Donor Evaluation and Management
There are very few absolute contraindications for abdominal organ donation, which can be summarized in the short form CHUMP: (1) Creutzfeldt-Jakob disease, (2) active HIV infection, (3) uncontrolled donor sepsis, (4) history of melanoma or other malignancy that poses a risk for transmission regardless of the apparent disease – free period, and (5) past history of non-curable malignancy (curable malignancy such as localized small kidney tumors, localized prostate cancer, localized colon malignancy >5 years previously may be considered after careful risk/benefit assessment). In addition to these general criteria, there are organ-specific criteria for guiding the acceptance of a liver for transplantation. A history of hepatitis or alcoholism is certainly a warning sign, but both livers from HBsAg-positive and/or HCV-positive donors are currently used worldwide, and suitability for transplant must be judged on a case-by-case basis. In general, in the case of a marginal liver donor, the intraoperative assessment by the donor surgeon, in addition to liver biopsy pathological evaluation, is the best single piece of information.
Technical Aspects of Liver Procurement
A midline laparotomy from the xyphoid to the pubis is performed and the round ligament divided. The intra-abdominal organs are explored to check for eventual malignancies, and the quality of the liver is assessed: in the absence of contraindications for a transplant, a sternotomy can be performed. Of note, in the presence of prior heart surgery, the complete warm dissection should be made prior to the sternotomy. It is also prudential to isolate and encircle the aorta prior to sternotomy in order to be ready to cannulate in the event of cardiac arrest/injury at thoracotomy. A blunt dissection behind the sternum just below the jugular notch should be performed until the fingertip can be placed retrosternal around the jugular notch. The sternotomy is then performed in a cranial to caudal direction with the sternum saw to avoid left innominate vein injury. The division of the left triangular ligament allows the mobilization of the left lateral segments of the liver and the exposure of the supraceliac aorta just below the diaphragm to be encircled. The division of the falciform ligament up to the suprahepatic inferior vena cava (IVC) provides more mobility of the liver, necessary when the IVC must be divided from a cardiac graft. Before starting the dissection of the hepatoduodenal ligament, the hepatogastric ligament must be inspected by dividing the lesser omentum. This ligament is usually very thin and transparent so that any replaced or accessory left hepatic artery should be easily visible. In addition, palpation of the ventral border of the foramen of Winslow makes it possible to identify a possible accessory or replaced right hepatic artery. Variations in the hepatic arterial supply can complicate the hilar dissection in up to one third of donors.
THE HILAR STRUCTURES
The hilar structures of the liver are then dissected free; the common bile duct (CBD) is dissected on the level of the edge of the second duodenal portion after opening of the peritoneum and visualization of the duct. In difficult cases, due to a high BMI, following the cystic duct out of the gall bladder can help to identify the CBD. The CBD should be encircled from the lateral border of the hepatoduodenal ligament in order to avoid injury of the portal vein. The CBD and the gallbladder are opened and flushed with normosaline solution. The origins of the gastroduodenal, gastric, and splenic arteries are then identified and encircled and, in the case of liver only procurement, will be taped just before cross-clamping in order to increase flushing through the hepatic artery to the liver.
VASCULAR CANULATION / SOLUTION PRESERVATION
The aorta can be isolated by two approaches. One approach requires mobilization of the right colon on top of Gerota’s fascia and should be extended into a Kocher maneuver to uncover both the inferior vena cava and the abdominal aorta; the other approach is performed by opening the root of the mesentery from the Treitz fascia, along the margin of the duodenum until visualization of the right iliac vessels and ureter is achieved. The inferior mesenteric artery can be tied and divided, and the abdominal aorta, just 2–3 cm above the bifurcation, isolated and encircled. The lumbar arteries could be either tied or clipped and then cut in order to provide mobility of the aorta and facilitate the cannulation. Two umbilical tapes are placed around the dissected segment of the aorta and secured by clamps and will be used to secure aortic cannulae to the vessel. The inferior mesenteric vein (IMV) is most commonly used for access into the portal system by ligating the distal part of it but leaving it uncut to retract the vein with a mosquito clamp. Another tie is then placed around the cranial portion of the vein, using it for occlusion of the vein by retracting it while a partial incision of the vein is performed. The portal cannula can be inserted into the IMV while the tension of the occluding tie is decreased before tying it around the vein and inserted cannula. At this point, 30,000-IU heparin should be given to prevent the blood from clotting after the cross-clamping. Once these preliminary procedures have been completed, the aortic cannulae (20-F armed cannulae) can be inserted into the distal abdominal aorta and secured with the umbilical tapes.
The subdiaphragmatic aorta is now clamped (cross-clamp), and cold preservation solution is then rapidly infused through the aortic and portal cannulae; the liver flow is decompressed by dividing the inferior vena cava in the chest. The abdomen is filled with water and ice. The choice of solution for infusion and its amount varies from center to center. The quality of the flush can be assessed by evaluating the outflow of the supradiaphragmatic IVC which should become more transparent with time as the blood in the abdominal organs is replaced by the preservation solution. After the flush is completed, some of the ice is removed from the abdomen to allow the cold dissection of the structures. The gastroduodenal, gastric, and splenic arteries can now be divided. Just below the gastroduodenal artery, the portal vein can be found and can be followed back, if pancreas procurement is not performed, by dividing the head of the pancreas. The cannulae in the IMV can now be removed, the splenic vein ligated and divided, and the venous cannulae replaced in the superior mesenteric vein once it is divided from its distal branches. The superior mesenteric artery (SMA) can now be found in the retro-pancreatic laminae and should be ligated, secured to a clamp and divided in order to find the aortic plane by following back the SMA. This dissection must be made on the left side of the SMA in order to avoid damage to a possible replaced or accessory right hepatic artery. The renal arteries are usually just below the SMA. They should be visualized before the suprarenal aorta is divided. This section must be made in 45°, first looking for ostia of accessory renal arteries before performing complete separation of the aorta. By following back the splenic and gastric arteries, the celiac trunk can be visualized. The aorta must now be divided just below the diaphragm, obtaining a patch containing the celiac trunk and the origin of the mesenteric artery. At this time point, a finger is placed in the supradiaphragmatic IVC helping to identify it while the diaphragm is cut. A portion of the diaphragm should be kept with the liver to ensure that this gross and fast dissection does not damage the organ. The diaphragm is cut to the right, and the incision is then continued between the right kidney and the liver, usually dividing the adrenal gland which is a good sign that none of the adjacent organs are damaged. The location for division of the infrahepatic IVC depends on the renal veins. These are identified on both sides, and the IVC can be safely divided on the virtual line about 1 cm above the renal veins. The only structures now holding the liver in the abdomen are the diaphragmatic pillars. By keeping the liver to the right thoracic cavity and holding the aortic patch, the resected IVC, and the portal vein with its cannulae, the liver removal can be completed by cutting the diaphragmatic muscles. The liver is freed and taken out of the abdomen. A further perfusion with cool preservation solution should be performed on the back table before packing the liver in the transportation box usually with 1 l of preservation solution. The liver can now be packed in the transportation box.
The liver is the biggest intestinal organ and plays a central role in the homeostasis of different physiological systems including nutrition and drug metabolism, the synthesis of plasma proteins and haemostatic factors, as well as the elimination of different endogenous and exogenous substances. Although the liver contributes with only 3% to total body weight, given its major role in homeostasis and high energy consumption, it receives 25% of total cardiac output (CO). Two vessels contribute to the perfusion of the liver. The majority (70%) of the hepatic perfusion is provided by the portal vein, which contributes 50% of the organ’s oxygen demand. The other 50% is provided by the hepatic artery, which makes up around 30% of total liver perfusion. Hepatic arterial blood flow is mainly dependent on the organ’s metabolic demands and controlled via autoregulatory mechanisms, whereas blood supply through the portal vein depends on the perfusion throughout the whole gastrointestinal tract and the spleen. This unique, dual perfusion system provides constant perfusion rates and oxygen supply, which is crucial for adequate liver function. These high oxygen demands are reflected in a hepatic vein saturation of almost 30%.
The liver is also unique in its ability of regeneration, which allows the performance of major surgery including, amongst others, extended resections of liver tumours, living donations and so on. Many patients have normal liver function parameters when they present for liver surgery, especially when the reason for resection is metastasis or a benign liver tumour. The most common causes of liver resections are the hepatocellular carcinoma (HCC) and the cholangiocellular carcinoma (CCC). Hepatocellular carcinoma (HCC) often develops in patients with underlying liver cirrhosis; many of these patients show signs of chronic liver dysfunction (CLD).
As explained previously, the liver plays a central role in a great deal of physiological systems. Therefore, in case of chronic liver dysfunction (CLD) or liver failure, several effects on other organ systems have to be expected. Consequently liver resections and bile duct surgery as having a high risk for perioperative cardiac events, with an estimated 30-day cardiac event rate (cardiac death and myocardial infarction) of more than 5%. Patients undergoing liver surgery pose a significant challenge to treating physicians in the perioperative period. Due to the improvement of surgical techniques, the “liver patient” is becoming more and more complex, confronting surgeons, anaesthetists and intensive care personnel with difficult intra- and postoperative courses, and considerable multiorgan disorders. The cornerstones of an optimal management are careful selection of the patients, appropriate monitoring and protection of the liver and other vital organs.
The gallbladder lies at the equator between the right and left hemiliver, an imaginary line known as Cantlie’s line or the Rex-Cantlie line coursing between segments 4b and 5, through the bed of the gallbladder towards the vena cava posteriorly. The gallbladder is mostly peritonealized, except for its posterior surface which lies on the cystic plate, a fibrous area on the underside of the liver.
The proportion if its circumference varies, from a pedicled gallbladder with little to no contact with the cystic plate to a mostly intrahepatic gallbladder surrounded by liver parenchyma. The gallbladder carries no muscularis mucosa, no submucosa, and a discontinuous muscularis and only carries a serosa on the visceral peritonealized surface. These anatomical specificities facilitate the direct invasion of gallbladder cancer into the liver. This is why the surgical treatment of gallbladder cancer mandates a radical cholecystectomy, which includes resection of a wedge of segments 4b and 5, when the T stage is higher or equal to T1b. From the body of the gallbladder, a conical infundibulum becomes a cystic duct that extends as the lower edge of the hepatocystic triangle towards the porta hepatis and joins with the common hepatic duct (CHD) to form the CBD. As in the rest of the biliary system, variation is the rule when it comes to the cystic duct confluence with the CHD. It can variably run parallel to it for a distance prior to inserting or spiral behind it and insert on its medial aspect. It can variably insert into the RHD or the RPD, the latter in 4% of livers and particularly when the RPD inserts into the CHD (i.e., below the left-right ductal confluence). This configuration is notorious for exposing the RPD to a risk of injury at the time of cholecystectomy. Rare variations of gallbladder anatomy, including gallbladder duplication and gallbladder agenesis, are also described but are rare. The CBD courses anterolaterally within the hepatoduodenal ligament, usually to the right of the hepatic artery and anterolaterally to the portal vein. However, hepatic arterial anatomy can vary, and when an accessory or replaced hepatic artery is present arising from the superior mesenteric artery, the accessory or replaced vessel courses lateral to the CBD. In its conventional configuration, the right hepatic artery crosses posteriorly to the RHD as it heads towards the right liver, but 25% of the time it crosses anteriorly. These anatomical variants are all relevant to developing a sound surgical strategy to treat hilar CCA. Of note, while left hepatic artery anatomy can also be quite variable, rarely does it affect surgical decision-making in CCA to the same degree as right hepatic artery anatomy.
Distally, the CBD enters the head of the pancreas, joining the pancreatic duct to form the hepatopancreatic ampulla. Just distal to this is the sphincter of Oddi, which controls emptying of ampullary contents into the second portion of the duodenum. When the junction of the CBD and the pancreatic duct occurs before the sphincter complex, reflux of pancreatic enzymes into the biliary tree can lead to chronic inflammatory changes and anatomical distortion resulting in choledochal cysts, known risk factors for the development of CCA. Unlike the rest of the liver parenchyma, which receives dual supply from the arterial and portal venous circulation, the biliary tree is exclusively alimented by the arterial system. The LHD and RHD are alimented respectively by the left hepatic artery and right hepatic artery, which can frequently display replaced, accessory, and aberrant origins – the left artery arising conventionally from the hepatic artery proper but alternatively from the left gastric artery and the right hepatic artery arising from the hepatic artery proper but also variably from the superior mesenteric artery. In hilar CCA, variable combinations of hepatic arterial anatomy and tumor location can either favor resectability or make a tumor unresectable.
Within the hilum of the liver, a plexus of arteries connects the right and left hepatic arteries. Termed the “hilar epicholedochal plexus,” this vascular network provides collateral circulation that can maintain arterial supply to one side of the liver if the ipsilateral vessel is damaged. The preservation of arterial blood supply to the liver remnant is crucial, particularly when creating an enterobiliary anastomosis. Its absence leads to ischemic cholangiopathy and liver abscesses that can be difficult to treat. The CBD receives arterial supply inferiorly from paired arterioles arising from the gastroduodenal artery and the posterior superior pancreaticoduodenal artery, the most important and constant arterial supply to the distal CBD. Proximally the CBD is alimented by paired arterioles of the right hepatic artery. These vessels, known as the marginal arteries, run in parallel to the CBD, laterally and medially to it. Denuding the CBD of this arterial supply risks stricture formation after choledochoenteric anastomosis.
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Pancreatic ductal adenocarcinoma (PDAC) carries one of the poorest overall prognosis of all human malignancies. The 5-year survival in patients with PDAC, for all stages, remains as low as 6–7%. The low survival rate is attributed to several factors, of which the two most important are aggressive tumor biology and late stage at which most patients are diagnosed. Only 10–20% of patients are eligible for resection at presentation, 30–40% are unresectable/locally advanced, and 50–60% are metastatic. Pancreatic cancer without distant metastasis can be divided into three categories: resectable, borderline resectable, and locally advanced. In absence of metastatic disease, the most important factor for improving survival and possibly offer cure is to achieve a margin-negative resection. Even after potential curative resection, most patients develop recurrences eventually, and 5-year survival of completely resected patients is only up to 25%. The aggressive tumor biology and its inherent resistance to chemotherapy and radiotherapy contributes to early recurrence and metastasis.
Pancreatic cancer surgery has evolved over the past few decades and remains the cornerstone of treatment of resectable and borderline resectable tumors. Advances in modern imaging give precise information on disease extension and vascular involvement that aids in surgical planning in order to achieve a margin-negative resection.
Surgical techniques for pancreatic cancer include pancreaticoduodenectomy, distal pancreatectomy with splenectomy, and total pancreatectomy. Standard lymphadenectomy for pancreatoduodenectomy should include removal of lymph node stations 5, 6, 8a, 12b1, 12b2, 12c, 13a, 13b, 14a, 14b, 17a, and 17b. Involvement of superior mesenteric vein (SMV)/portal vein(PV) was previously considered as a contraindication for resection. However, curative resection along with SMV/PV with vascular reconstruction has now become a standard practice in specialized high-volume centers. To improve margin-negative resections, specially in borderline resectable tumors with proximity to vascular structures, SMA first approach was proposed as a new modification of standard pancreatico-duodenectomy. In a systematic review, SMA first approach was shown to be associated with better perioperative outcomes, such as blood loss, transfusion requirements, pancreatic fistula, delayed gastric emptying, and reduced local and metastatic recurrence rates. In case of arterial involvement, there is no good evidence at present to justify arterial resections for right-sided pancreatic tumors. However, the modified Appleby procedure, which includes en bloc removal of celiac axis with or without arterial reconstruction, when used in appropriately selected patients, offers margin negative resection with survival benefit for locally advanced pancreatic body and tail tumors and should be performed in high-volume centers. Most evidence does not support advantage of more extended resections such as removal of the para-aortic lymph nodes and nerve plexus and multivisceral resections routinely. Such extended resections are associated with compromised quality of life because of associated higher perioperative morbidity and intractable diarrhea. However, in highly selected patients, with preserved performance status and stable or nonprogressive disease on neoadjuvant treatment, such extended resections can provide survival advantage over palliative treatments. Radical surgery in the presence of oligometastatic disease has also been reported to prolong survival in highly selected patients.
Benign liver tumours are common and are frequently found coincidentally. Most benign liver lesions are asymptomatic, although larger lesions can cause non-specific complaints such as vague abdominal pain. Although rare, some of the benign lesions, e.g. large hepatic adenomas, can cause complications such as rupture or bleeding. Asymptomatic lesions are often managed conservatively by observation. Surgical resection can be performed for symptomatic lesions or when there is a risk of malignant transformation. The type of resection is variable, from small, simple, peripheral resections or enucleations, to large resections or even liver transplantation for severe polycystic liver disease.
Hepatocellular adenomas (HCA) are rare benign hepatic neoplasms in otherwise normal livers with a prevalence of around 0.04% on abdominal imaging. HCAs are predominantly found in women of child-bearing age (2nd to 4th decade) with a history of oral contraceptive use; they occur less frequently in men. The association between oral contraceptive usage and HCA is strong and the risk for a HCA increases if an oral contraceptive with high hormonal potency is used, and if it is used for over 20 months. Long-term users of oral contraceptives have an estimated annual incidence of HCA of 3–4 per 100000. More recently, an increase in incidence in men has been reported, probably related to the increase in obesity, which is reported as another risk factor for developing HCA. In addition, anabolic steroid usage by body builders and metabolic disorders such as diabetes mellitus or glycogen storage disease type I are associated with HCAs. HCAs in men are generally smaller but have a higher risk of developing into a malignancy. In the majority of patients, only one HCA is found, but in a minority of patients more than 10 lesions have been described (also referred to as liver adenomatosis).
Small HCAs are often asymptomatic and found on abdominal imaging being undertaken for other purposes, during abdominal surgery or at autopsy. Some patients present with abdominal discomfort, fullness or (right upper quadrant) pain due to an abdominal mass. It is not uncommon that the initial symptoms of a HCA are acute onset of abdominal pain and hypovolaemic shock due to intraperitoneal rupture. In a series of patients who underwent resection, bleeding was reported in up to 25%. The risk of rupture is related to the size of the adenoma. Exophytic lesions (protruding from the liver) have a higher chance of bleeding compared to intrahepatic or subcapsular lesions (67% vs 11% and 19%, respectively, P<0.001). Lesions in segments II and III are also at higher risk of bleeding compared to lesions in the right liver (35% vs 19%, P = 0.049).
There is no guideline for the treatment of HCAs, although there are general agreements. In men, all lesions should be considered for surgical resection independent of size, given the high risk of malignant transformation, while taking into account comorbidity and location of the lesion. Resection should also be considered in patients with HCAs due to a metabolic disorder. In women, lesions <5 cm can be observed with sequential imaging after cessation of oral contraceptive treatment. In larger tumours, treatment strategies vary. Some clinicians have proposed non-surgical management if hormone therapy is stopped and patients are followed up with serial radiological examinations. The time period of waiting is still under debate, however recent studies indicate that a waiting period of longer than 6 months could be justified.
More recently, the subtypes of the Bordeaux classification of HCA have been studied related to their risk of complications. Some groups report that percutaneous core needle biopsy is of limited value because the therapeutic strategy is based primarily on patient sex and tumour size. Others report a different therapeutic approach based on subtype. Thomeer et al. concluded that there was no evidence to support the use of subtype classification in the stratification and management of individual patients related to risk of bleeding. Size still remains the most important feature to predict those at risk of bleeding during follow-up. However, malignant transformation does seem to be related to differences in subtypes. β-catenin-mutated HCAs trigger a potent mitogenic signalling pathway that is prominent in HCC. Cases of inflammatory HCAs can also show activation of the β-catenin pathway with a risk of developing malignancy. Therefore, β-catenin-mutated and inflammatory HCAs are prone to malignant degeneration, and particularly if >5cm. In these circumstances, invasive treatment should be considered.
Since the initial descriptions of orthotopic liver transplantation (OLT) in the 1960s, both the number of patients receiving transplants and the indications for the procedure have increased significantly. OLT represents the only treatment modality for many patients with a diverse spectrum of disease, with the predominant common factor end-stage liver failure. Advances in perioperative care of the donor and recipient, organ preservation methods, and surgical techniques have resulted in a 5 year overall survival of 78% for all recipients (Kim et al, 2015).
The first published description of human liver transplantation was by Starzl and colleagues in 1963 at the University of Colorado. In this seminal paper, the dismal outcomes of three OLT recipients were described, including one intraoperative death from uncorrectable coagulopathy and two survivors of 7 and 22 days. In addition to the pioneering conceptual framework and implementation of LT, the advanced techniques included grafts from non–heart-beating donors, venovenous bypass in the recipients, choledochocholedochostomy, and coagulation monitoring by using thromboelastography (TEG). Many of these concepts remain or have reentered the realm of LT more than 40 years after their initial description. Based largely on the initial body of work by Starzl and colleagues, this section describes the surgical procedures commonly used worlwide.
The typical deceased donor has had a catastrophic head injury or an intracerebral bleed, with brain death but without multisystem organ failure. Electrolyte imbalance and hepatic steatosis in the donor are predictors of graft nonfunction. A “donor risk index” has been derived to assess the likelihood of good graft function. Key adverse factors include older donor age (especially >60 years of age), use of a split or partial graft, and a non–heart-beating donor, from which the organs are harvested after the donor’s cardiac output ceases, in contrast to the more typical deceased donation in which the organs are harvested prior to cardiovascular collapse. Use of non–heart-beating donors is associated with reduced rates of long-term graft survival and increased risk of biliary complications, which correlate with the duration of “warm ischemia” after cardiovascular collapse and before retrieval of the organ. With the critical shortage of deceased organ donors, expansion of the donor pool has included acceptance of donors 70 years of age and older for selected recipients. Prior to hepatectomy, the harvesting team makes a visual and, if necessary, histologic assessment of the donor organ. Particular attention is paid to anatomic variants in the hepatic artery that may complicate the graft arterial anastomosis in the recipient. Once donor circulation is interrupted, the organ is rapidly infused with a cold preservation solution (e.g., University of Wisconsin, histidine-tryptophan-ketoglutarate, or Institut Georges Lopez solution). Donor iliac arteries and veins are also retrieved in case vascular grafting is required. After its arrival at the recipient institution, further vascular dissection, with arterial reconstruction if necessary, is performed before implantation.
Major challenges remain in LT, including the shortage of donor organs, threat of recurrent disease, and morbidity associated with lifelong therapeutic immunosuppression. Nevertheless, the availability of LT has transformed the lives of patients with advancing liver disease and their health care providers from an ultimately futile effort to manage the complications of cirrhosis into a life-prolonging and life-enhancing intervention.
The AGA recently published a Clinical Practice Update reviewing the best available evidence on pancreatic necrosis, regardless of cause. The update provides 15 best practice advice points that include the need for multidisciplinary care coordination and referral to a tertiary-care center as appropriate. The update describes supportive care, avoidance of prophylactic antibiotics, and optimization of nutrition. In addition, there is an included algorithm for the management of pancreatic necrosis requiring debridement. Debridement within the early acute phase of pancreatitis (within the first 2–4 weeks) should be avoided if possible secondary to increased morbidity and mortality. Intervention in the late phase (> 2–4 weeks) is indicated for patients with infected necrosis or persistent organ dysfunction and failure to thrive. Multiple approaches are available for the management of infected necrosis, including but not limited to percutaneous, endoscopic, or laparoscopic transgastric, or open debridement. In addition, a combination approach using percutaneous drainage followed by videoscopic retroperitoneal debridement or step-up approach can also be used. Since the publication of a multicenter RCT (PANTER) in 2010, the step-up approach for necrotizing pancreatitis has been increasingly used.
The step-up approach or video-assisted retroperitoneal debridement (VARD) is a minimally invasive technique that begins with percutaneous drain placement for necrotizing pancreatitis followed by a minimally invasive retroperitoneal necrosectomy. Patients who underwent the step-up approach versus open necrosectomy had less multiple-organ failure, incisional hernias, and newonset diabetes, but no difference in mortality. The 2020 AGA Clinical Practice Update on the management of pancreatic necrosis suggests that best practice is that ‘‘minimally invasive operative approaches to the debridement of acute necrotizing pancreatitis are preferred to open surgical necrosectomy when possible, given lower morbidity’’. However, the update also notes that open necrosectomy still has a role in the modern management of acute necrotizing pancreatitis, particularly for cases whereby less invasive techniques are not feasible.
Minimally Invasive Versus Open Techniques
Despite advances in laparoscopic and robotic approaches, the vast majority of distal pancreatectomies continue to be performed via an open approach. Recent retrospective data have demonstrated that minimally invasive distal pancreatectomy is associated with decreased blood loss and shorter hospital stays than open pancreatectomy. A large recent study utilizing the Nationwide Inpatient Sample database suggested, first, that the minimally invasive approach is becoming more widely utilized, increasing from 2.4 to 7.3 % over a study period from 1998 to 2009. Second, that study reported that the minimally invasive approach was associated with decreased length of stay as well as decreased incidence of infectious complications, bleeding complications, and blood transfusions. This population-based study echoes conclusions drawn by a large multi-institutional study performed several years previously. Drawing on a combined patient sample of 667 patients, with 24 % initially attempted laparoscopically, the authors were able to demonstrate lower overall complication rate, decreased blood loss, and shorter hospital stays among patients undergoing laparoscopic approach via a multivariate analysis.
Notably, there was no significant difference in the pancreatic leak rate between the open and laparoscopic approaches, although there was a nonsignificant trend favoring the laparoscopic approach. More recently, the robotic approach has generated significant interest as a technique for performing distal pancreatectomy. Retrospective analysis has suggested that the robotic approach is well suited for pancreatectomy. Fistula rates, however, remain a concern. A retrospective review of patients undergoing robotic pancreatic operations included 83 patients who underwent distal pancreatectomy. About 27 % were identified as having a ISPGF type A pancreatic leak; 12 and 4.8 % were identified as having a grade B or C leak, respectively.
Identifying Risk Factors
For pancreaticoduodenectomy (PTD) , a fistula risk score has been recently developed that has been shown to be highly predictive of POPF. This score assigns points based on gland texture, gland pathology, duct diameter, and intraoperative blood loss. In general, high blood loss, soft gland texture, and smaller duct diameter confer increased risk of POPF, whereas pancreatic adenocarcinoma and pancreatitis as the indication for PTD confer protection for the development of pancreatic fistula versus other diagnoses. Also of note, higher fistula risk scores correlated with greater incidence of clinically relevant (ISGPF grade B or C) fistula. The adaptation of this risk score to patients undergoing distal pancreatectomy is yet to be validated; however, at least one published study indicates that this scoring system may have limitations in the setting of distal pancreatectomy. In that study, risk factors for pancreatic fistula after stapled gland transection in patients undergoing distal pancreatectomy were examined, and in a multivariate analysis, only the presence of diabetes and the use of a 4.1-mm staple cartridge were associated with increased risk of pancreatic fistula formation.
Cholangiocarcinoma is an uncommon cancer that occurs within the intrahepatic and extrahepatic portions of the bile duct system. In North America, the incidence of extrahepatic cholangiocarcinoma is 0.5–2 per 100,000 and 0.95 per 100,000 for intrahepatic cholangiocarcinoma. Up to 50% of patients will be lymph node (LN) positive at presentation, 5% are multifocal tumors, and 10–20% will have peritoneal involvement at presentation. Risk factors for cholangiocarcinoma are primary sclerosing cholangitis (PSC) with a lifetime risk 10–40%, parasitic infection, previous sphincteroplasty, congenital anomalies of the biliary tree (choledochal cyst, Caroli’s disease, anomalous pancreaticobiliary duct junction), and chronic biliary inflammatory disease (hepatitis B/C, liver cirrhosis, recurrent pyogenic cholangitis). The most common presentation is painless jaundice and weight loss in the setting of extrahepatic duct involvement. In Western countries, 80% are extrahepatic (20% distal and 60% hilar) and 20% are intrahepatic.
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• Ca 19–9 can be elevated in up to 85% of patients with cholangiocarcinoma, but is not specific; elevation can also occur in the setting of obstructive jaundice without malignancy. If it remains elevated after biliary decompression, it could indicate the presence of malignancy. Elevated pre- and postoperative Ca 19–9 predict poor survival.
• For perihilar tumors, decisions regarding which side of the liver to resect depend on right- or left-sided dominance, volume of future liver remnant, and the extent of vascular and ductal involvement.
• Some centers report that 30–50% of tumors will be deemed unresectable at the time of surgery, despite accurate preoperative imaging.
• Quality Indicators: Pathologic Analysis—R0 margin, regional lymphadenectomy includes three or more LN.
Intrahepatic cholangiocarcinoma: Surgical resection is the only potential cure with removal of involved liver segments. There is emerging evidence that recommends a routine hilar LN and dissection for its prognostic value, M1 disease includes involvement of celiac,periaortic or caval LN.
Distal bile duct (below the cystic duct): Surgical resection is the only potential cure. Pancreaticoduodenectomy including en bloc resection of extrahepatic bile duct and gallbladder. Regional nodes include: Hilar (CBD, common hepatic, portal, cystic), Posterior and anterior pancreaticoduodenal Nodes along SMV, Nodes along right and lateral wall of SMA.
Hilar (above the cystic duct): En bloc resection of extrahepatic bile duct and gallbladder, including right and left hepatectomy, or extended right/left hepatectomy, Caudate lobe should be removed. Regional nodes include: Hilar (CBD, hepatic,portal, cystic), Pericholedochal nodes in hepatoduodenal ligament.
Tradicionalmente, a marca de um grande cirurgião está relacionada à habilidade técnica, conhecimento e perspicácia diagnóstica, enquanto pouco foco é dado a outras habilidades de Liderança. Hoje, as habilidades não técnicas, como habilidades de comunicação e liderança, acabam se traduzindo em maior segurança do paciente, experiência e resultados. O dia em que o cirurgião inicia seu primeiro trabalho o define como um líder, e isso é particularmente verdadeiro para o cirurgião do Aparelho Digestivo, pois é imediatamente considerado um especialista. Os cirurgiões são líderes preparados para aproveitar as muitas oportunidades de desempenho que as posições acadêmicas fornecem para executar seus interesses fora do atendimento tradicional ao paciente. Algumas pessoas nascem com habilidades de liderança e outras as desenvolvem com o tempo. É claro que esse processo deve começar cedo e que os estudantes de medicina e residentes devem estar preparados para papéis de liderança conforme RODRIGO VIANA explica neste vídeo para ajudar no desenvolvimento das habilidades críticas e não clínicas relacionadas à liderança de uma equipe e ao ensino. Para alguns, os papéis principais podem mudar ou desviar a carreira do atendimento ao paciente. Para outros, um equilíbrio entre as carreiras clínicas e administrativas pode ser cumprido em um papel definido. Independentemente disso, estabelecer metas e trabalhar para alcançá-las dentro da construção de uma equipe é a marca de todos os líderes de sucesso.
The most common presenting sign for patients with malignancy of the periampullary region is obstructive jaundice. While a significant proportion of these patients will be asymptomatic, the deleterious systemic consequences of uncontrolled hyperbilirubinemia may still occur. Furthermore, symptoms such as pruritus can be debilitating and have a significant impact on the quality of life. Thus, some have advocated preoperative drainage of the biliary system in patients with resectable periampullary malignancies, given widespread availability of endoscopic retrograde cholangiopancreatography and its perceived safety profile. On the other hand, the purported benefits of routine preoperative drainage in this patient population (namely, resolution of symptoms in symptomatic patients while awaiting surgery, restoration of the enterohepatic cycle, and a potential decrease in postoperative morbidity) have proven to be largely theoretical, and now there are high-quality phase III data that demonstrate the deleterious effects of routine stenting. A seminal study originating from the Netherlands in 2010 evaluated this issue in the only modern randomized controlled trial to date evaluating preoperative endoscopic biliary decompression for these patients. In their multicenter study, they randomized 202 patients with newly diagnosed pancreatic head cancer and bilirubin levels between 2.3 and 14.6 mg/dL to preoperative biliary drainage for 4–6 weeks vs. immediate surgery which was to be performed within a week of enrollment. The primary endpoint was the development of serious complications within 120 days after randomization. Serious complications were defined as complications related to the drainage procedure or the surgical intervention that required additional medical, endoscopic, or surgical management, and that resulted in prolongation of the hospital stay, readmission to the hospital, or death. The reported overall rate of serious complications in this study favored the immediate surgery group (39 vs. 74%; RR 0.54–95% [CI], 0.41–0.71; P < 0.001), complications related to surgery were equivalent (37 vs. 47%; P = 0.14), and there was no difference in mortality rates or length of hospital stay. The observed drainage-related complications included a 15% rate of stent occlusion, 30% need for exchange, and 26% incidence of cholangitis.
“Based on these results, the authors concluded that the morbidity associated with the drainage procedure itself had an additive effect on the postoperative morbidity of patients undergoing pancreatic head resection for cancer and recommended against its routine use in this population.“
A Cochrane systematic review of all available randomized studies (including the abovementioned study by van der Gaag et al.) evaluating preoperative biliary drainage was published in 2012. In this study, Fang et al. assessed the impact of this intervention on survival, serious morbidity (defined as Clavien-Dindo grade 3 or 4), and quality of life. Furthermore, they sought to assess differences in total length of hospital stay and cost. They identified six randomized trials of which four used percutaneous transhepatic biliary drainage and the remaining two used endoscopic sphincterotomy and stenting. The pooled analysis of 520 patients (of which 51% underwent preoperative biliary drainage) showed no difference in mortality, but importantly, it showed a significantly higher incidence of serious morbidity in the preoperative drainage group with a rate ratio (RaR) of 1.66 (95% CI 1.28–2.16;P = 0.002). There was no difference in length of hospital stay and not enough data reported for analysis of cost or quality of life.
“Based on the available level 1 data, the authors concluded that there was no evidence to support or refute routine preoperative biliary drainage in patients with obstructive jaundice.“
However, this review also underscored the fact that preoperative biliary drainage may be associated with an increased rate of adverse events and thus questioned the safety of this practice. This Cochrane review included old studies that evaluated patients undergoing percutaneous drainage, a technique used less frequently today for periampullary malignancies. Furthermore, several of these trials included patients with hilar and other types of biliary obstruction. However, the concept of preoperative decompression, as well as its purported benefits and observed results, may be reasonably extrapolated to patients with periampullary lesions.
Liver cancer is the sixth most common cancer and, in 2018, was the fourth leading cause of cancer-related death worldwide. The rates of incidence and mortality are approximately 2 to 3 times higher for men than for women. Hepatocellular carcinoma (HCC) is the most common primary liver cancer and accounts for 75% to 85% of diagnoses, followed by intrahepatic cholangiocarcinoma (10%–15%), and other rare liver histologies. The improvement and safety of surgical techniques for liver resection and transplant, and advancements in ablation, transarterial chemoembolization (TACE), and systemic therapies have expanded the treatment options for patients with HCC. Liver transplant is the ideal treatment option for patients with HCC and poorly compensated liver disease because it removes both HCC and damaged liver and reduces the risk for early recurrence. However, shortages in donor liver and long waiting times to transplant are significant barriers to this treatment approach. As such, liver resection remains an effective treatment option for patients with HCC. The use of a multidisciplinary approach and the knowledge of each therapeutic option is critical in the management of patients with HCC.
Minimal future liver remnant requirements
Liver resection remains the treatment of choice for HCC. Two major preoperative considerations for HCC resection are the patient’s liver function and the predicted future liver remnant (FLR). The intrinsic liver function of patients with HCC is often impaired because this patient population generally has chronic liver disease, including viral hepatitis, alcoholic hepatitis, and nonalcoholic steatohepatitis. As such, studies report that more FLR is needed for patients undergoing resection for HCC than for patients undergoing resection of secondary liver cancer (ie, metastatic disease). The minimal requirement of FLR/standardized liver volume (standardized liver volume 5 x 794 1 1267.28 x body surface area) is 30% in patients with hepatic injury and fibrosis and 40% in patients with cirrhosis, whereas it is 20% to 25% for patients with normal liver.
Anatomic resection versus nonanatomic resection
Anatomic resection of Couinaud segment for small HCC was reported in 1981 by Makuuchi and colleagues. HCC frequently invades to the intrahepatic vascular structures and spreads through the portal vein. As such, the complete removal of tumor-bearing portal territory was reported to be theoretically superior to nonanatomic resection. The technique proposed by Makuuchi and colleagues is detailed as follows: (1) under the guidance of intraoperative ultrasonography, the portal vein of interest is identified and punctured using a 22-gauge needle; (2) blue dye is injected into the portal vein; (3) the territory of the dyed surface is marked using electrocautery; and (4) liver resection is performed using ultrasonography guidance and intersegmental hepatic veins are exposed. This technique was recently refined using fluorescence imaging. By using transportal injection or systemic intravenous injection of indocyanine green, the portal vein territory was more clearly visualized on the liver surface compared with the traditional method. Many retrospective studies reported that anatomic resection was associated with better survival and lower recurrence than nonanatomic resection. In contrast, other studies showed that survival did not differ significantly between patients undergoing anatomic resection and those undergoing nonanatomic resection. Therefore, this clinical question remains unanswered and needs to be further elucidated.
Laparoscopic liver resection
Laparoscopic liver resection (LLR) has been increasingly used worldwide. In their systemic review, Nguyen and colleagues reported on the safety of LLR with low rates of morbidity and mortality for both major and minor resections, as well as appropriate oncologic results compared with open liver resection (OLR). These results are most likely caused by patient selection and the advantages of the laparoscopic approach, including a magnified view and the hemostatic effect caused by pneumoperitoneum. Three retrospective studies including more than 200 patients showed that the 5-year overall survival (OS) was not significantly different between patients undergoing LLR for HCC and those undergoing OLR for HCC. However, no randomized controlled trials (RCTs) comparing long-term outcomes in patients undergoing LLR versus OLR for HCC have been reported. For patients with colorectal liver metastases, a recent RCT (Oslo-CoMet study) showed that median OS in patients undergoing LLR was similar to those undergoing OLR: 80 months versus 81 months.
Liver Resection Versus Ablation
It remains unclear whether liver resection or ablation is the most effective treatment of small HCC lesions. To answer this clinical question, 5 RCTs have been reported. Two of these studies showed that liver resection was associated with better survival than radiofrequency ablation and 3 showed that survival did not differ significantly between patients undergoing resection and those undergoing ablation. The shortcomings of these RCTs include insufficient patient follow-up; unclear treatment allocation; and different inclusion criteria, including tumor number, tumor diameter, and Child-Pugh grade. Nonetheless, for patients with small HCCs (ie,<3 cm), the current evidence shows that both resection and ablation can be recommended.
Liver Resection Versus Transarterial Chemoembolization
There has been 1 RCT comparing the outcomes of patients undergoing resection for HCC with those undergoing TACE. For patients outside of Milan criteria, resection was associated with better survival than TACE. The authors found 8 cohort studies comparing outcomes after resection with TACE using the propensity score adjustment. Although the studies had different inclusion criteria, the data show that resection is associated with better survival than TACE in selected patients who have multiple HCCs.
Liver Resection Versus Liver Transplant
Liver transplant is an established treatment option for patients who have early-stage HCC and poorly compensated cirrhosis and/or portal hypertension. However, the preferred treatment of patients who have early-stage HCC and wellcompensated cirrhosis is not established. Several retrospective studies have evaluated outcomes after liver resection for HCC in this setting, comparing them with those of transplant. However, most are limited by small sample sizes and low statistical power. No prospective studies have been performed on this topic given the inability to randomize patients to liver resection versus transplant. The authors found 2 studies including more than 200 patients. They both suggest that transplant is associated with better survival than liver resection in patients within Milan criteria and Child-Pugh A or B. Nonetheless, it should be noted that graft availability and waiting times for transplant differ between countries, which greatly influences the selection of liver resection versus transplant for patients with early-stage HCC.
The current evidence suggests that, for patients with small HCC lesions (<3 cm), OS is likely to be similar for patients undergoing liver resection versus ablation. For selected patients with multiple HCCs, liver resection may be associated with better OS than TACE. For the past 10 years, sorafenib has been the only effective medical therapy available for unresectable HCC. Recently, several promising new therapies, including multikinase inhibitors and immunotherapies, have been reported. Perioperative use of these new therapies may further improve outcomes in patients undergoing liver resection for HCC and potentially change the current treatment guidelines.
Com imensa satisfação é realizada a 3ª Edição da JORNADA MARANHENSE DE CIRURGIA DIGESTIVA, com abordagem de temas inovadores sobre a cirurgia digestiva, os avanços na medicina em relação a essa especialidade e procedimentos de mínima invasibilidade a fim de atualização e aprendizado da comunidade médica maranhense. Para isso, contamos com grandes nomes da área de Cirurgia do Aparelho Digestivo da região meio-norte brasileiro que trouxeram para a Jornada palestras enriquecedoras e discussões de casos.
“The concept of the critical view was described in 1992 but the term CVS was introduced in 1995 in an analytical review of the emerging problem of biliary injury in laparoscopic cholecystectomy. CVS was conceived not as a way to do laparoscopic cholecystectomy but as a way to avoid biliary injury. To achieve this, what was needed was a secure method of identifying the two tubular structures that are divided in a cholecystectomy, i.e., the cystic duct and the cystic artery. CVS is an adoption of a technique of secure identification in open cholecystectomy in which both cystic structures are putatively identified after which the gallbladder is taken off the cystic plate so that it is hanging free and just attached by the two cystic structures. In laparoscopic surgery complete separation of the body of the gallbladder from the cystic plate makes clipping of the cystic structures difficult so for laparoscopy the requirement was that only the lower part of the gallbladder (about one-third) had to be separated from the cystic plate. The other two requirements are that the hepatocystic triangle is cleared of fat and fibrous tissue and that there are two and only two structures attached to the gallbladder and the latter requirements were the same as in the open technique. Not until all three elements of CVS are attained may the cystic structures be clipped and divided. Intraoperatively CVS should be confirmed in a “time-out” in which the 3 elements of CVS are demonstrated. Note again that CVS is not a method of dissection but a method of target identification akin to concepts used in safe hunting procedures. Several years after the CVS was introduced there did not seem to be a lessening of biliary injuries.
Operative notes of biliary injuries were collected and studied in an attempt to determine if CVS was failing to prevent injury. We found that the method of target identification that was failing was not CVS but the infundibular technique in which the cystic duct is identified by exposing the funnel shape where the infundibulum of the gallbladder joins the cystic duct. This seemed to occur most frequently under conditions of severe acute or chronic inflammation. Inflammatory fusion and contraction may cause juxtaposition or adherence of the common hepatic duct to the side of the gallbladder. When the infundibular technique of identification is used under these conditions a compelling visual deception that the common bile duct is the cystic duct may occur. CVS is much less susceptible to this deception because more exposure is needed to achieve CVS, and either the CVS is attained, by which time the anatomic situation is clarified, or operative conditions prevent attainment of CVS and one of several important “bail-out” strategies is used thus avoiding bile duct injury.
CVS must be considered as part of an overall schema of a culture of safety in cholecystectomy. When CVS cannot be attained there are several bailout strategies such a cholecystostomy or in the case of very severe inflammation discontinuation of the procedure and referral to a tertiary center for care. The most satisfactory bailout procedure is subtotal cholecystectomy of which there are two kinds. Subtotal fenestrating cholecystectomy removes the free wall of the gallbladder and ablates the mucosa but does not close the gallbladder remnant. Subtotal reconstituting cholecystectomy closes the gallbladder making a new smaller gallbladder. Such a gallbladder remnant is undesirable since it may become the site of new gallstone formation and recurrent symptoms . Both types may be done laparoscopically.”
Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101-25.
First described by Pablo Mirizzi in 1948 as “functional hepatic syndrome”, Mirizzi’s syndrome was initially thought to be the result of a “physiologic sphincter” of the hepatic duct. It is now understood to be a result of mechanical obstruction of the common hepatic duct secondary to an impacted stone in the gallbladder neck, Hartmann’s pouch, or the cystic duct. The syndrome is very uncommon in Western populations with a reported prevalence of 0.05%-5.7% in large modern series of patients undergoing biliary surgery. With chronic stone impaction, inflammation and recurrent cholangitis can develop with subsequent erosion into the common bile duct (CBD) and resultant biliobiliary fistula between the gallbladder and CBD.
The syndrome encompasses a spectrum of disease. Broadly speaking, Mirizzi’s syndrome can be grouped into two major categories: (1) external compression of the CBD without a fistula (Type 1), and (2) erosion into the CBD causing a cholecystobiliary fistula (Type II-IV). Csendes classification is currently being used to reflect the above classification. Retrospective studies have identified an association between Mirizzi’s syndrome and gallbladder cancer, with an incidence as high as 28%, relative to an incidence of 1-2% in patients with uncomplicated gallstone disease. As with other malignant processes of the biliary tract, biliary stasis and chronic inflammation have been suggested to play a role. In general, it is difficult to distinguish benign Mirizzi’s syndrome from a neoplastic process preoperatively, although older patient age, significantly elevated Ca 19-9, and imaging features suggestive of invasion into the liver or a mass filling the gallbladder should raise suspicion for malignancy.
The most common presenting symptoms are right upper quadrant pain, jaundice, nausea/vomiting, and fever. This spectrum of findings overlaps with several other pathologic processes of the hepatobiliary tract, making preoperative diagnosis difficult. Additionally, the clinical picture may be complicated by the concurrent presence of acute cholecystitis, pancreatitis, or even gallstone ileus. Mirizzi’s syndrome should be suspected in any patient presenting with right upper quadrant pain and abnormal liver enzymes (particularly elevated bilirubin and alkaline phosphatase) or imaging suggestive of an impacted stone. Three findings on imaging together suggest a diagnosis of Mirizzi’s: 1) dilation of the biliary system above the level of the gallbladder neck, 2) the presence of a stone impacted in the gallbladder neck, and 3) an abrupt change to a normal width of the common duct below the level of the stone. Such findings should prompt further imaging to better define the biliary tree, either indirectly though magnetic resonance cholangiopancreatography (MRCP), or directly through endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC). No imaging modality is entirely sensitive for Mirizzi’s syndrome and the key is to maintain a high index of suspicion.
Management of Mirizzi’s syndrome depends on the degree of fistula. In Type I disease, laparoscopic cholecystectomy is usually achievable, either total (classic) or subtotal, depending on the specific intraoperative findings. If the view of safety can be attained with the critical structures isolated, a classic cholecystectomy may be performed. If the view of safety cannot be achieved due to inflammation or adhesions, the gallbladder is taken down retrograde and opened near the cystic duct orifice. All stones are removed, including any impacted stones, and the cystic duct orifice is examined for the presence of bile to determine whether it is patent. If the cystic duct is patent, it should be ligated (if possible), or the remnant gallbladder should be sutured closed over it (choledochoplasty). An external closed suction drain may be left in the gallbladder fossa and removed the following day if drainage is non-bilious. More commonly, the cystic duct is obliterated, and a subtotal cholecystectomy with removal of all stones is sufficient.
Management of Mirizzi’s syndrome in the presence of a biliobiliary fistula is more complex. If the fistula involves <1/3 of the CBD circumference (Type II), options include primary repair using absorbable suture, closure over a T-tube, or choledochoplasty using the remnant gallbladder. The last approach is preferable to maintain the diameter of the CBD and minimize the risk of subsequent stricture but requires that sufficient gallbladder remnant be available to allow closure. In the presence of a more extensive fistula (Type III or IV), bilioenteric anastomosis is usually the best option.
The global obesity epidemic has dramatically increased the prevalence of NAFLD and made it the leading cause of chronic liver disease in Western nations. NAFLD is considered the hepatic manifestation of the metabolic syndrome and shares a strong association with type 2 diabetes mellitus, obstructive sleep apnea (OSA), and cardiovascular disease. Although cardiovascular disease is the leading cause of death in patients with NAFLD, the subset of patients who meet histopathologic criteria for NASH are those at greatest risk of liver-related morbidity and mortality. Ludwig and colleagues coined the term NASH in 1980 to describe a cohort of middle-aged patients with elevated serum liver enzyme levels who had evidence of alcohol-associated hepatitis on biopsy specimens in the absence of alcohol consumption. Subsequent study led to the proposed “2-hit” hypothesis in which a sequential progression from isolated fatty liver (IFL) to NASH involved the initial “hit” of hepatic steatosis followed by a second “hit” of oxidative stress resulting in liver injury. It was subsequently recognized that patients who have steatohepatitis on a liver biopsy specimen are at greatest risk for progression to cirrhosis compared with those who have IFL. Correspondingly, our understanding of the pathogenesis of NAFLD has evolved from the 2-hit hypothesis. NASH is expected to become the most common cause of cirrhosis and the leading indication for LT in the USA in the 2020s. As a major public health concern, an understanding of its epidemiology and pathogenesis is paramount to facilitate our ability to effectively diagnose and treat patients with NAFLD and NASH.
NAFLD is an increasingly frequent cause of cirrhosis and HCC. In fact, a report published in 2018 listed NAFLD as the second leading non-neoplastic indication for LT in adults in the USA, following alcohol-associated liver disease. Obesity (BMI ≥30 kg/m2) and type 2 diabetes mellitus are commonly encountered in patients with NAFLD; these 2 diseases have been recognized as risk factors for HCC, irrespective of the presence or etiology of cirrhosis. Although BMI is not necessarily a reliable indicator of adiposity in patients with end-stage liver disease, particularly in those with fluid retention and ascites, it is commonly used by many LT centers during the patient selection process. Morbid obesity (BMI ≥40 kg/m2 without significant obesity-related comorbidities or BMI ≥35 kg/m2 associated with obesity-related comorbidities) is commonly regarded as a relative contraindication to LT; however, data from the Organ Procurement and Transplantation Network demonstrate that 16.5% and 5% of patients who underwent LT in 2016 had a BMI greater than or equal to 35 kg/m2 and greater than or equal to 40 kg/m2, respectively.
NAFLD and Liver Transplantation
Analysis of data from the UNOS registry has suggested that the risk of primary graft nonfunction is increased and short- and long-term survival is poorer in morbidly obese liver transplant recipients with various causes of end-stage liver disease. However, when analyzed as an entire cohort and not stratified by BMI, patients with NAFLD have patient and graft survival rates that are comparable to those for other indications for LT. Many of the key precipitants of NAFLD (obesity, hyperlipidemia, and insulin resistance) are exacerbated by immunosuppression. Recurrence of NAFLD after LT causes graft injury, although graft loss does not typically occur. De novo NAFLD after LT has also been described. In the absence of specific therapy for NAFLD, therapeutic efforts after LT should center on weight control, optimal diabetic management, and use of a lipid-lowering agent, if indicated. Intensive noninvasive weight loss interventions pre-LT appear to be successful (reduction of BMI to <35 kg/m2) in a large proportion of patients (84%) enrolled in carefully monitored multidisciplinary protocols; however, 60% of patients regained weight to a BMI ≥35 kg/m2 post-LT. Although bariatric surgery is feasible in selected patients with NAFLD, this intervention is typically reserved for patients with early stages of liver disease and, as is the case for many other abdominal surgical procedures, is contraindicated in those with decompensated cirrhosis because of high morbidity and mortality. A strategy of combining LT with sleeve gastrectomy during the same operation has only been evaluated in small prospective series. The mean surgical time was not significantly different between LT and combined LT/sleeve gastrectomy, and the mean BMI reduction with the combined surgical approach was 20 kg/m2. Metabolic complications, such as post-transplant diabetes mellitus, as well as steatosis of the graft noted by US were significantly less frequent in patients undergoing LT/sleeve gastrectomy compared with patients who lost weight noninvasively pre-LT. The safety and efficacy of this combined surgical approach and other combinations of less invasive weight loss interventions, such as endoscopic techniques, pre-LT must be confirmed by large prospective studies before they can be recommended. Bariatric interventions are still an option post-LT; however, the procedure should be performed by an experienced surgeon, and the role of less invasive endoscopic techniques postLT is still under investigation.
Sleeve Gastrectomy vs NAFLD
Bariatric surgery leads to substantial weight loss that results in improved metabolic parameters and hepatic histology in patients with NAFLD, according to numerous large retrospective and prospective cohort studies. In one study of 109 patients with NASH who underwent follow-up liver biopsy one year after bariatric surgery, 85% of patients had resolution of NASH, and 33% had improvement in fibrosis. Initial concerns that fibrosis would worsen with rapid weight loss were unfounded, as demonstrated in a meta-analysis in which fibrosis improved by 11.9% from baseline after bariatric surgery. Although bariatric surgery is not recommended as a treatment for NASH, the abundant positive data in its favor suggest that surgical weight loss is a viable option for patients with comorbid conditions that would warrant the surgery for other reasons. Patients with NASH cirrhosis are at potentially higher risk for surgical complications, although some centers have demonstrated encouraging results with sleeve gastrectomy in patients with Child-Pugh class A cirrhosis.
Laparoscopic hepatic resection is an emerging option in the field of hepatic surgery. With almost 3000 laparoscopic hepatic resections reported in the literature for benign and malignant tumors, with a combined mortality of 0.3% and morbidity of 10.5%, there will be an increasing demand for minimally invasive liver surgery. Multiple series have been published on laparoscopic liver resections; however, no randomized controlled trial has been reported that compares laparoscopic with open liver resection. Large series, meta-analyses, and reviews have thus far attested to the feasibility and safety of minimally invasive hepatic surgery for benign and malignant lesions.
The conversion rate from a laparoscopic approach to an open procedure was 4.1%. The most common type of laparoscopic liver resection performed is a wedge resection or segmentectomy (45%), followed by left lateral sectionectomy (20%). Major anatomic hepatectomies are still less frequently performed: right hepatectomy (9%) and left hepatectomy (7%). Cumulative morbidity and mortality was 10.5% and 0.3%.
BENEFITS OF LAPAROSCOPIC APPROACH
More importantly, almost all the studies comparing laparoscopic with open liver resection consistently showed a significant earlier discharge to home after laparoscopic liver resection. Lengths of stay were variable based on the country of origin of the studies but were consistently shorter for laparoscopic liver resection. Three studies published in the United States presented a length of stay of 1.9 to 4.0 days after laparoscopic liver resection. Studies from Europe showed an average length of stay of 3.5 to 10 days whereas those from Asia reported an average of length of stay of 4 to 20 days after laparoscopic liver resection.
Vanounou and colleagues used deviation-based cost modeling to compare the costs of laparoscopic with open left lateral sectionectomy at the University of Pittsburgh Medical Center. They compared 29 laparoscopic with 40 open cases and showed that patients who underwent the laparoscopic approach faired more favorably with a shorter length of stay (3 vs 5 days, P<.0001), significantly less postoperative morbidity (P 5 .001), and a weighted-average median cost savings of $1527 to $2939 per patient compared with patients who underwent open left lateral sectionectomy.
Initial concerns about the adequacy of surgical margins and possible tumor seeding prevented the widespread adoption of laparoscopic resection approaches for liver cancers. In comparison studies, there were no differences in margin-free resections between laparoscopic and open liver resection. In addition, no incidence of port-site recurrence or tumor seeding has been reported. With more than 3000 cases of minimally invasive hepatic resection reported in the literature (and no documentation of any significant port-site or peritoneal seeding), the authors conclude that this concern should not prevent surgeons from accepting a laparoscopic approach.
There were no significant differences in overall survival in the 13 studies that compared laparoscopic liver resection with open liver resection for cancer. For example, Cai and colleagues showed that the 1-, 3-, and 5-year survival rates after laparoscopic resection of HCC were 95.4%, 67.5%, and 56.2% versus 100%, 73.8%, and 53.8% for open resection. For resection of colorectal cancer liver metastasis, Ito and colleagues showed a 3-year survival of 72% after laparoscopic liver resection and 56% after open liver resection whereas Castaing and colleagues51 showed a 5-year survival of 64% after laparoscopic liver resection versus 56% after open liver resection.
Compared with open liver resections, laparoscopic liver resections are associated with less blood loss, less pain medication requirement, and shorter length of hospital stay. A randomized controlled clinical trial is the best method to compare laparoscopic with open liver resection; however, such a trial may be difficult to conduct because patients are unlikely to subject themselves to an open procedure when a minimally invasive approach has been shown feasible and safe in experienced hands. In addition, many patients would have to be accrued to detect a difference in complications that occur infrequently. Short of a large randomized clinical trial, meta-analysis and matched comparisons provide the next best option to compare laparoscopic with open liver resection. For laparoscopic resection of HCC or colorectal cancer metastases, there has been no difference in 5-year overall survival compared with open hepatic resection. In addition, from a financial standpoint, the minimally invasive approach to liver resection may be associated with higher operating room costs; however, the total hospital costs were offset or improved due to the associated shorter length of hospital stay with the minimally invasive approach.
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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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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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 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%.
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, PYY increased significantly and ghrelin was suppressed in both groups. It is unclear whether PYY 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 PYY 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.
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.
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.
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.
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.
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).