2 or higher who undergo fundoplication for GERD the recommendation and practice of many surgeons is to perform a laparoscopic gastric bypass in lieu of fundoplication owing to its favorable effect on other comorbid conditions. In addition, advocates of the RYGB are promoting a conversion to an RYGB instead of a redo fundoplication.
In a recent study, Stefanidis and colleagues followed 25 patients who had previous failed fundoplication, which was taken down and converted to an RYGB. Patients were followed with the Gastrointestinal Quality of Life Index and the Gastrointestinal Symptoms Rating Sale. The revision surgery led to resolution of GERD symptoms for a majority of the patients. The authors concluded that an RYGB after a failed fundoplication has excellent symptomatic control of symptoms and excellent quality of life. However, owing to the technical challenges of the procedure and the potential for high morbidity, it should only be performed by experienced surgeons.
GERD AFTER SLEEVE GASTRECTOMY
Sleeve gastrectomy (SG), which was originally described as a first stage of the biliopancreatic diversion, is a relatively new treatment alternative for morbid obesity. It has become popular owing to its technical simplicity and its proven weight loss outcomes. Although it has many positive effects on obesity and obesity-related comorbidities, the association between GERD and SG remains controversial. Although some studies have reported improvement in GERD symptoms after SG, the majority of studies have reported an increase in GERD symptoms. The International Sleeve Gastrectomy Expert Panel reported a postoperative rate of GERD symptoms after SG in up to 31%; however, others cited increased GERD prevalence after surgery between 2.1% and 34.9%.
Studies Showing an INCREASE: Several studies have shown an increase of GERD after SG at various time points. The comparison between different studies is difficult owing to variations in the definition of GERD. Although some have utilized the use of proton pump inhibitors as a diagnostic tool, others have used the definition of typical heartburn and/or acid regurgitation occurring at least once per week. Few studies used objective data to define reflux.
Tai and colleagues examined symptoms of GERD and erosive esophagitis at 1 year after laparoscopic sleeve gastrectomy (LSG). The groups concluded that there was a significant increase in the prevalence of GERD symptoms and erosive esophagitis (P<.001), in addition to a significant increase in the prevalence of hiatal hernias (P<.001), which was higher in patients who presented with erosive esophagitis after LSG. Others have shown a similar increase of GERD at 1 year. Himpens and colleagues compared adjustable gastric banding (AGB) and SG at 1 and 3 years after procedures. GERD seemed de novo after 1 year in 8.8% and 21.8% of patients with AGB and SG, respectively. At 3 years, however, rates changed to 20.5% and 3.1% in the ABG and SG groups. Another study followed patients for more than 6 years and reported 23% to 26% of patients reporting frequent episodes of GERD. Various mechanisms have been postulated to cause symptoms of GERD after LSG. As SG alters the gastroesophageal anatomy, it has been hypothesized that the anatomic abnormalities created contribute to the development of GERD in patients.
Lazoura and colleagues showed that the final shape of the sleeve can influence the development of GERD. The group showed that patients with tubular pattern and inferior pouch (preservation of the antrum) did better in terms of regurgitation and vomiting compared with a tubular sleeve with a superior pouch. Others have also suggested the importance of antral preservation to avoid GERD development. An increase in acid production capacity can cause reflux in the case of an overly dilated sleeve, whereas impaired esophageal acid clearance can lead to reflux in a smaller sleeve. Formation of a neofundus can in an effort to avoid fistulas may also lead to development of GERD. Daes and colleagues further concentrated on describing and standardizing the procedure to reduce GERD symptoms. The authors identified 4 technical errors that led to development of GERD after the procedure: relative narrowing at the junction of the vertical and horizontal parts of the sleeve, dilation of the fundus, twisting of the sleeve, and persistence of hiatal hernia or a patulous cardia. By ensuring careful attention to surgical technique and performing a concomitant hiatal hernia repair in all patients, they reduced the rate of postoperative GERD to only 1.5%. The group concluded that hiatal hernia is the most important predisposing factor.
Studies Showing REDUCTION: Several studies have reported either decreased or no association between GERD and LSG. Interestingly, in some of these studies, GERD improvement has been reported as a secondary outcome. Rawlins and colleagues reported an improvement of symptoms in 53% of patients, but de novo GERD in 16% of patients. A multicenter prospective database review examined GERD in all 3 major bariatric procedures and reported improvement in all. The authors used medication use to define GERD. A small portion of patients reported worsening GERD, which was highest in the SG group. Sharma and colleagues also reported an improvement of GERD as assessed by symptom questionnaires, as well as improvement in grade of esophagitis on endoscopy. The possible mechanisms for improvement of GERD postoperatively are faster gastric emptying, reduction in gastric reservoir function, gastrointestinal hormonal modifications, decrease in acid secretions, and decrease in weight. Daes and colleagues reported a decrease in incidence of GERD by using a standardized operative technique and concomitant repair of hiatal hernia.
Owing to conflicting reports about the association between GERD and LSG, this procedure is controversial in patients with preexisting GERD. If LSG is considered in this population, hiatal hernia repair and meticulous technique are essential. We would like to emphasize the importance of preoperative testing to define the anatomy and evaluate preexisting GERD, esophagitis, Barrett’s esophagus, or the presence of hiatal hernia.
The incidence of HCC is increasing in the worldwide. Surgery in the form of liver resection or transplantation remains the mainstay of curative treatment for HCC, even though selected patients with small tumours may also be cured with ablation. Liver resection and transplantation are not necessarily two binary choices in most patients and, despite all the debates, are often complementary treatment modalities ideally suited to different patient groups. Thus characterisation of patient and tumour characteristics to guide decision making is vital to achieve the best outcome for patients.
1.Anatomical Resection or Not?
The aim of liver resection in patients with HCC and CLD is that it should be curative with resection of tumour vascular territories and also preserve as much liver volume as possible to prevent postoperative liver failure. EASL guidelines recommend anatomical resection of HCC, whereby the lines of resection match the limits of one or more functional segments of the liver. This is based on evidence suggesting superior oncological outcomes in addition to a reduction in the risk of bleeding and biliary fistula. Although there are no randomised data, a meta-analysis including 2000 patients from 12 non-randomised comparative trials did not show any benefit of anatomical compared with non-anatomical resection in 1-, 3- and 5-year survival, recurrence rate, postoperative morbidity or blood loss . It is practice to perform an anatomical resection for tumours >2 cm, and for smaller tumours in anatomically favourable positions, a wedge with adequate margin is often sufficient. Modifying techniques to maximise parenchymal preservation preserving adequate margins are often the key in these patients.
2. Anterior Approach
The anterior approach, as described by Professor Belghiti , has been advocated for large right-sided tumours. This technique involves transection of the liver parenchyma to the IVC without mobilisation of the liver with the theoretical advantage of less tumour seeding. A prospective randomised controlled trial compared the anterior and conventional approach on 120 patients with large (>5 cm) HCCs. The anterior approach group had less blood transfusion requirements and a significantly longer overall survival (68.1 v 22.6 months; p = 0.006).
As in liver resection for other indications, there is no good evidence to indicate that a single method of parenchymal transection, application of fibrin sealants or intermittent inflow occlusion is beneficial in surgery for HCC. There is also no evidence to suggest that using special equipment for liver resection is of any benefit in decreasing the mortality, morbidity, or blood transfusion requirements. Surgeons should use techniques in which they have been trained and can demonstrate acceptable outcomes.
4. Laparoscopic Approach
Laparoscopic HCC resections are gaining popularity as the approach is more widely adopted across centres. It is important that patients for laparoscopic resection are selected based on the technical capabilities of the surgeon and centre, and the proper mentoring takes place during the learning curve. A summary of published metaanalyses concluded that the laparoscopic approach was associated with improved short-term outcomes (blood loss, complication rates and hospital length of stay) without compromising long-term oncological outcomes. It is worth noting that there are no randomised data; however a number of trials are in progress. Furthermore,their analysis suggested that the incidence of postoperative ascites and liver failure is decreased in the selected group of laparoscopic liver resections . A further metaanalysis of cirrhotic patients up to Child-Pugh B undergoing laparoscopic compared with open liver resection for HCC confirmed these perioperative benefits .
5. Robotic Approach
Although still very much in its infancy, the application of robotic surgery to HCC resection can theoretically yield similar advantages in short-term outcomes to the laparoscopic technique. The only comparative study between robotic and open liver resection for HCC included 183 patients undergoing robotic hepatectomy who were compared using propensity scoring with a cohort of 275 open resections. The robotic group required longer operating time (343 vs 220 min), shorter hospital stays (7.5 vs 10.1 days) and lower dosages of postoperative patient-controlled analgesia (350 vs 554 ng/kg). The 3-year disease-free survival of the robotic group was comparable with that of the open group (72.2% vs 58.0%; p = 0.062), as was the 3-year overall survival (92.6 vs 93.7%; p = 0.431). The associated financial costs of robotic surgery still pose a limitation to its adoption, and it is unclear if this approach is associated with any significant advantages over laparoscopic rather than open resection.
6. Associating Liver Partition with Portal Vein Ligation for Staged
ALPPS is still considered an experimental technique in which a first-stage procedure consisting of physical liver splitting and portal vein ligation is followed by a second stage of resection of the HCC and associated liver segments. The advantage seen in colorectal liver metastases is that of rapid hypertrophy for the FLR. There are only limited data describing outcomes of ALPPS for HCC; however an analysis of 35 patients in the international ALPPS registry showed an impressive FLR hypertrophy of 47% following the first stage of the procedure that was associated with a 31% perioperative mortality rate. The majority of these patients were in the intermediate-stage category of the BCLC algorithm. Further evaluation is required prior to routine use of ALPPS for HCC resection, and it is the view of the authors that ALPPS may be a procedure best reserved for carefully selected patients who have bilateral disease.
7. Combined Resection with RFA for Bilobar HCC
For patients with multiple or bilobar HCC in whom resection is contraindicated due to inadequate FLR, combined resection and radiofrequency ablation (RFA) may yield better results than alternative treatments. A single-centre study compared patients with bilobar liver HCCs who underwent resection (n = 89), combination of resection and RFA (n = 114) and TACE (n = 161). The results showed that 1-, 3- and 5-year survival was better in both resection and combined resection, and RFA groups compared with TACE and survival and disease-free survival were comparable between both surgical groups. They concluded that resection combined with RFA provided a chance for cure in patients with bilobar HCC, and provided liver function is preserved, aggressive treatment can improve prognosis.
In the healthy adult, the pancreas is a soft, retroperitoneal glandular organ, lying transversely and oblique and draped over the vertebral column at the level of L1–L2 vertebrae. The bulk or volume of the pancreas varies and increases during the first 2–3 decades of life but progressively atrophies with aging. The pancreas is divided into five parts: the head, neck, body, tail, and uncinate process. The neck, head, and uncinate process are encompassed by the C-loop of the duodenum, to the anatomic right of the midline, and are in intimate relationship with the superior mesenteric vessels medially. The body extends laterally to the anatomic left, posterior to the stomach, with the tail terminating in the splenic hilum.
The organ is surrounded by a thin capsule that is loosely attached to its surface. Most of the anterior surface of the pancreas is covered with peritoneum, except where it is crossed by the root of the transverse mesocolon, as well as where there is direct contact with the first part of the duodenum and the splenic hilum. The head of the pancreas is the thickest part of the gland. Anteriorly, it is related to the origin of the transverse mesocolon. Posteriorly, the head is related to the inferior vena cava (IVC), the right gonadal vein near its entrance into the vena cava, and the right crus of the diaphragm. The common bile duct runs either on the posterior surface of the pancreatic head or is embedded within the parenchyma of the gland.
The transitional zone between the head and the body of the pancreas is termed the neck. It is defined by its anatomic location anterior to the formation of the portal vein (usually by the confluence of the superior mesenteric and splenic veins).It is approximately 2 cm wide and usually the most anteriorly located portion of the pancreas. Anteriorly the neck is covered by peritoneum and is related to the pylorus superiorly. Its posterior aspect is grooved by the superior mesenteric vein (SMV) and the portal vein (PV).
The anterior body of the pancreas is covered by the peritoneal layer that constitutes part of the posterior wall of the lesser sac. Toward the inferior border of the pancreas, the peritoneal layer is reflected anteroinferiorly to form the superior leaf of the transverse mesocolon. The posterior surface of the body lies on the fusion fascia of Toldt in the retroperitoneum, the so-called bloodless plane of Treves. The posterior body is related to the abdominal aorta and the origin of the superior mesenteric artery (SMA), the left crus of the diaphragm, the left renal vein, the left kidney, and the left adrenal gland, from right to left.
The pancreas has important relationships to major blood vessels, of relevance to surgery of the pancreas. The splenic vein runs along the posterior surface of the gland in a groove of variable depth, sometimes almost entirely embedded within the pancreatic parenchyma. The celiac trunk and its branches emanate along the superior border of the body, with the common hepatic artery running to the right and the splenic artery to the left. The inferior border of the pancreas is crossed posteriorly by the inferior mesenteric vein (IMV), typically at its confluence with the splenic vein, and it serves as a useful landmark for identification of the former vessel on cross-sectional imaging.
The tail of the pancreas is the relatively mobile, left-most part of the pancreas that is confined between the layers of the splenorenal ligament together with the splenic artery and the origin of the splenic vein. It is 1.5–3.5 cm long in adults and may extend variably to the hilum of the spleen in 50% of cases and may extend posterior to vessels in the hilum. This makes the tail of the pancreas vulnerable to injury during splenectomy and needs to be visualized prior to ligating the splenic vessels. The uncinate process can be considered as a distinct part of the pancreas due to its different embryologic origin and its location extending posterior to the superior mesenteric vessels.
It extends in the plane between the superior mesenteric vessels anteriorly and the aorta posteriorly. Superiorly, it relates to the left renal vein. It lies immediately superior to the third part of the duodenum, such that tumors arising in the uncinate process can compress the former leading to duodenal obstruction. The main pancreatic duct of Wirsung begins at the tail of the pancreas and runs through the body roughly midway between the superior and inferior border. It receives multiple small ductules throughout its course that drain the pancreatic parenchyma, thus increasing progressively in diameter from 1 mm in the tail to 3 mm in the head. It deviates inferiorly and posteriorly in the head as it courses toward the main ampulla. The pancreatic duct and bile duct are usually separated by the transampullary septum before joining in a “Y” configuration within the duodenal wall.
The terminal part of the two ducts is surrounded by a complex circular arrangement of smooth muscle fibers known as the sphincter of Oddi. The sphincter of Oddi is anatomically distinct from the muscular layers of the duodenum, and it has a dual function: (a) to regulate flow of biliary and pancreatic secretions into the duodenal lumen and (b) to impede reflux of intestinal content into the pancreatobiliary ductal system. The accessory duct of Santorini runs superior and parallel to the duct of Wirsung. It drains part of the head of the pancreas into the minor duodenal papilla, roughly 1–2 cm proximal to the ampulla of Vater. The pattern of fusion of the main and accessory ducts is variable and can be entirely separate (pancreas divisum).
Obesity is one of the most significant health problems worldwide, and the prevalence has been increasing over the past decade. Despite improvement in the performance of bariatric surgery, complications are not uncommon. These complications vary according to baseline patient characteristics, the duration of time since the operation, and the type of bariatric surgery performed. Endoscopy is the cornerstone in the diagnosis of postoperative complications after bariatric surgery, and may even be performed in the early postoperative course. With an increasing number of patients being referred for endoscopic evaluation following bariatric surgery, it is essential to develop an understanding of the anatomic changes for optimal assessment and appropriate treatment of these patients.
Early and late dumping syndrome occurs not uncommonly in patients who have undergone gastric bypass surgery when large quantities of simple carbohydrates are ingested. Early dumping typically occurs within 15 minutes of ingestion and has been attributed to rapid fluid shifts from the plasma into the bowel from hyperosmolality of the food. Late dumping occurs hours after eating and results from hyperglycemia and the subsequent insulin response leading to hypoglycemia. When hypoglycemia is severe, treatment with a low carbohydrate diet and an alphaglucosidase inhibitor may be effective. Furthermore, restoration of gastric restriction using an endoscopic approach to reduce the aperture of the GJA has also demonstrated to be effective in management of this condition.
The initial management of dumping syndrome is dietary modifications. Recommendations include consuming smaller meals by dividing daily calorie intake into six meals and delaying liquids at least 30 min after meals Rapidly absorbable simple carbohydrates should also be avoided. Adjuncts to diet modification include pectin and guar gum, which slow down gastric emptying by increasing food viscosity. Acarbose, which interferes with carbohydrate absorption in the small intestines, has also proven to relieve symptoms in small studies. After dietary modifications, medications such as somatostatin analogs (e.g., octreotide) alleviate symptoms by delaying gastric emptying and small bowel transit time, as well as inhibiting gastric hormones and insulin secretion. Multiple studies have evaluated both short- and longterm somatostatin therapies, with results showing sustained symptom control in patients refractory to dietary modifications. In severe cases refractory to medical management, surgical interventions, such as narrowing of the anastomosis, conversion of the prior bariatric surgery, and using jejunostomy parenteral feeding, may help. Follow-up with gastrointestinal specialists and the patient’s bariatric surgeon is strongly recommended if dumping syndrome is suspected.
An important metabolic complication which is attracting increasing interest is postprandial hyperinsulinemic hypoglycemia (PHH), characterized by hypoglycemic symptoms developing 1–3 h after a meal accompanied by a low blood glucose level. This condition should be distinguished from early dumping syndrome where symptoms develop within minutes to 1 h after a meal of caloric dense food, caused by the rapid and unregulated emptying of food into the jejunum, which induces rapid fluid entry into the small bowel. Early dumping often occurs early in the postoperative period, most commonly after Roux-en-Y gastric bypass, whereas PHH may develop months to years after surgery.
Symptoms related to post-PHH usually develop late after surgery in contrast to early dumping. Symptoms are wide ranging, but are usually related to Whipple’s triad: symptomatic hypoglycemia, a low plasma glucose level, and resolution of symptoms after the administration of glucose. Symptoms of hypoglycemia may include anxiety, sweating, tremors, palpitations, confusion, weakness, lightheadedness, dizziness, blurred vision, disorientation, and possibly loss of consciousness.
Because of variability in degree of symptoms and the absence of a clear pathophysiology, management of this condition can be challenging. Fortunately, a significant percentage of patients with milder forms of the condition can be managed with dietary modifications consisting of frequent small meals with a low glycemic index. This requires supervision by a dietitian and long-term patient compliance. Additional benefit has been obtained by the addition of acarbose, an α glucosidase inhibitor in doses 100–300 mg. Successful management has been also reported in case reports or small case series with diazoxide, calcium channel blockers, and somatostatin analogues. The role of GLP-1 in the pathogenesis of this condition is supported by the observation that infusions of GLP-1 antagonists corrected hypoglycemia in these patients. These agents are investigational at present, but provide opportunity for additional future treatment approaches. For patients with persistent symptoms despite medical treatment, reversal of the bariatric procedure should be considered. Partial pancreatectomy, although used in the past, is now not recommended because of the significant morbidity and poor long-term symptom control. Postprandial hyperinsulinemic hypoglycemia is an important, potentially dangerous late complication of metabolic surgery. Successful diagnosis and management of this condition requires multidisciplinary specialty resources and essential long-term follow-up capabilities.
Bariatric procedures differ in their ability to ameliorate T2DM, with intestinal bypass procedures generally associated with greater glycemic control and remission rates than purely restrictive procedures. There has been until now a paucity of data from RCTs comparing the efficacy of various bariatric procedures to treat diabetes. The recently published RCT by Schauer et al. also indicates superior efficacy of RYGB over sleeve gastrectomy in the treatment of diabetes in obese individuals. On the other hand, BPD produced greater remission of diabetes in morbidly obese patients compared to RYGB (95 % versus 75 %) in the RCT reported by Mingrone et al.
Sleeve Gastrectomy as Metabolic Surgery
Karamanakos et al. showed that LSG suppressed fasting and postprandial ghrelin levels and attributed this decrease in ghrelin to improved postoperative satiety and greater weight loss at 1year compared to LRYGB. The LRYGB group in this study had an initial decrease in ghrelin levels after surgery, but these levels returned to normal levels within 3 months. Lee et al. studied the treatment of patients with a low body mass index and type 2 diabetes mellitus between the two groups. LRYGB is reportedly more effective than LSG; they conclude that both procedures have strong hindgut effects after surgery, but LRYGB has a significant duodenal exclusion effect on cholecystokinin. The LSG group had lower acylated ghrelin and des-acylated ghrelin levels but greater concentrations of resistin than the LRYGB group. In addition to evaluations of ghrelin, there are now several small studies demonstrating that gastric emptying is increased after sleeve gastrectomy. The loss of a large reservoir in the gastric fundus and body and preservation of the antral pump provide a reasonable explanation for this finding. A secondary effect of earlier distal bowel stimulation with nutrients after meals due to increased gastric emptying time may be similar to the effects seen after gastric bypass.
Several mechanistic studies have demonstrated early and exaggerated postprandial peak levels of Peptide YY3–36 and GLP-1 after LSG. GLP-1 is an incretin that stimulates insulin production and releases from pancreatic islet cells, and the increased PYY3–36 results in satiety and reduced food intake. Karamanakos et al. have independently shown that the sleeve gastrectomy does have the effect of increasing the transit time of chyme despite an intact pylorus as measured by increased postprandial PYY levels.
Peterli et al. performed a randomized prospective trial with 13 LRYGB and 14 LSG patients to investigate the potential mechanism of LSG focusing on foregut and hindgut mechanisms. They found marked improvement in glucose homeostasis 1 week after surgery in both groups. This improvement was associated with early, exaggerated increases in GLP-1 secretion at 1 week, 3 months, and 1 year postoperatively in both groups. In addition to changes in GLP-1, PYY3–36 increased significantly and ghrelin was suppressed in both groups. It is unclear whether PYY3–36 has a direct effect on glucose homeostasis or if its effects are exhibited via appetite reduction and concomitant weight loss. Preoperatively, some patients had a blunted PYY3–36 and GLP-1 response suggesting some “resistance” to these gut hormones in obese patients. These findings suggest that the LSG should not be viewed merely as a restrictive procedure but also as a procedure that has neurohormonal and incretin effects.
Gastric Bypass versus Laparoscopic Sleeve Gastrectomy
Ramon et al. compared the effects of LRYGB and LSG on glucose metabolism and levels of gastrointestinal hormones such as ghrelin, leptin, GLP-1, peptide YY (PYY), and pancreatic polypeptide (PP) in morbid obese patients. This prospective, randomized study confirmed that the postprandial response of ghrelin, GLP-1, and PYY was maintained in patients undergoing LSG for 12 months after surgery and was similar to the LRYGB group results. A prospective, randomized study by Woelnerhanssen et al. compared the 1-year results of LRYGB and LSG for weight loss, metabolic control, and fasting adipokine levels. The authors confirmed a close association of specific adipokines with obesity and with the changes observed with weight loss after two different bariatric surgical procedures. The concentrations of circulating leptin levels decreased by almost 50 % as early as 1 week postoperatively and continued to decrease until 12 months postoperatively and adiponectin increased progressively. No differences were found between the LRYGB and LSG groups regarding adipokine changes.
How to choice a procedure?
The choice of procedure is an important determinant of outcome with a decreasing gradient of efficacy predicted from BPD, RYGB to SG and then
LAGB. Other factors that have been positively correlated with diabetes remission are percentage of excess weight loss (% EWL), younger age, lower preop HbA1c, and shorter duration of diabetes (less than 5 years). Severity of diabetes, as judged by preop treatment modality, has also been noted to be a significant factor.
Schauer et al. have reported in their series of 191 obese diabetic patients (the majority of whom were on oral agents or insulin) a diabetes remission rate of 97 % in diet-controlled, 87 % in oral agent treated, and 62 % in insulin-treated subjects. This was also confirmed by a recent retrospective analysis of 505 morbidly obese diabetic patients who underwent RYGB. In this study, a more recent diagnosis of T2DM and the absence of preoperative insulin therapy were significant predictors of remission, independent of the percentage of EWL.
Dixon et al. have recently identified diabetes duration < 4 years, BMI > 35 kg/m2, and fasting c-peptide concentration > 2.9 ng/ mL as three clinically useful cutoffs and independent preoperative predictors of remission after analyzing the outcomes of 154 ethnic Chinese subjects after gastric bypass. C-peptide > 3 ng/mL has also previously been shown to be an important predictor of diabetes resolution after sleeve gastrectomy in non-morbidly obese diabetic subjects by Lee et al.
Sleeve gastrectomy (SG), or longitudinal gastric resection, consists in a resection of the greater curvature of the stomach. In bariatric surgery, it was introduced by Hess in 1988 and by Marceau in 1990 as a component of the biliopancreatic diversion with duodenal switch (BPD/DS). Resecting the greater curvature of the stomach was aimed at reducing the risk of ulcer at the level of the duodeno-ileal anastomosis of the BPD/ DS. In fact, for those authors, the amount of stomach removed was estimated to be roughly 60% and the restriction was moderate. With a view to reducing the mortality associated with laparoscopic BPS/DS in super-super-obese patients, Regan et al. described a 60-French (F) bougiecalibrated isolated sleeve gastrectomy (ISG) as a first step in a two-stage program of laparoscopic BPD/DS in 2000. Since then, primary ISG has gained popularity in a staged surgery program for high-risk patients. Although medium- to long-term results are not known, and some technical details are still being discussed, the good short-term results obtained regarding weight loss, as well as co-morbidity and the acceptable rate of complications, have broadened the indications for primary ISG and assured its place in the armamentarium of bariatric surgical procedures. In June 2007, a position statement on SG as a bariatric procedure was endorsed by the ASMBS, and in October 2007 the First International Consensus Summit for Sleeve Gastrectomy was held in New York City.
As expected, the operation is restrictive (satiety occurs very quickly). Indeed, with the current calibration of the sleeve, its volume is less than 10% of the entire stomach and its distensibility is 10 times less than that of the resected stomach and fundus. Nevertheless, after 6 months, patients can cope with a mug-sized meal (200 ml) of solid food. Even if the size of the meal is small, the volume of the remaining stomach is larger by far than after purely restrictive procedures (gastric banding, vertical banded gastroplasty). Melissas et al. demonstrated an accelerated gastric emptying of solid food into the duodenum and the intestine at 6 and 24 months, and this could explain some enterohormonal changes . In addition to these mechanical effects, SG has hormonal effects. This operation is “anorexigenic”; the patients feel little hunger and have only a mild interest in eating. Most of them could skip a meal each day for at least 1 year after surgery. The fundus is known to be the major source of ghrelin, an orexigenic hormone. It has been proved that the level of ghrelin is dramatically reduced after the currently performed SG with the entire fundus resected, and to a higher degree than with gastric banding or gastric bypass. Other hormonal changes have been noted, such as a rise in the level of fasting PYY or GLP1, a hormone that induces also a feeling of satiety. This latter point has yet to be assessed in human beings. These incretin modifications could play a role in the remarkable short-term effects observed on diabetes. Thus it appears that LSG is a multifactorial procedure with a mild restrictive aspect and a complex neurohormonal aspect.
Acute pancreatitis is a common intra-abdominal inflammatory condition of varied aetiology. The disease is mild in the vast majority of patients and has a favourable outcome. The acute severe form of the disease on the other hand is a lethal form with a high mortality and morbidity. A number of strategies have provided clinical benefit in severe acute pancreatitis (SAP). Of these, nutritional management is by far the most effective. SAP is associated with persistent end-organ failure, commonly respiratory, circulatory and renal. Treatment is targeted to support these organs. As of now there is no definitive therapy for acute pancreatitis. Patients are managed with fluids, analgesics, antibiotics and nutritional supplements besides adequately treating local complications such as pseudocyst and walled-off pancreatic necrosis by suitable interventional methods, be it endoscopic or percutaneous. The focus here is nutritional support in the management of SAP.
Which Form of Nutrition: Parenteral or Enteral?
This depends largely on the functional integrity of the stomach and small intestine. Patients of SAP often have poor gastric emptying and paralytic ileus, which is made worse with the use of narcotics. Moreover, local complications of pancreatitis (peripancreatic fluid collections) can have a pressure effect on the stomach and/or duodenum. As a result oral feeds may not be possible in these patients. Patients on ventilator support also cannot be given oral feeds.
Enteral feeding through the nasogastric or nasojejunal tubes is often not tolerated by patients because of discomfort. In addition, these tubes often get displaced or withdrawn. Reinsertion of the tubes, under endoscopic or radiological guidance, is cumbersome in such patients. All these factors favour parenteral feeding. The distinct advantage of enteral nutrition is that it prevents mucosal atrophy and transmigration of bacteria (an important causeof sepsis in SAP). Also, enteral feeding augments intestinal motility and is cheaper than parenteral preparations. Enteral nutrition improves motility in patients with paralytic ileus. The relative merits of these forms of nutritional therapy have been evaluated in a systematic review. Eight published randomized trials including a total of 348 patients were included. Enteral feeding was given through a nasojejunal tube and parenteral nutrition through a catheter placed in a central vein. Enteral nutrition was shown to reduce mortality, multi-organ failure, systemic infection and surgical intervention in comparison with parenteral nutrition. The length of hospital stay too was shown to be reduced. In view of these, enteral nutrition appears to be a better option while managing patients of SAP and has been recommended by the American College of Gastroenterology, American Gastroenterological Association and International Association of Pancreatology.
When should enteral feeding be started?
Patients with mild acute pancreatitis can usually be started on oral feeds in 2–3 days. Those with moderately severe acute pancreatitis can be started on oral feeding only after a variable period and hence should receive enteral nutritional support. Early enteral feeding has been shown to avoid end-organ failure in a large series of patients (1200).
Enteral feeding started within 48 h of onset of illness was associated with organ failure in 21% of patients as opposed to 81% when enteral feeding was started after 48 h. This benefit of early enteral feeding has also been shown in a recent meta-analysis. However, there was no benefit in mortality with early enteral feeding. In yet another randomized controlled trial, early enteral feeding (within 24 h) was compared with on-demand enteral feeding after 72 h.
The primary endpoint of this study was major infection or death. The study did not detect any significant difference in the primary endpoint in either group (early or on-demand feeding). However, it did show that patients receiving on-demand nutrition tolerated oral feeds without using a tube.
- Nasogastric or Nasojejunal
Should the feed be administered in the stomach through a nasogastric (NG) tube or in the jejunum through a nasojejunal (NJ) tube? Gastric feeding is thought to increase pain and aggravate pancreatitis due to food-induced pancreatic stimulation. In view of this, NJ feeding is practised. However, placement of a NJ tube is cumbersome and needs a skilled endoscopist or radiologist. It causes more inconvenience to patients. A nasogastric (NG) tube is thus an alternative. A number of studies have been published comparing NG and NJ feeding. The results of these studies can be summarized as follows: There was no difference in mortality. Feeds were equally tolerated in the two groups and NG feeding is simple. NG feed was not shown to increase pain and is thus as good as NJ feeding. A meta-analysis subsequently published showed no difference in mortality, hospital stay and infection rate between the two groups. Both forms of feeding were equally well tolerated. NJ feeding thus is not advised in the management of most patients with SAP. However, it still has a place when the patient has a high risk of aspiration. Also, patients on a ventilator and those not tolerating NG feed should be fed through NJ tube. The other issue concerning enteral feeding in SAP is the composition of the feed.
- Type of Formulation
Various commercially available formulations include (1) polymeric formulations comprising complex lipids, carbohydrates and proteins and (2) elemental formulations comprising simple amino acids, carbohydrates and free fatty acids. Other formulations used are glutamine-rich feeds and feeds with probiotics, fibres, etc. Immuno-nutrition using arginine, glutamine and polyunsaturated fatty acids has been evaluated in multiple studies and compared with standard feeding. A metaanalysis showed some benefit in mortality but not for prevention of infection, end-organ failure or inflammatory response. This benefit was not seen with the use of probiotics or fibre-based feeds. A systematic review did not show any benefit of immuno-nutrition or probiotics. It also showed that polymeric formulations are as well tolerated as oligomeric ones (elemental).
In the epoch of minimally invasive management of biliary and pancreatic disorders, endoscopic retrograde cholangiopancreatography (ERCP) combined with endoscopic sphincterotomy (ES) has become a prevalent procedure all over the world. Even though ES is a safe procedure, it carries a small but significant number of serious complications which include pancreatitis, bleeding, cholangitis and perforation. As per old literature, ERCP-related perforations were reported in 0.5–2.1% of sphincterotomies with a mortality rate of 16–18%. However, the improvement in the experience and skill of the endoscopy specialists combined with advancements in technology have reduced the incidence of perforation to <0.5% over the years. Sphincterotomy (56%) and guidewire manipulation (23%) are widespread causes of perforations related to endoscopic retrograde cholangiopancreatography (ERCP). There is a dearth of evidence-based strategies with respect to the proper management of ERCP perforations. While one set of investigators promote on-demand conservative and surgical management, based on a clinical course, the others support operative repair in all cases on account of the complications associated with the delayed operative intervention.
INDICATIONS OF SURGICAL MANAGEMENT
1. Large extravasation of contrast at the time of ERCP defined as incomplete dissipation of contrast after 1 min on follow-up plain film.
2. If there is only a small amount of contrast extravasation, where there is complete dissipation after 1 min of ERCP, on follow-up plain film, then a UGI with contrast injection on fluoroscopy is performed in 2–8 h. If this shows extravasation, we recommend surgical exploration.
3. Follow-up CT scan showing a collection due to perforation in the retroperitoneum or intraperitoneum.
4. Retained hardware unable to be removed by endoscopy along with perforation.
5. Massive subcutaneous emphysema.
6. Failure of conservative management.
A delay in diagnosis or in surgery will lead to death. The reason is that there is a massive autodigestion of body tissues which is due to a constant release of enzymes, and this eventually leads to sepsis. The principle of treatment by surgery is the same as endoscopic treatment. Any case that is suspected to have ERCP-induced perforation is kept nil by mouth, and the gastric contents are decompressed by Ryles tube and intravenous antibiotics.
This is done by diverting bile, enteric and pancreatic juices away from the site of perforation. However simple drainage will also cause the juices to flow through the perforation site and body cavities before draining out of the tubes. This could be avoided by diverting the juices through well-controlled different paths which could be done by the following procedures:
1. T-tube in CBD;
2. Placement of duodenostomy tube—lateral/end duodenostomy;
3. Duodenal diverticulization;
4. Pyloric exclusion;
5. Roux-en-Y duodenojejunostomy.
The disadvantage of using Roux-en-Y duodenojejunostomy is that if the edges are inflamed, then the sutures will not hold properly. However other procedures can be used even when the edges are inflamed. Even though duodenostomy appears to be simple, a part of gastric and duodenal contents pass across the perforation site.
Duodenal diverticulization involves three things: (1) tube to divert duodenal and pancreatic juice, (2) T-tube in CBD to divert bile and (3) distal
gastrectomy and Billroth II anastomosis to provide an alternate pathway for food and gastric juice, thereby preventing these from passing through the site of perforation. Although this procedure has been proved to be successful, it is less widely used due to its complex nature. Pyloric exclusion is a simpler form in which the pylorus is closed by purse string by long-standing absorbing sutures like PDS 2.0 instead of distal gastrectomy. Similar to duodenal diverticulization, T-tube drainage of the CBD and loop gastrojejunostomy are done. The duodenal perforation is closed over a duodenostomy tube.
Whenever there is collection which is localized to the retroperitoneum, retroperitoneal surgical approach can be carried out. Advantages of this procedure are (1) it permits gravitational drainage, (2) avoids septic complication of the peritoneal cavity, (3) directs retroperitoneal necrosectomy with post-operative washes and (4) avoids complex intra-abdominal surgeries. However the disadvantage of this procedure is that it can be used only for retroperitoneal-contained perforations.
The most critical component of the treatment of Retroperitineal Sarcoma (RPS) remains the surgical excision, and the best chance for cure is at the time of primary surgery. Surgery should achieve a macroscopically complete excision of the tumor (R0 or R1), minimizing marginality, ideally through an en-bloc resection of all potentially involved structures as determined by careful preoperative imaging in combination with intraoperative findings.
Operative planning also includes the functional assessment of critical organs—eg, the function of each kidney. Contraindications to primary resection are believed to be bilateral renal involvement; encasement of the superior mesenteric artery, celiac axis, and porta hepatis; and spinal cord involvement.
When planning for surgery, it is paramount to take into consideration the histology of the RPS as well as its predicted behavior pattern, as these differ widely. Indeed, the largest transatlantic multi-institutional series identified histologic subtype as a predictor of patterns of local and distant recurrence. Moreover, analysis of a large, single-institution database demonstrated that histologic subtype is the strongest predictor of disease-specific death and affects both local and distant recurrence. Of greater interest, the patterns of contiguous organ involvement are also heavily dependent on histologic subtype.
In light of these data, surgeons oncologists should decide the extent of surgical resection in a multidisciplinary setting at a specialized center after review of imaging and pathology, given that the pattern of growth and prognostic risks vary broadly among the different histologic subtypes. For example, liposarcoma is the histologic subtype with the highest recurrence rate. In addition, it is the one with the least clear separation from normal retroperitoneal fat, given that the well-differentiated component of liposarcoma is virtually undistinguishable from normal fat. As a consequence, the extent of surgery should be aimed at removing all ipsilateral retroperitoneal fat en bloc with the mass at the price of sacrificing at least the ipsilateral kidney and colon and part of or the entire psoas muscle.
A staged approach can be followed in virtually all cases. The stages include:
A. Generous laparotomy, exploration, and retraction.
B. Division of the gastrocolic ligament, division of the transverse colon (plus distal ileum if on the right side), and assessment of the duodenum/head of the pancreas if on the right side, or body/tail of the pancreas and spleen if on the left side.
C. Liberation of duodenum/head of the pancreas if on the right side or body/tail of the pancreas and spleen and duodenojejunal junction if on the left side (when possible) and partial duodenal resection or pancreaticoduodenectomy (< 5% of right-sided retroperitoneal sarcomas) if on the right side or distal pancreatectomy and splenectomy if on the left (40%–50% of left-sided retroperitoneal sarcomas), when too adherent/invaded by the tumor.
D. Dissection of the inferior vena cava (IVC) if on the right side or aorta if on the left side, ligating ipsilateral renal vessels and other collaterals and dissection of the iliac vessels.
E. Peritonectomy, resection of the psoas muscle in the pelvis (plus rectal resection if on the left side) after identification and liberation of the femoral nerve (unless directly invaded) and possibly of the femoral cutaneous branch, while the genitofemoralis and ilioinguinal nerves are usually resected, as these lie between the tumor and the psoas fascia.
F. Section of the origin of the psoas major from the spine, sparing the roots of the femoral nerve and possibly the iliohypogastric nerve, liberation/resection of the costodiaphragmatic fold, and removal of the specimen.
Subcapsular liver dissection or partial hepatectomy are rarely needed for tumors located on the right side, whereas a complete liberation of the right liver lobe is usually of help. Similarly, sleeve gastrectomy or proximal gastrectomy is rarely required for tumors located on the left side. Finally, vascular resections (predominantly iliac vessels on either side and IVC on the right side) are required in 4% of cases.
Leiomyosarcoma and other rarer histologic subtypes such as solitary fibrous tumor are much more well-defined tumors. Their border can be clearly separated from retroperitoneal fat/structures. A wide resection is still required but not necessarily involving the adjacent organs if these are not clearly invaded.
Extended surgery may raise concern for added morbidity. A recent multi-institutional collaboration, however, found that a radical resection is safe and is associated with low 30-day mortality (1.8%). Severe complications were associated with increased age, transfusion requirements, and organ resection score, with a more pronounced risk in patients undergoing splenectomy and pancreatectomy and Whipple procedure.
Although major vascular resection (MVR) is associated with higher morbidity, vascular involvement does not preclude resection because it can be safely performed in specialized centers. MVR may be necessary either due to the origin of the RPS, as is the case for leiomyosarcoma of the IVC, or due to local invasion and involvement. Whereas multiple strategies for approaching MVR can be used, a good understanding of the vasculature and collaterals is critical prior to attempting resection and reconstruction, given that IVC resections are well tolerated if a good network of collaterals is present.
In essence, resection of RPS requires technical expertise in multiple sites throughout the abdominal and pelvic cavity, including the handling of large vessels. Single organ/site expertise is not sufficient. The ability to orchestrate a team of complementary surgical experts is critical to successful management of RPS patients. To minimize the risk of intraoperative and perioperative morbidity, RPS resection should be undertaken by surgical teams with expertise in specific aspects of the anatomy of the retroperitoneal space—for example, expertise in retroperitoneal autonomic and somatic nerves, the lymphatic system, paravertebral vessels, and organs of the gastrointestinal tract.
Required expertise also includes experience with additional procedures, such as full-thickness thoracoabdominal wall resection and reconstruction, diaphragmatic resection and reconstruction, major vascular resection and reconstruction, and bone resection. Surgical teams with these abilities, which may accrue from prior participation in multidisciplinary surgical teams, can achieve macroscopically complete tumor resection in the majority of patients.
Hepatic hemangioma (HH) is the most common benign liver tumor. It consists of blood-filled cavities fed by the hepatic arterial circulation, with walls lined by a single layer of endothelial cells, a veritable chaotic entanglement of distorted blood vessels confined to a region as small as a few mm and as large as 10 cm, 20 cm and even 40 cm. The frequency is higher among adults, with a prevalent age at the initial diagnostic in the range of 30-50 years. Literature places the HH incidence at 0.4% to 20% of the total population. At necropsy, the frequency is of 0.4 to 7.3%, all the authors agreeing with an incidence of over 7%. The HH prevalence in the general population varies greatly, most often being discovered incidentally during imaging investigations for various unrelated pathologies. Regarding sex distribution, it seems that women are more susceptible, as confirmed by all pertaining studies, with a reported 4.5:1 to 5:1 ratio of female to male cases. Most often, HH are mono-lesions but multiple-lesions are possible; they account for 2.3% and up to 20-30% of the cases, depending on the source. At the initial diagnosis, the majority of HH measure below 3 cm in size, the so-called capillary hemangiomas; of these, only 10% undergo a size increase with time, for reasons still unknown. The next size class covers lesions between 3 cm and 10 cm in size, referred to as medium hemangiomas. Lastly, giant or cavernous hemangiomas measure up to 10 cm, with occasional literature reports of giant HH reaching 20-40+ cm in size. Location-wise they are most often found in the right liver lobe, often in segment IV, often marginal.
Operative intervention for liver hemangiomas remains a controversial topic. Previous studies from major hepatobiliary centres have proposed varying indications for a hemangioma resection. Findings from the present study demonstrate that operative management of symptomatic hemangiomas remains an effective therapy and can be performed with low morbidity to the patient. However, aside from abdominal symptoms, prophylactic resections in the setting of hemangioma enlargement, size, or patient anxiety is not advised as the risk of developing life-threatening associated complications is rare.
Established Complications. In the minority of cases that present as a surgical emergency due to haemorrhage, rupture, thrombosis and infarction, surgical management may be the only appropriate course of action. There is also a role for the elective surgical management of giant haemangiomata, albeit in a highly selected group of patients. As demonstrated by the data presented above, an operative approach with the objective of preventing future complications of giant haemangiomata is less easy to justify.
Diagnostic Uncertainty. Despite improvements in non-invasive imaging technology, cases of diagnostic uncertainty continue to pose a challenge. In situations where it is not possible to exclude malignancy, surgical intervention by formal liver resection may be indicated. In almost all situations, the use of percutaneous liver biopsy for the differentiation of giant haemangiomata from malignant liver lesions cannot be justified. The risks of haemorrhage as a result of biopsying a giant haemangioma are appreciable and, together with the risks of needle track seeding and intra-abdominal dissemination of a potentially curable malignancy, mean that biopsy in this setting must be avoided.
Incapacitating Symptoms. Having taken all possible steps to ensure that symptoms are attributable to the haemangioma, surgical resection may be justified on grounds of intractable symptoms. Patients with clearly defined abdominal compressive symptoms may be more likely to derive benefit from surgery than patients with non-specific abdominal discomfort, although this is not backed up by a meaningful body of evidence. Management of this group of patients is, by necessity, highly individualised. Despite apparently satisfactory surgical management, symptoms persist in approximately 25% of patients following resection of seemingly symptomatic haemangiomata.
While most people with HH show no sign or symptom, and most HH are non-progressing and do not require treatment, there is a small number of cases with rapid volumetric growth or complications, which prompt for appropriate therapy. The results of clinical and laboratory investigations to date, mostly for imaging techniques, have demonstrated that for small HH, regular follow-up is enough. For cavernous HH, the evolution is unpredictable and often unfavorable, with serious complications requiring particular surgical expertise in difficult cases. Hepatic hemangiomas require a careful diagnosis to differentiate from other focal hepatic lesions, co-occurring diagnoses are also possible.
In a 2011 New Yorker article, Dr. Atul Gawande explored the idea that surgeons should consider a performance coach. Like athletes, he reasons, surgeons rely on complex physical movements to achieve their goals. Guidance and refinement by a trained eye could improve their performance.
Surgical coaching is a controversial topic (one which colleagues and I are actively investigating). But in the years following Dr. Gawande’s article, this idea opened the door to a broader concept: the “surgeon athlete.” An “athlete” is one whose performance depends on a carefully choreographed interplay between mind and body: heightened focus and anticipation along with quick decision-making and coordination. Combined with the reliance on teamwork and requisite stamina, this is wholly within the job description of a surgeon. Many surgeons are likely to find this concept silly. But our profession has imprudently encouraged surgical trainees to disregard the critical fine-tuning of their minds and bodies. We demand perfection, stamina, and encyclopedic knowledge, while discouraging the healthy habits that improve performance. Ironically, the sports world is more advanced in applying science to their training. And by ignoring this indisputable science, we are really hurting our patients. Because in order to best take care of them, we need to first take care of ourselves.
Laparoscopic versus Open gastrectomy
Surgery is the only curative therapy for gastric cancer but most operable gastric cancer presents in a locally advanced stage characterized by tumor infiltration of the serosa or the presence of regional lymph node metastases. Surgery alone is no longer the standard treatment for locally advanced gastric cancer as the prognosis is markedly improved by perioperative chemotherapy. The decisive factor for optimum treatment is the multidisciplinary team specialized in gastric cancer. However, despite multimodal therapy and adequate surgery only 30% of gastric cancer patients are alive at 3 years.
The same principles that govern open surgery is applied to laparoscopic surgery. To ensure the same effectiveness of laparoscopic gastrectomy (LG) as conventional open gastrectomy, all the basic principles such as properly selected patients, sufficient surgical margins, standardized D2 lymphadenectomy, no-touch technique, etc., should be followed.
LG may be considered as a safe procedure with better short-term and comparable long-term oncological results compared with open gastrectomy. In addition, there is HRQL advantages to minimal access surgery. There is a general agreement that a laparoscopic approach to the treatment of gastric cancer should be chosen only by surgeons already highly skilled in gastric surgery and other advanced laparoscopic interventions. Furthermore, the first procedures should be carried out during a tutoring program. Diagnostic laparoscopy is strongly recommended as the first step of laparoscopic as well as open gastrectomies. The advantage of early recovery because of reduced surgical trauma would allow earlier commencement of adjuvant chemotherapy and the decreased hospital stay and early return to work may offset the financial costs of laparoscopic surgery.
The first description of LG was given by Kitano, Korea in 1994 and was initially indicated only for early gastric cancer patients with a low-risk lymph node metastasis. As laparoscopic experience has accumulated, the indications for LG have been broadened to patients with advanced gastric cancer. However, the role of LG remains controversial, because studies of the long-term outcomes of LG are insufficient. The Japanese Gastric Cancer Association guidelines in 2004 suggested endoscopic mucosal resection or endoscopic submucosal dissection for stage 1a (cT1N0M0) diagnosis; patients with stage 1b (cT1N1M0) and cT2N0M0) were referred for LG. Totally laparoscopic D2 radical distal gastrectomy using Billroth II anastomosis with laparoscopic linear staplers for early gastric cancer is considered to be safe and feasible. Laparoscopy-assisted total gastrectomy shows better short-term outcomes compared with open total gastrectomy in eligible patients with gastric cancer.
There was a significant reduction of intraoperative blood loss, a reduced risk of postoperative complications, and a shorter hospital stay. Western patients are relatively obese and there is an increased risk of bleeding if lymphadenectomy is performed. LG is technically difficult in the obese than in the normal weight due to reduced visibility, difficulty retracting tissues, dissection plane hindered by adipose tissue, and difficulty with anastomosis. Open gastrectomy is thus preferable for the obese. However, obesity is not a risk factor for survival of patients but it is independently predictive of postoperative complications. Careful approach is being needed, especially for male patients with high body mass index.
Robotic surgery will become an additional option in minimally invasive surgery. The importance of performing effective extended lymph node dissection may provide the advantage of using robotic systems. Such developments will improve the quality of life of patients following gastric cancer surgery. A multicenter study with a large number of patients is needed to compare the safety, efficacy, value (efficacy/cost ratio) as well as the long-term outcomes of robotic surgery, traditional laparoscopy, and the open approach.
Organ specialization and case load have been a big issue during recent years and for most cancers a direct relation between high volume and a better outcome has been demonstrated by reviewing the recent literature. Concentration in clinics of high-risk procedures with a certain volume (procedures such as esophagectomy, pancreatectomy and hepatic resection) might prevent many postoperative deaths per year. Also, other procedures such as thyroidectomy and colon resections have shown the same tendency to a lesser extent. Reduction of postoperative mortality by 5% is in general as effective as toxic adjuvant treatment and should have high priority in achieving the highest quality in cancer surgery.
Not only can a reduction in morbidity and mortality be achieved but also a better functional and even financial outcome is possible. Sometimes too much attention has been focused on numbers per year, since even smaller hospitals with dedicated teams can achieve good results. It is very likely that not only volume but also training and specialization result in a better outcome. The setting of an absolute number of cases is not very productive and diverts attention from organized multidisciplinary mee-tings, appropriate infrastructure and availability of modern techniques.
The focus of interest should be directed more towards analyzing and optimizing the whole process of diagnosis and treatment, since this whole process can put the patient at severe risk, especially during the in-patient period. Avoidance of mistakes has received a lot of attention during recent years. It has resulted in interest in patient safety as a concept. Since the publication of the report To Err is Human issued by the Institute of Medicine the approach to errors has changed.
Individuals can make mistakes but a system approach concentrates on the conditions under which individuals work and tries to build defenses to overt or mitigate the effects of mistakes. This is very well visualized by the Swiss cheese model. Several layers of defense, each with its own holes, are put around a procedure. Both active failures and latent conditions cause holes in each layer. The usual way of thinking is to close the holes in the last layer of defense; however, redesigning the process and the closing of a hole in a much earlier layer will probably be more effective.
Root cause analysis is the way to go back in the process and try to identify weak points in the procedure. A good example is the incorrect position of a colostomy after an abdominoperineal resection. It is easy to blame the resident for not selecting the correct position during surgery or even marking the wrong spot the day before the operation. A better solution would be either proper training of the junior or having the right spot tattooed during the outpatient clinic by a stoma therapist.
Marking of the correct part and site of the body has become a safety measure and the patient should be instructed to ask for this procedure for there own safety. It is important to get rid of the ‘blame and shame’ culture and introduce a more open environment in which it is possible to report on near misses and mistakes. The safety climate in a surgical department can be measured in a validated way and is an essential part of a culture in which patient safety can flourish. Reduction of complications in the direct postoperative period after a surgical procedure has many aspects not related to the cancer surgery itself, but to the invasive nature of the intervention.
Great attention to every detail during the preoperative work-up and clinical period may result in the reduction of adverse events. This is what is termed ‘the first time at risk’ above. There are also examples of actions in optimizing results that are more cancer specific. For instance the use of techniques stimulating wound healing after an abdominoperineal resection such as an omentoplasty or rectal abdominis flap may prevent a delay in adjuvant systemic treatment for rectal cancer.
Careful attention towards wound healing in sarcoma will avoid postponement of the necessary adjuvant radiotherapy. Omitting a computer scan with iodine-containing contrast in the diagnostic work-up for a thyroid cancer makes postoperative radioactive treatment with iodine possible earlier resulting in a possible better outcome. Harvesting a sufficient number of lymph nodes in colon cancer may avoid discussions about the indication for adjuvant chemotherapy.
Most of the examples for patient safety in the clinical period are in relation to optimal use of multimodality treatment or to effects of surgery in general. Sometimes there has to be a balanced risk of the acceptance with a more extensive surgical procedure of a higher morbidity to achieve a better long-term cancer result. The reverse is also possible when a good short-term outcome of a local excision in rectal cancer has to be counterbalanced by a higher local recurrence rate. Quality assurance for all the participating disciplines (both diagnostic and therapeutic) is a key element in the set up of clinical prospective randomized trials.
There has been significant improvement in the perioperative results following liver resection, mainly due to techniques that help reduce blood loss during the operation. Extent of liver resection required in HCC for optimal oncologic results is still controversial. On this basis, the rationale for anatomically removing the entire segment or lobe bearing the tumor, would be to remove undetectable tumor metastases along with the primary tumor.
SIZE OF TUMOR VERSUS TUMOR FREE-MARGIN
Several retrospective studies and meta-analyses have shown that anatomical resections are safe in patients with HCC and liver dysfunction, and may offer a survival benefit. It should be noted, that most studies are biased, as non-anatomical resections are more commonly performed in patients with more advanced liver disease, which affects both recurrence and survival. It therefore remains unclear whether anatomical resections have a true long-term survival benefit in patients with HCC. Some authors have suggested that anatomical resections may provide a survival benefit in tumors between 2 and 5 cm. The rational is that smaller tumors rarely involve portal structures, and in larger tumors presence of macrovascular invasion and satellite nodules would offset the effect of aggressive surgical approach. Another important predictor of local recurrence is margin status. Generally, a tumor-free margin of 1 cm is considered necessary for optimal oncologic results. A prospective randomized trial on 169 patients with solitary HCC demonstrated that a resection margin aiming at 2 cm, safely decreased recurrence rate and improved long-term survival, when compared to a resection margin aiming at 1 cm. Therefore, wide resection margins of 2 cm is recommended, provided patient safety is not compromised.
Intraoperative ultrasound (IOUS) is an extremely important tool when performing liver resections, specifically for patients with HCC and compromised liver function. IOUS allows for localization of the primary tumor, detection of additional tumors, satellite nodules, tumor thrombus, and define relationship with bilio-vascular structures within the liver. Finally, intraoperative US-guided injection of dye, such as methylene-blue, to portal branches can clearly define the margins of the segment supplied by the portal branch and facilitate safe anatomical resection.
The anterior approach to liver resection is a technique aimed at limiting tumor manipulation to avoid tumoral dissemination, decrease potential for blood loss caused by avulsion of hepatic veins, and decrease ischemia of the remnant liver caused by rotation of the hepatoduodenal ligament. This technique is described for large HCCs located in the right lobe, and was shown in a prospective, randomized trial to reduce frequency of massive bleeding, number of patients requiring blood transfusions, and improve overall survival in this setting. This approach can be challenging, and can be facilitated by the use of the hanging maneuver.
Multiple studies have demonstrated that blood loss and blood transfusion administration are significantly associated with both short-term perioperative, and long-term oncological results in patients undergoing resection for HCC. This has led surgeons to focus on limiting operative blood loss as a major objective in liver resection. Transfusion rates of <20 % are expected in most experienced liver surgery centers. Inflow occlusion, by the use of the Pringle Maneuver represents the most commonly performed method to limit blood loss. Cirrhotic patients can tolerate total clamping time of up to 90 min, and the benefit of reduced blood loss outweighs the risks of inflow occlusion, as long as ischemia periods of 15 min are separated by at least 5 min of reperfusion. Total ischemia time of above 120 min may be associated with postoperative liver dysfunction. Additional techniques aimed at reducing blood loss include total vascular isolation, by occluding the inferior vena cava (IVC) above and below the liver, however, the hemodynamic results of IVC occlusion may be significant, and this technique has a role mainly in tumors that are adjacent to the IVC or hepatic veins.
Anesthesiologists need to assure central venous pressure is low (below 5 mmHg) by limiting fluid administration, and use of diuretics, even at the expense 470 N. Lubezky et al. of low systemic pressure and use of inotropes. After completion of the resection, large amount of crystalloids can be administered to replenish losses during parenchymal dissection.
Laparoscopic liver resections were shown to provide benefits of reduced surgical trauma, including a reduction in postoperative pain, incision-related morbidity, and shorten hospital stay. Some studies have demonstrated reduced operative bleeding with laparoscopy, attributed to the increased intra-abdominal pressure which reduces bleeding from the low-pressured hepatic veins. Additional potential benefits include a decrease in postoperative ascites and ascites-related wound complications, and fewer postoperative adhesions, which may be important in patients undergoing salvage liver transplantation. There has been a delay with the use of laparoscopy in the setting of liver cirrhosis, due to difficulties with hemostasis in the resection planes, and concerns for possible reduction of portal flow secondary to increased intraabdominal pressure. However, several recent studies have suggested that laparoscopic resection of HCC in patients with cirrhosis is safe and provides improved outcomes when compared to open resections.
Resections of small HCCs in anterior or left lateral segments are most amenable for laparoscopic resections. Larger resections, and resection of posterior-sector tumors are more challenging and should only be performed by very experienced surgeons. Long-term oncological outcomes of laparoscopic resections was shown to be equivalent to open resections on retrospective studies , but prospective studies are needed to confirm these findings. In recent years, robotic-assisted liver resections are being explored. Feasibility and safety of robotic-assisted surgery for HCC has been demonstrated in small non-randomized studies, but more experience is needed, and long-term oncologic results need to be studied, before widespread use of this technique will be recommended.
ALPPS: Associating Liver Partition with Portal vein ligation for Staged hepatectomy
The pre-operative options for inducing atrophy of the resected part and hypertrophy of the FLR, mainly PVE, were described earlier. Associating Liver Partition with Portal vein ligation for Staged hepatectomy (ALPPS) is another surgical option aimed to induce rapid hypertrophy of the FLR in patients with HCC. This technique involves a 2-stage procedure. In the first stage splitting of the liver along the resection plane and ligation of the portal vein is performed, and in the second stage, performed at least 2 weeks following the first stage, completion of the resection is performed. Patient safety is a major concern, and some studies have reported increased morbidity and mortality with the procedure. Few reports exist of this procedure in the setting of liver cirrhosis. Currently, the role of ALPPS in the setting of HCC and liver dysfunction needs to be better delineated before more widespread use is recommended.
Understanding the intrahepatic anatomy is crucial to perform liver resections and, in particular, parenchymal-sparing resections. The Couinaud’s liver segmentation system is based on the identification of the three hepatic veins and the plane passing by the portal vein bifurcation. Nowadays, Couinaud’s classification is widely used clinically, because it is best adapted for surgery and has become essential in localizing and monitoring various intrahepatic lesions.
As above-mentioned, Couinaud’s portal segmentation is entirely different from the historically defined two hemilivers based on external landmarks and is also partially different from Healey’s arteriobiliary segmen-tation. According to Couinaud’s descriptions, the right, middle and left hepatic veins divide the liver into four sectors (called suprahepatic segmentation by Couinaud), each of which is supplied by a portal pedicle that consists of a branch of the hepatic artery, portal vein and bile duct.
The middle hepatic vein runs in the main portal scissura (midplane of the liver) which separates the liver into the right and the left hemiliver. The main portal scissura moves forward from the gallbladder fossa anteriorly to the left of the suprahepatic IVC posteriorly, and in clinical practice, these external landmarks may be used as external demarcation line between the functional right and left hemiliver. Both the right and left hemilivers are further separated into sectors by the right and left portal scissura holding the right and left hepatic veins separately.
In the right hemiliver, the right portal scissura divides the right hemiliver into the right anterior sector (right paramedian sector) and the right posterior sector (right lateral sector). It is noteworthy that in the right hemiliver, Healey’s liver sections which he defined as segments are accurately the same as Couinaud’s sectors. In the left hemiliver, the left portal scissura divides the left liver into the anterior sector (left medial sector or left paramedian sector) and the posterior sector (left posterior sector or left lateral sector).
The anterior sector consists of segments 4 and 3, and the posterior sector only includes segment 2. However, in the left hemiliver, Healey’s liver sections which he defined as segments are not the same as Couinaud’s sectors. In the right hemiliver, as Healey’s sections are precisely the same as Couinaud’s sectors, the right anterior sector (section) can be further subdivided into segment 8 superiorly and segment 5 inferiorly. The right posterior sector (Healey’s section) is also further subdivided into segment 7 superiorly and segment 6 inferiorly.
In the left hemiliver, Healey’s sections are not the same as Couinaud’s sectors. The Healey’s left medial section locates between the main portal scissura and the falciform ligament, and it is comprised only of segment 4, which can further be subdivided into segment 4A superiorly and segment 4B inferiorly, while the Healey’s left lateral section is comprised of segments 2 and 3, being divided by the left hepatic vein which runs in the left portal scissura.
For the Couinaud’s left medial sector, it is comprised of segments 3 and 4, locating between the middle hepatic vein running in the main portal scissura and the left hepatic vein running in the left portal scissura. The falciform ligament and the umbilical fissure separate segment 4 from segment 3. The Couinaud’s left lateral sector, which is located within the left territory of the left hepatic vein, is comprised only of segment 2. The caudate lobe is defined as segment 1 in both the Couinaud’s portal and the Healey’s arteriobiliary segmentation systems. This segment is surrounded by the major vascular structures, with the retrohepatic posteriorly, the main portal pedicle inferiorly and the hepatocaval confluence superiorly. Its inflow vasculature originates from both the right and the left portal pedicles, and its biliary drainage exists as a similar pattern. Its venous drainage directly enters into the retrohepatic IVC.
After the first major hepatic resection, a left hepatic resection, carried out in 1888 by Carl Langenbuch, it took another 20 years before the first right hepatectomy was described by Walter Wendel in 1911. Three years before, in 1908, Hogarth Pringle provided the first description of a technique of vascular control, the portal triad clamping, nowadays known as the Pringle maneuver. Liver surgery has progressed rapidly since then. Modern surgical concepts and techniques, together with advances in anesthesiological care, intensive care medicine, perioperative imaging, and interventional radiology, together with multimodal oncological concepts, have resulted in fundamental changes. Perioperative outcome has improved significantly, and even major hepatic resections can be performed with morbidity and mortality rates of less than 45% and 4% respectively in highvolume liver surgery centers. Many liver surgeries performed routinely in specialized centers today were considered to be high-risk or nonresectable by most surgeons less than 1–2 decades ago.Interestingly, operative blood loss remains the most important predictor of postoperative morbidity and mortality, and therefore vascular control remains one of the most important aspects in liver surgery.
“Bleeding control is achieved by vascular control and optimized and careful parenchymal transection during liver surgery, and these two concepts are cross-linked.”
First described by Pringle in 1908, it has proven effective in decreasing haemorrhage during the resection of the liver tissue. It is frequently used, and it consists in temporarily occluding the hepatic artery and the portal vein, thus limiting the flow of blood into the liver, although this also results in an increased venous pressure in the mesenteric territory. Hemodynamic repercussion during the PM is rare because it only diminishes the venous return in 15% of cases. The cardiovascular system slightly increases the systemic vascular resistance as a compensatory response, thereby limiting the drop in the arterial pressure. Through the administration of crystalloids, it is possible to maintain hemodynamic stability.
In the 1990s, the PM was used continuously for 45 min and even up to an hour because the depth of the potential damage that could occur due to hepatic ischemia was not yet known. During the PM, the lack of oxygen affects all liver cells, especially Kupffer cells which represent the largest fixed macrophage mass. When these cells are deprived of oxygen, they are an endless source of production of the tumour necrosis factor (TNF) and interleukins 1, 6, 8 and 10. IL 6 has been described as the cytokine that best correlates to postoperative complications. In order to mitigate the effects of continuous PM, intermittent clamping of the portal pedicle has been developed. This consists of occluding the pedicle for 15 min, removing the clamps for 5 min, and then starting the manoeuvre again. This intermittent passage of the hepatic tissue through ischemia and reperfusion shows the development of hepatic tolerance to the lack of oxygen with decreased cell damage. Greater ischemic tolerance to this intermittent manoeuvre increases the total time it can be used.
The incidence of recurrence in incisional hernia prosthetic surgery is markedly lower than in direct plasties. Indeed after the autoplasties of the preprosthetic period, the recurrence rate ranged from 35% for ventral hernias. Chevrel and Flament, in 1990, reported on 1,033 patients who had undergone laparotomy. The recurrence rate at 10-year follow-up was 14–24% for patients treated without the use of prostheses but only 8.6% for those in whom a prosthesis was implanted. A similar incidence was reported by Chevrel in 1995: 18.3% recurrence without prostheses, 5.5% with prostheses. Likewise, Wantz, in 1991, noted a recurrence rate of 0–18.5% in prosthetic laparo-alloplasties.
At the European Hernia Society (EHS)-GREPA meeting in 1986, the recurrence rate without prostheses was reported to be between 7.2 and 17% whereas in patients who had been treated with a prosthesis the recurrence was between 1 and 5.8%. A case study published by Flament in 1999 showed a 5.6% recurrence rate for operations with prostheses placed behind the muscles and in front of the fascia, and a 3.6% of such figure consisted of a small-sized lateroprosthetic recurrence. These rates were in contrast to the 26.8% recurrence reported by other surgeons for operations without prostheses.
Studies of recurrence are, of course, influenced by the size of the initial defect and the length of follow-up. Nevertheless, it is beyond dispute that the use of prostheses is associated with a lower rate of recurrence independent of the nature of the incisional hernia. The factors that lead to relapse are recognisable in the original features of the ventral hernia, i.e. combined musculo-aponeurotic parietal involvement, septic complications in the first operation, the nature and appropriateness of treatment, the kind of prosthesis and its position. Also important is whether the surgery was an emergency case and the relation to occlusive phenomena, visceral damage
and whether these problems were addressed at the same time.
Obesity is also an important risk factor for recurrence. In addition to its association with a higher surgical complications rate, related to the high intraabdominal pressure, there are deficits in wound cicatrisation as well as respiratory and metabolic pathologies. In such patients, the laparoscopic approach is very useful to significantly reduce the onset of general and wall complications, and the data concerning recurrence are encouraging, ranging between 1 and 9% in the largest laparoscopic case studies. The important multicentric study of Heniford et al., in 2000, reported a recurrence rate of 3.4% after 23 months. In 2003, the same author, in a study with an average follow-up of 20 months (range 1–96) showed a recurrence rate of 4.7% for different, identifiable causes: intestinal iatrogenic injuries and mesh infection with its removal, insufficient fixation of the prosthesis and abdominal trauma in the first postoperative period.
The incidence of recurrence after laparoscopic treatment may also be related to general patient factors and to the onset of local complications, mistakes in opting for laparoscopic treatment and deficits in implanting and fixing the prosthesis. With respect to the latter, it is very important to allow a large overlap compared to the diameter of the defect. Long-term data analysis, with large case studies, is still needed to obtain detailed information about recurrence, and this is particularly true in the assessment of relatively new techniques.
Gallbladder cancer is uncommon disease, although it is not rare. Indeed, gallbladder cancer is the fifth most common gastrointestinal cancer and the most common biliary tract cancer in the United States. The incidence is 1.2 per 100,000 persons per year. It has historically been considered as an incu-rable malignancy with a dismal prognosis due to its propensity for early in-vasion to liver and dissemination to lymph nodes and peritoneal surfaces. Patients with gallbladder cancer usually present in one of three ways: (1) advanced unresectable cancer; (2) detection of suspicious lesion preoperatively and resectable after staging work-up; (3) incidental finding of cancer during or after cholecystectomy for benign disease.
Although, many studies have suggested improved survival in patients with early gallbladder cancer with radical surgery including en bloc resection of gallbladder fossa and regional lymphadenectomy, its role for those with advanced gallbladder cancer remains controversial. First, patients with more advanced disease often require more extensive resections than early stage tumors, and operative morbidity and mortality rates are higher. Second, the long-term outcomes after resection, in general, tend to be poorer; long-term survival after radical surgery has been reported only for patients with limited local and lymph node spread. Therefore, the indication of radical surgery should be limited to well-selected patients based on thorough preoperative and intra-operative staging and the extent of surgery should be determined based on the area of tumor involvement.
Surgical resection is warranted only for those who with locoregional disease without distant spread. Because of the limited sensitivity of current imaging modalities to detect metastatic lesions of gallbladder cancer, staging laparoscopy prior to proceeding to laparotomy is very useful to assess the
abdomen for evidence of discontinuous liver disease or peritoneal metastasis and to avoid unnecessary laparotomy. Weber et al. reported that 48% of patients with potentially resectable gallbladder cancer on preoperative imaging work-up were spared laparotomy by discovering unresectable disease by laparoscopy. Laparoscopic cholecystectomy should be avoided when a preoperative cancer is suspected because of the risk of violation of the plane between tumor and liver and the risk of port site seeding.
The goal of resection should always be complete extirpation with microscopic negative margins. Tumors beyond T2 are not cured by simple cholecystectomy and as with most of early gallbladder cancer, hepatic resection is always required. The extent of liver resection required depends upon whether involvement of major hepatic vessels, varies from segmental resection of segments IVb and V, at minimum to formal right hemihepatectomy or even right trisectionectomy. The right portal pedicle is at particular risk for advanced tumor located at the neck of gallbladder, and when such involvement is suspected, right hepatectomy is required. Bile duct resection and reconstruction is also required if tumor involved in bile duct. However, bile duct resection is associated with increased perioperative morbidity and it should be performed only if it is necessary to clear tumor; bile duct resection does not necessarily increase the lymph node yield.
Portal vein Embolizations (PVE) is commonly used in the patients requiring extensive liver resection but have insufficient Future Liver Remanescent (FLR) volume on preoperative testing. The procedure involves occluding portal venous flow to the side of the liver with the lesion thereby redirecting portal flow to the contralateral side, in an attempt to cause hypertrophy and increase the volume of the FLR prior to hepatectomy.
PVE was first described by Kinoshita and later reported by Makuuchi as a technique to facilitate hepatic resection of hilar cholangiocarcinoma. The technique is now widely used by surgeons all over the world to optimize FLR volume before major liver resections.
PVE works because the extrahepatic factors that induce liver hypertrophy are carried primarily by the portal vein and not the hepatic artery. The increase in FLR size seen after PVE is due to both clonal expansion and cellular hypertrophy, and the extent of post-embolization liver growth is generally proportional to the degree of portal flow diversion. The mechanism of liver regeneration after PVE is a complex phenomenon and is not fully understood. Although the exact trigger of liver regeneration remains unknown, several studies have identified periportal inflammation in the embolized liver as an important predictor of liver regeneration.
PVE is technically feasible in 99% of the patients with low risk of complications. Studies have shown the FLR to increase by a median of 40–62% after a median of 34–37 days after PVE, and 72.2–80% of the patients are able to undergo resection as planned. It is generally indicated for patients being considered for right or extended right hepatectomy in the setting of a relatively small FLR. It is rarely required before extended left hepatectomy or left trisectionectomy, since the right posterior section (segments 6 and 7) comprises about 30% of total liver volume.
PVE is usually performed through percutaneous transhepatic access to the portal venous system, but there is considerable variability in technique between centers. The access route can be ipsilateral (portal access at the same side being resected) with retrograde embolization or contralateral (portal access through FLR) with antegrade embolization. The type of approach selected depends on a number of factors including operator preference, anatomic variability, type of resection planned, extent of embolization, and type of embolic agent used. Many authors prefer ipsilateral approach especially for right-sided tumors as this technique allows easy catheterization of segment 4 branches when they must be embolized and also minimizes the theoretic risk of injuring the FLR vasculature or bile ducts through a contralateral approach and potentially making a patient ineligible for surgery.
However, majority of the studies on contralateral PVE show it to be a safe technique with low complication rate. Di Stefano et al. reported a large series of contralateral PVE in 188 patients and described 12 complications (6.4%) only 6 of which could be related to access route and none precluded liver resection. Site of portal vein access can also change depending on the choice of embolic material selected which can include glue, Gelfoam, n-butyl-cyanoacrylate (NBC), different types and sizes of beads, alcohol, and nitinol plus. All agents have similar efficacy and there are no official recommendations for a particular type of agent.
Proponents of PVE believe that there should be very little or no tumor progression during the 4–6 week wait period for regeneration after PVE. Rapid growth of the FLR can be expected within the first 3–4 weeks after PVE and can continue till 6–8 weeks. Results from multiple studies suggest that 8–30% hypertrophy over 2–6 weeks can be expected with slower rates in cirrhotic patients. Most studies comparing outcomes after major hepatectomy with and without preoperative PVE report superior outcomes with PVE. Farges et al. demonstrated significantly less risk of postoperative complications, duration of intensive care unit, and hospital stay in patients with cirrhosis who underwent right hepatectomy after PVE compared to those who did not have preoperative PVE. The authors also reported no benefit of PVE in patients with a normal liver and FLR >30%. Abulkhir et al. reported results from a meta-analysis of 1088 patients undergoing PVE and showed a markedly lower incidence of Post Hepatectomy Liver Failure (PHLF) and death compared to series reporting outcomes after major hepatectomy in patients who did not undergo PVE. All patients had FLR volume increase, and 85% went on to have liver resection after PVE with a PHLF incidence of 2.5% and a surgical mortality of 0.8%. Several studies looking at the effect of systemic neoadjuvant chemotherapy on the degree of hypertrophy after PVE show no significant impact on liver regeneration and growth.
The volumetric response to PVE is also a very important factor in understanding the regenerative capacity of a patient’s liver and when used together with FLR volume can help identify patients at risk of poor postsurgical outcome. Ribero et al. demonstrated that the risk of PHLF was significantly higher not only in patients with FLR ≤ 20% but also in patients with normal liver who demonstrated ≤5% of FLR hypertrophy after PVE. The authors concluded that the degree of hypertrophy >10% in patients with severe underlying liver disease and >5% in patients with normal liver predicts a low risk of PHLF and post-resection mortality. Many authors do not routinely offer resection to patients with borderline FLR who demonstrate ≤5% hypertrophy after PVE.
Careful analysis of outcome based on liver remnant volume stratified by underlying liver disease has led to recommendations regarding the safe limits of resection. The liver remnant to be left after resection is termed the future liver remnant (FLR). For patients with normal underlying liver, complications, extended hospital stay, admission to the intensive care unit, and hepatic insufficiency are rare when the standardized FLR is >20% of the TLV. For patients with tumor-related cholestasis or marked underlying liver disease, a 40% liver remnant is necessary to avoid cholestasis, fluid retention, and liver failure. Among patients who have been treated with preoperative systemic chemotherapy for more than 12 weeks, FLR >30% reduces the rate of postoperative liver insufficiency and subsequent mortality.
When the liver remnant is normal or has only mild disease, the volume of liver remnant can be measured directly and accurately with threedimensional computed tomography (CT) volumetry. However, inaccuracy may arise because the liver to be resected is often diseased, particularly in patients with cirrhosis or biliary obstruction. When multiple or large tumors occupy a large volume of the liver to be resected, subtracting tumor volumes from liver volume further decreases accuracy of CT volumetry. The calculated TLV, which has been derived from the association between body surface area (BSA) and liver size, provides a standard estimate of the TLV. The following formula is used:
TLV (cm3) = –794.41 + 1267.28 × BSA (square meters)
Thus, the standardized FLR (sFLR) volume calculation uses the measured FLR volume from CT volumetry as the numerator and the calculated TLV as the denominator: Standardized FLR (sFLR) = measured FLR volume/TLV Calculating the standardized TLV corrects the actual liver volume to the individual patient’s size and provides an individualized estimate of that patient’s postresection liver function. In the event of an inadequate FLR prior to major hepatectomy, preoperative liver preparation may include portal vein embolization (PVE).
This page provides links to prerecorded webcasts of surgical procedures. These are actual operations performed at medical centers in the Brazil. Please note that you cannot send in questions by email, though the webcast may say that you can, because you are not seeing these videos live. The videos open in a second window. If you have a pop-up blocker, you will need to disable it to view the programs.
Cholangiocarcinoma (CCA) is a rare but lethal cancer arising from the bile duct epithelium. As a whole, CCA accounts for approximately 3 % of all gastrointestinal cancers. It is an aggressive disease with a high mortality rate. Unfortunately, a significant proportion of patients with CCA present with either unresectable or metastatic disease. In a retrospective review of 225 patients with hilar cholangiocarcinoma, Jarnagin et al. reported that 29 % of patients had either unresectable disease were unfit for surgery. Curative resection offers the best chance for longterm survival. Whereas palliation with surgical bypass was once the preferred surgical procedure even for resectable disease, aggressive surgical resection is now the standard.
In both the UK and the USA the annual death rate due to inguinal and femoral hernia has decreased in the last two to three decades. In the UK, deaths for inguinal and femoral hernia declined from 22 to 55% respectively from 1975 to 1990. The annual deaths in the USA per 100,000 population for patients with hernia and intestinal obstruction decreased from 5.1 in 1968 to 3.0 in 1988. For inguinal hernia with obstruction, 88% of patients underwent surgery with a mortality rate of 0.05%. These figures could be interpreted as showing that elective groin hernia surgery has reduced overall mortality rates.
In support of this contention is the fact that strangulation rates are lower in the USA than in the UK, which could be a consequence of the three times higher rate of elective hernia surgery in the USA. Even so, the available statistics show that rates of elective hernia surgery in the USA per 100,000 population fell from 358 to 220 between 1975 and 1990, although this may be an artifact of the data collection systems rather than a real decline.
During the period 1991–1992, 210 deaths occurring following inguinal hernia repair and 120 deaths following femoral hernia repair were investigated by the UK National Confidential Enquiry Into Perioperative Deaths. This enquiry is concerned with the quality of delivery of surgery, anesthesia, and perioperative care. Expert advisers compare the records of patients who have died with index cases. In this group of 330 patients many were elderly (45 were aged 80–89 years) and significantly infirm unfit; 24 were ASA grade III and 21 ASA grade IV. Postoperative mortality was attributed to preexisting cardiorespiratory problems in the majority of cases. In a nationwide study in Denmark of 158 patients dying after acute groin hernia repair, Kjaergaard et al. also found that these patients were old (median age 83 years) and fragile (>80% with significant comorbidity), with frequent delay in diagnosis and subsequent treatment. Clearly this group of patients requires high-quality care by an experienced surgeon and anesthetist with skills equivalent to that of the ASA grade of the patient.
Postoperative care should necessarily take place in a high-dependency unit or intensive therapy unit; this may necessitate transfer of selected patients to appropriate hospitals and facilities. Sensible decisions must be made in consultation with relatives of extremely elderly, frail, or moribund patients to adopt a humane approach, which may rule out interventional surgery.
Forty percent of patients with femoral hernia are admitted as emergency cases with strangulation or incarceration, whereas only 3% of patients with direct inguinal hernias present with strangulation. This clearly has implications for the prioritization on waiting lists when these types of hernia present electively to outpatient clinics. A groin hernia is at its greatest risk of strangulation within 3 months of its onset. For inguinal hernia at 3 months after presentation, the cumulative probability of strangulation is 2.8%, rising to 4.5% after 2 years. For femoral hernia the risk is much higher, with a 22% probability of strangulation at 3 months after presentation rising to 45% at 21 months. Right-sided hernias strangulate more frequently than left-sided hernias; this is possibly related to mesenteric anatomy.
In a randomized trial, evaluating an expectative approach to minimally symptomatic inguinal hernias, Fitzgibbons et al. in the group of patients randomized to watchful waiting found a risk of an acute hernia episode of 1.8 in 1,000 patient years. In another trial, O’Dwyer and colleagues, randomizing patients with painless inguinal hernias to observation or operation, found two acute episodes in 80 patients randomized to observation. In both studies, a large percentage of patients randomized to nonoperative care were eventually operated due to symptoms. Neuhauser, who studied a population in Columbia where elective herniorrhaphy was virtually unobtainable, found an annual rate of strangulation of 0.29% for inguinal hernias.
Management of Strangulation
Diagnosis is based on symptoms and signs supplemented by diagnostic imaging when indicated. Pain over the hernia site is invariable, and obstruction with strangulation of intestine will cause colicky abdominal pain, distension, vomiting, and constipation. Physical examination may reveal degrees of dehydration with or without CNS depression, especially in the elderly if uremia is present, together with abdominal signs of intestinal obstruction. Femoral hernias can be easily missed, especially in the obese female, and a thorough examination should be performed in order to make the correct diagnosis. Frequently, however, physical examination alone is insuf fi ciently accurate to con fi rm the presence of a strangulating femoral hernia vs. lymphadenopathy vs. a lymph node abscess. In these instances, one may elect to perform radiographic studies such as an ultrasound or a CT scan on an urgent or emergent basis.
The choice of incision will depend on the type hernia if the diagnosis is confi dent. When the diagnosis is in doubt, a half Pfannenstiel incision 2 cm above the pubic ramus, extending laterally, will give an adequate approach to all types of femoral or inguinal hernia. The fundus of the hernia sac can then be approached and exposed and an incision made to expose the contents of the sac. This will allow determination of the viability of its contents. Nonviability will necessitate conversion of the transverse incision into a laparotomy incision followed by release of the constricting hernia ring, reduction of the contents of the sac, resection, and reanastomosis. Precautions should be taken to avoid contamination of the general peritoneal cavity by gangrenous bowel or intestinal contents. In the majority of cases, once the constriction of the hernia ring has been released, circulation to the intestine is reestablished and viability returns. Intestine that is initially dusky, aperistaltic, or dull in hue may pink up with a short period of warming with damp packs once the constriction band is released. If viability is doubtful, resection should be performed. Resection rates are highest for femoral or recurrent inguinal hernias and lowest for inguinal hernias. Other organs, such as bladder or omentum, should be resected, as the need requires. After peritoneal lavage and formal closure of the laparotomy incision, specific repair of the groin hernia defect should be performed. In this situation prosthetic mesh should not be used in an operative fi eld that has been contaminated and in which there is a relatively high risk of wound infection. The hernia repair should follow the general principles for elective hernia repair. It should be kept in mind, that in this group of predominantly frail and elderly patients with a very high postoperative mortality risk, the primary objective of the operation is to stop the vicious cycle of strangulation, and only secondary to repair the hernia defect.
The risk of an acute groin hernia episode is of particular relevance, when discussing indication for operation of painless or minimally symptomatic hernias. A sensible approach in groin hernias would be, in accordance with the guidelines from the European Hernia Society to advise a male patient, that the risk of an acute operation, with an easily reducible (“disappears when lying down”) inguinal hernia with little or no symptoms, is low and that the indication for operation in this instance is not absolute, but also inform, that usually the hernia after some time will cause symptoms, eventually leading to an operation. In contrast, female patients with a groin hernia, due to the high frequency of femoral hernias and a relatively high risk of acute hernia episodes, should usually be recommended an operation.
There are many local and systemic factors that affect wound healing. The physician should be actively working to correct any abnormality that can prevent or slow wound healing.
A health care provider can improve wound healing by controlling local factors. He or she must clean the wound, debride it, and close it appropriately. Avulsion or crush wounds below under general management of wounds) need to be debrided until all nonviable tissue is removed. Grossly contaminated wounds should be cleaned as completely as possible to remove particulate matter (foreign bodies) and should be irrigated copiously. Bleeding must be controlled to prevent hematoma formation, which is an excellent medium for bacterial growth. Hematoma also separates wound edges, preventing the proper contact of tissues that is necessary for healing.
Radiation affects local wound healing by causing vasculitis, which leads to local hypoxia and ischemia. Hypoxia and ischemia impede healing by reducing the amount of nutrients and oxygen that are available at the wound site. Infection decreases the rate of wound healing and detrimentally affects proper granulation tissue formation, decreases oxygen delivery, and depletes the wound of needed nutrients. Care must be taken to clean the wound adequately. All wounds have some degree of contamination, if the body is able to control bacterial proliferation in a wound, that wound will heal. The use of cleansing agents (the simplest is soap and water) can help reduce contamination. A wound that contains the highly virulent streptococci species should not be closed. Physicians should keep in mind the potential for Clostridium tetani in wounds with devitalized tissue and use the proper prophylaxis.
In addition to controlling local factors, the physician must address systemic issues that can affect wound healing. Nutrition is an extremely important factor in wound healing. Patients need adequate nutrition to support protein synthesis, collagen formation, and metabolic energy for wound healing. Patients need adequate vitamins and nutrients to facilitate healing; folic acid is critical to the proper formation of collagen. Adequate fat intake is required for the absorption of vitamins D, A, K, and E. Vitamin K is essential for the
carboxylation of glutamate in the synthesis of clotting factors II, VII, IX, and X. Decreasing clotting factors can lead to hematoma formation and altered wound healing. Vitamin A increases the inflammatory response, increases collagen synthesis, and increases the influx of macrophages into a wound. Magnesium is required for protein synthesis, and zinc is a cofactor for RNA and DNA polymerase. Lack of any one of these vitamins or trace elements will adversely affect wound healing. Uncontrolled diabetes mellitus results in uncontrolled hyperglycemia, impairs wound healing, and alters collagen
formation. Hyperglycemia also inhibits fibroblast and endothelial cell proliferation within the wound. Medications will also affect wound healing. For example, steroids blunt the inflammatory response, decrease the available vitamin A in the wound, and alter the deposition and remodeling of collagen. Chronic illness (immune deficiency, cancer, uremia, liver disease, and jaundice) will predispose to infection, protein deficiency, and malnutrition, which, as noted previously, can affect wound healing. Smoking has a systemic effect by decreasing the oxygencarrying capacity of hemoglobin. Smoking may also decrease collagen formation within a wound. Hypoxia results in a decrease in oxygen delivery to a wound and retards healing.
The abdomen is the lower part of the trunk below the diaphragm. Its walls surround a large cavity called the abdominal cavity. The abdominal cavity is much more extensive than what it appears from the outside. It extends upward deep to the costal margin up to the diaphragm and downward within the bony pelvis. Thus, a considerable part of the abdominal cavity is overlapped by the lower part of the thoracic cage above and by the bony pelvis below. The abdominal cavity is subdivided by the plane of the pelvic inlet into a larger upper part, i.e., the abdominal cavity proper, and a smaller lower part, i.e., the pelvic cavity. Clinically the importance of the abdomen is manifold. To the physician, the physical examination of the patient is never complete until he/she thoroughly examines the abdomen. To the surgeon, the abdomen remains an enigma because in number of cases the cause of abdominal pain and nature of abdominal lump remains inconclusive even after all possible investigations. To summarize, many branches of medicine such as general surgery and gastroenterology are all confined to the abdomen.
The incidence of choledocholithiasis in patients undergoing cholecystectomy is estimated to be 10 %. The presence of common bile duct stones is associated with several known complications including cholangitis, gallstone pancreatitis, obstructive jaundice, and hepatic abscess. Making the diagnosis early and prompt management is crucial. Traditionally, when choledocholithiasis is identified with intraoperative cholangiography during the cholecystectomy, it has been managed surgically by open choledochotomy and place- ment of a T-tube. This open surgical approach has a morbidity rate of 10–15 %, mortality rate of <1 %, with a <6 % incidence of retained stones. Patients who fail endoscopic retrieval of CBD stones, as well as cases in which an endoscopic approach is not appropriate, should be explored surgically.
Acute obstruction of the bile duct by a stone causes a rapid distension of the biliary tree and activation of local pain fibers. Pain is the most common presenting symptom for choledocholithiasis and is localized to either the right upper quadrant or to the epigastrium. The obstruction will also cause bile stasis which is a risk factor for bacterial over- growth. The bacteria may originate from the duodenum or the stone itself. The combination of biliary obstruction and colo- nization of the biliary tree will lead to the development of fevers, the second most common presenting symptom of cho- ledocholithiasis. Biliary obstruction, if unrelieved, will lead to jaundice. When these three symptoms (pain, fever, and jaundice) are found simultaneously, it is known as Charcot’s triad. This triad suggests the diagnosis of acute ascending cholangitis, a potentially life-threatening condition. If not treated promptly, this can lead to hypotension and decreased metal status, both signs of severe sepsis. When combined with Charcot’s triad, this constellation of symptoms is commonly referred to as Reynolds pentad.
Laparoscopic common bile duct exploration
Laparoscopic common bile duct exploration (LCBDE) allows for single stage treatment of gallstone disease, reducing overall hospital stay, improving safety and cost-effectiveness when compared to the two-stage approach of ERCP and laparoscopic cholecystectomy. Bile duct clearance can be confirmed by direct visualization with a choledochoscope. But, before the advent of choledochoscope, bile duct clearance was uncertain, and blind instrumentation of the duct resulted in accentuated edema and inflammation. Due to advancement in instruments, optical magnification, and direct visualization, laparoscopic exploration of the CBD results in fewer traumas to the bile duct. This has led to an increasing tendency to close the duct primarily, reducing the need for placement of T-tubes. Still, laparoscopic bile duct exploration is being done in only a few centers. Apart from the need for special instruments, there is also a significant learning curve to acquire expertise to be able to perform a laparoscopic bile duct surgery.
Morbidity and mortality rates of laparoscopic exploration are comparable to ERCP (2–17 and 1–5 %), and there is no clear difference in primary success rates between the two approaches. However, the endoscopic approach may be preferable for elderly and frail patients, who are at higher risk with surgery. Patients older than 70–80 years of age have a 4–10 % mortality rate with open duct exploration. It may be as high as 20 % in elderly patients undergoing urgent procedures. In comparison, advanced age and comor- bidities do not have a significant impact on overall complication rates for ERCP. A success rate of over 90 % has been reported with laparoscopic CBD exploration. Availability of surgical expertise and appropriate equipment affect the success rate of laparoscopic exploration, as does the size, number of the CBD stones, as well as biliary anatomy. Over the years, laparoscopic exploration has become efficient, safe, and cost effective. Complications include CBD laceration, stricture formation, bile leak, abscess, pancreatitis, and retained stones.
In cases of failure of laparoscopic CBD exploration, a guidewire or stent can be passed through the cystic duct, common bile duct, and through the ampulla into the duodenum followed by cholecystectomy. This makes the identification and cannulation of the ampulla easier during the post- operative ERCP. Laparoscopic common bile duct exploration is traditionally performed through a transcystic or transductal approach. The transcystic approach is appropriate under certain circumstances. These include a small stone (<10 mm) located in the CBD, presence of small common bile duct (<6 mm), or if there is poor access to the common duct. The transductal approach is preferable in cases of large stones, stones in proximal ducts (hepatic ducts), large occluding stones in a large duct, presence of multiple stones, or if the cystic duct is small (<4 mm) or tortuous. Contraindications for laparoscopic approach include lack of training, and severe inflammation in the porta hepatis making the exploration difficult and risky.
With advancement in imaging technology, laparoscopic and endoscopic techniques, management of common bile duct stone has changed drasti- cally in recent years. This has made the treatment of this condition safe and more efficient. Many options are now available to manage this condition, and any particular modality for treatment should be chosen carefully based on the patient related factors, institutional protocol, available expertise, resources, and cost-effectiveness.
Patients with acute appendicitis can present at different stages of the disease process, ranging from mild mucosal inflammation to frank perforation with abscess formation. The reported overall incidence of acute appendicitis varies with age, gender, and geographical differences. Interestingly, while the incidence of non-perforated appendicitis in the United States decreased between 1970 and 2004, no significant decline in the rate of perforated appendicitis was observed despite the increasng use of computed tomography (CT) and fewer negative appendectomies.
Of 32,683 appendectomies sampled from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) hospitals between 2005 and 2008, 5,405 patients (16.5%) had a preoperative diagnosis of acute appendicitis with peritonitis/abscess.
The definition of complicated appendicitis varies slightly in the literature. Clinicopathological diagnoses (gangrenous, perforated, appendiceal abscess/phlegmon) of acute appendicitis are commonly used for its definition. Classically, patients at the extremes of age are more likely to present with complicated appendicitis. Similarly, pre-morbid conditions including diabetes and type of medical insurance are significantly associated with the risk of perforation.
The importance of early appendectomy has also been emphasized to prevent perforation of the appendix and the sub- sequent negative impact on patient outcomes. However, more recent meta-analysis data supports the safety of a relatively short (12–24 h) delay before appendectomy, which was not significantly associated with increased rate of complicated appendicitis. Teixeira et al. also showed that the time to appendectomy was not a significant risk factor for perforated appendicitis but did result in a significantly increased risk of surgical site infection.
The outcome of patients with complicated appendicitis is significantly worse than patients with uncomplicated appendicitis. A population-based study from Sweden showed that, in a risk-adjusted model, patients with perforated appendicitis were 2.34 times more likely to die after appendectomy than non- perforated appendicitis patients. Because of its higher mortality and morbidity in patients with complicated appendicitis, the management of complicated appendicitis has evolved significantly over the last few decades.
Open or Laparoscopic Surgery
Since the first laparoscopic appendectomy was described by Semm in 1983, multiple studies have compared operative time, complication rates, length of hospital stay, hospital cost, and other outcomes between open and laparoscopic appendectomy for acute appendicitis. The most recent Cochrane review included 67 studies showing that laparoscopic appendectomy was associated with a lower incidence of wound infection, reduced postoperative pain, shorter postoperative length of hospital stay, and faster recovery to daily activity. In contrast, reduced risk of intra-abdominal abscesses and shorter operative time were found as the advantages of open appendectomy.
Due to increased surgeon experience in uncomplicated appendicitis, laparoscopic appendectomy is more frequently attempted even in complicated appendicitis cases as an alternative approach to open appendectomy. Although the general surgical steps for complicated appendicitis are similar to those for uncomplicated appendicitis, the laparoscopic procedure can be more technically demanding. Therefore, conversion from laparoscopic appendectomy to open appendectomy can be expected.
Despite these concerns, the laparoscopic approach in patients with com- plicated appendicitis has been proven to be safe and comparable to open appendectomy. Retrospective studies using a large database in the United States uniformly showed more favorable clinical outcomes (mortality, morbidity, length of hospital stay, readmission rate) and hospital costs in patients who underwent laparoscopic appendectomy when compared to open appendectomy. The real risk of developing an intra- abdominal abscess after laparoscopic appendectomy remains unclear. A meta-analysis by Markides et al. found no significant difference in the intra-abdominal abscess rate between laparoscopic and open appendectomy for complicated appendicitis, whereas Ingraham et al. showed a higher likelihood of developing an organ-space surgical site infection in patients undergoing laparoscopic appendectomy.