Once the decision for surgery has been made, an operative plan needs to be discussed and implemented. Should one initially start with laparoscopic surgery for the “bad gallbladder”? If a laparoscopic approach is taken, when should bail-out maneuvers be attempted? Is converting to open operation still the standard next step? A 2016 study published by Ashfaq and colleagues sheds some light on our first question. They studied 2212 patients who underwent laparoscopic cholecystectomy, of which 351 were considered “difficult gallbladders.” A difficult gallbladder was considered one that was necrotic or gangrenous, involved Mirizzi syndrome, had extensive adhesions, was converted to open, lasted more than 120 minutes, had a prior tube cholecystostomy, or had known gallbladder perforation. Seventy of these 351 operations were converted to open. The indications for conversion included severe inflammation and adhesions around the gallbladder rendering dissection of triangle of Calot difficult (n 5 37 [11.1%]), altered anatomy (n 5 14 [4.2%]), and intraoperative bleeding that was difficult to control laparoscopically (n 5 6 [1.8%]). The remaining 13 patients (18.5%) included a combination of cholecystoenteric fistula, concern for malignancy, common bile duct exploration for stones, and inadvertent enterotomy requiring small bowel repair. Comparing the total laparoscopic cholecystectomy group and the conversion groups, operative time and length of hospital stay were significantly different; 147 +- 47 minutes versus 185 +- 71 minutes (P<.005) and 3+-2 days versus 5+-3 days (P 5 .011), respectively. There was no significant difference in postoperative hemorrhage, subhepatic collection, cystic duct leak, wound infection, reoperation, and 30-day mortality.2 From these findings, we can glean that most cholecystectomies should be started laparoscopically, because it is safe to do so. It is the authors’ practice to start laparoscopically in all cases.
Despite the best efforts of experienced surgeons, it is sometimes impossible to safely obtain the critical view of safety in a bad gallbladder with dense inflammation and even scarring in the hepatocystic triangle. Continued attempts to dissect in this hazardous region can lead to devastating injury, including transection of 1 or both hepatic ducts, the common bile duct, and/or a major vascular injury (usually the right hepatic artery). Therefore, it is imperative that any surgeon faced with a bad gallbladder have a toolkit of procedures to safely terminate the operation while obtaining maximum symptom and source control, rather than continue to plunge blindly into treacherous terrain. If the critical view of safety cannot be achieved owing to inflammation, and when further dissection in the hepatocystic triangle is dangerous, these authors default to laparoscopic subtotal cholecystectomy as our bail-out procedure of choice. The rationale for this approach is that it resolves symptoms by removing the majority of the gallbladder, leading to low (although not zero) rates of recurrent symptoms. It is safe, and can be easily completed laparoscopically, thus avoiding the longer hospital stay and morbidity of an open operation. There is now significant data supporting this approach. In a series of 168 patients (of whom 153 were laparoscopic) who underwent subtotal cholecystectomy for bad gallbladders, the mean operative time was 150 minutes (range, 70–315 minutes) and the average blood loss was 170 mL (range, 50–1500 mL). The median length of stay for these patients was 4 days (range, 1–68 days), and there were no common bile duct injuries.23 There were 12 postoperative collections (7.1%), 4 wound infections (2.4%), 1 bile leak (0.6%), and 7 retained stones (4.2%), but the 30-day mortality was similar to those who underwent a total laparoscopic cholecystectomy. A systematic review and meta-analysis by Elshaer and colleagues showed that subtotal cholecystectomy achieves comparable morbidity rates compared with total cholecystectomy. These data support the idea that we should move away from the idea that the only acceptable outcome for a cholecystectomy is the complete removal of a gallbladder, especially when it is not safe to do so. This shift toward subtotal cholecystectomy has been appropriately referred to as the safety first, total cholecystectomy second approach.
The gold standard for the surgical treatment of symptomatic cholelithiasis is conventional laparoscopic cholecystectomy (LC). The “difficult gallbladder” is a scenario in which a cholecystectomy turns into an increased surgical risk compared with standard cholecystectomy. The procedure may be difficult due to processes that either obscure normal biliary anatomy (such as acute or chronic inflammation) or operative exposure (obesity or adhesions caused by prior upper abdominal surgery). So, when confronted with a difficult cholecystectomy, the surgeon has a must: to turn the operation into a safe cholecystectomy, which can mean conversion (to an open procedure), cholecystostomy, or partial/ subtotal cholecystectomy. The surgeon should understand that needs to rely on damage control, to prevent more serious complications if choosing to advance and progress to a complete cholecystectomy.
When to Predict a Difficult Laparoscopic Cholecystectomy
A difficult cholecystectomy may be predicted preoperatively based on patient characteristics and ultrasound and laboratory findings. This is probably a very important step in mitigating the high risk associated with a difficult procedure and may serve either to reschedule the procedure or design intraoperative strategies of management to guarantee a safe performance of the surgical procedure.
The following situations are associated with a higher chance of a difficult cholecystectomy:
• Acute cholecystitis (more than 5 days of onset)
• Previous cholecystitis episode
• Male sex
• Sclero-atrophic gallbladder
• Thick walls (>5 mm)
• Previous signs of canalicular dwelling (clinical and laboratory)
Through multivariate analysis, Bourgoin identified these elements of predictive help to identify difficult LC: male sex, previous cholecystitis attack, fibrinogen, neutrophil, and alkaline phosphatase levels. Another important point is the fact of conversion from a laparoscopic procedure to an open and traditional cholecystectomy, usually through a right subcostal incision. Conversion should not be considered as a personal failure, and the surgeon needs to understand the concept of “safety first,” considering that conversion is performed in order to complete the procedure without additional risks and preventing complications and not solving intraoperative complications. It is also useful to define a time threshold to aid in the decision to convert. It is not worth taking an hour and a half and still dissecting adhesions, preventing the correct visualization of the cystic pedicle. This time limit represents a method to prevent inefficiencies in the operating room (OR) schedule as well as additional expenditures.
A smart surgeon should rely to conversion in the following situations:
• Lack of progress in the procedure
• Unclear anatomy/any grade of uncertainty
• CVS not achieved
• Bleeding/vascular injury
• BD injury
• Lack of infrastructure, expertise, and support
The primary goal of a laparoscopic cholecystectomy in the treatment of symptomatic cholelithiasis is the safe remotion of the gallbladder and the absence of common bile duct injury. Some tips to take into account:
– Never perform a laparoscopic cholecystectomy without a skilled surgeon close by.
– Beware of the easy gallbladder.
– Slow down, take your time.
– Knowledge is power, conversión can be the salvation!
– Do not repair a bile duct injury (unless you have performed at least 25 hepaticojejunostomies).
– Do not ignore postoperative complaints (pain, jaundice, major abdominal discomfort, fever)
Other options when confronted with a difficult laparoscopic cholecystectomy are:
– A percutaneous cholecystostomy, if the risk was identified preoperatively or the patient is a poor surgical candidate;
– An intraoperative cholangiography, which may aid in identifying an injury to the bile duct and solve it, if you are an experienced surgeon;
– A subtotal or partial cholecystectomy;
– Ask for help;
– Conversion to an open procedure;
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.
“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.
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.
“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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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.
In the setting of a normal ejection fraction, fluid is only administered when the expectation is that cardiac output will increase, and vasopressors are utilized if the aforementioned devices show fluid will not increase cardiac output. Excess fluid in certain general surgical cases can cause ileus and bowel edema, and in cardiac cases, it can cause hemodilution. Patients randomized to restricted and liberal fluid resuscitation strategies found a clear linear relationship between total fluids administered (and weight gain) and complications following colorectal surgery including pulmonary edema and tissue-healing complications. Further multiple studies exist demonstrating fewer complications with normovolemia than with liberal strategies of fluid resuscitation.
It must be understood that goal-directed therapy does, in no way, mean reduction in fluid administration. For some procedures, it may be necessary to administer more than anticipated fluid volumes (orthopedics), while for others, the opposite may be true (abdominal). Normovolemia is important to maintain perfusion without volume overload. Thus, the idea behind goaldirected therapy is to maintain zero fluid balance coupled with minimal weight gain or loss. Hypovolemia is associated with reduced circulating blood volume, decreased renal perfusion, altered coagulation, microcirculation compromise, and endothelial dysfunction, among other processes. Hypervolemia is associated with splanchnic edema, decreased pulmonary gas exchange secondary to pulmonary edema, impaired wound healing, anastomotic dehiscence, decreased mobility, altered coagulation, and endothelial dysfunction, amidst others processes.
From a recent Cochrane review, there is no evidence that colloids are superior to crystalloid for resuscitation in patients. Therefore, crystalloid fluids should generally be the primary intravenous fluid during the perioperative course. In cardiac surgery, the utilization of 0.9% normal saline solution was associated with hyperchloremia and poor postoperative outcomes, including higher length of stay and increased mortality.118 Further, a more balanced crystalloid, such as Plasma-Lyte, was associated with improved outcomes in 22,851 surgical patients. In this study, there was a 2.05 odds ratio predictor of mortality with normal saline. Other complications such as acute kidney injury, gastrointestinal complications, major hemorrhage, and major infection were also increased in the group of
patients that were hyperchloremic after normal saline administration. Based on such evidence, it would seem prudent to proceed with a more balanced solution, such as PlasmaLyte, to reduce complications.
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.
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.
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In both the UK and the USA the annual death rate due to inguinal and femoral hernia has decreased in the last two to three decades. In the UK, deaths for inguinal and femoral hernia declined from 22 to 55% respectively from 1975 to 1990. The annual deaths in the USA per 100,000 population for patients with hernia and intestinal obstruction decreased from 5.1 in 1968 to 3.0 in 1988. For inguinal hernia with obstruction, 88% of patients underwent surgery with a mortality rate of 0.05%. These figures could be interpreted as showing that elective groin hernia surgery has reduced overall mortality rates.
In support of this contention is the fact that strangulation rates are lower in the USA than in the UK, which could be a consequence of the three times higher rate of elective hernia surgery in the USA. Even so, the available statistics show that rates of elective hernia surgery in the USA per 100,000 population fell from 358 to 220 between 1975 and 1990, although this may be an artifact of the data collection systems rather than a real decline.
During the period 1991–1992, 210 deaths occurring following inguinal hernia repair and 120 deaths following femoral hernia repair were investigated by the UK National Confidential Enquiry Into Perioperative Deaths. This enquiry is concerned with the quality of delivery of surgery, anesthesia, and perioperative care. Expert advisers compare the records of patients who have died with index cases. In this group of 330 patients many were elderly (45 were aged 80–89 years) and significantly infirm unfit; 24 were ASA grade III and 21 ASA grade IV. Postoperative mortality was attributed to preexisting cardiorespiratory problems in the majority of cases. In a nationwide study in Denmark of 158 patients dying after acute groin hernia repair, Kjaergaard et al. also found that these patients were old (median age 83 years) and fragile (>80% with significant comorbidity), with frequent delay in diagnosis and subsequent treatment. Clearly this group of patients requires high-quality care by an experienced surgeon and anesthetist with skills equivalent to that of the ASA grade of the patient.
Postoperative care should necessarily take place in a high-dependency unit or intensive therapy unit; this may necessitate transfer of selected patients to appropriate hospitals and facilities. Sensible decisions must be made in consultation with relatives of extremely elderly, frail, or moribund patients to adopt a humane approach, which may rule out interventional surgery.
Forty percent of patients with femoral hernia are admitted as emergency cases with strangulation or incarceration, whereas only 3% of patients with direct inguinal hernias present with strangulation. This clearly has implications for the prioritization on waiting lists when these types of hernia present electively to outpatient clinics. A groin hernia is at its greatest risk of strangulation within 3 months of its onset. For inguinal hernia at 3 months after presentation, the cumulative probability of strangulation is 2.8%, rising to 4.5% after 2 years. For femoral hernia the risk is much higher, with a 22% probability of strangulation at 3 months after presentation rising to 45% at 21 months. Right-sided hernias strangulate more frequently than left-sided hernias; this is possibly related to mesenteric anatomy.
In a randomized trial, evaluating an expectative approach to minimally symptomatic inguinal hernias, Fitzgibbons et al. in the group of patients randomized to watchful waiting found a risk of an acute hernia episode of 1.8 in 1,000 patient years. In another trial, O’Dwyer and colleagues, randomizing patients with painless inguinal hernias to observation or operation, found two acute episodes in 80 patients randomized to observation. In both studies, a large percentage of patients randomized to nonoperative care were eventually operated due to symptoms. Neuhauser, who studied a population in Columbia where elective herniorrhaphy was virtually unobtainable, found an annual rate of strangulation of 0.29% for inguinal hernias.
Management of Strangulation
Diagnosis is based on symptoms and signs supplemented by diagnostic imaging when indicated. Pain over the hernia site is invariable, and obstruction with strangulation of intestine will cause colicky abdominal pain, distension, vomiting, and constipation. Physical examination may reveal degrees of dehydration with or without CNS depression, especially in the elderly if uremia is present, together with abdominal signs of intestinal obstruction. Femoral hernias can be easily missed, especially in the obese female, and a thorough examination should be performed in order to make the correct diagnosis. Frequently, however, physical examination alone is insuf fi ciently accurate to con fi rm the presence of a strangulating femoral hernia vs. lymphadenopathy vs. a lymph node abscess. In these instances, one may elect to perform radiographic studies such as an ultrasound or a CT scan on an urgent or emergent basis.
The choice of incision will depend on the type hernia if the diagnosis is confi dent. When the diagnosis is in doubt, a half Pfannenstiel incision 2 cm above the pubic ramus, extending laterally, will give an adequate approach to all types of femoral or inguinal hernia. The fundus of the hernia sac can then be approached and exposed and an incision made to expose the contents of the sac. This will allow determination of the viability of its contents. Nonviability will necessitate conversion of the transverse incision into a laparotomy incision followed by release of the constricting hernia ring, reduction of the contents of the sac, resection, and reanastomosis. Precautions should be taken to avoid contamination of the general peritoneal cavity by gangrenous bowel or intestinal contents. In the majority of cases, once the constriction of the hernia ring has been released, circulation to the intestine is reestablished and viability returns. Intestine that is initially dusky, aperistaltic, or dull in hue may pink up with a short period of warming with damp packs once the constriction band is released. If viability is doubtful, resection should be performed. Resection rates are highest for femoral or recurrent inguinal hernias and lowest for inguinal hernias. Other organs, such as bladder or omentum, should be resected, as the need requires. After peritoneal lavage and formal closure of the laparotomy incision, specific repair of the groin hernia defect should be performed. In this situation prosthetic mesh should not be used in an operative fi eld that has been contaminated and in which there is a relatively high risk of wound infection. The hernia repair should follow the general principles for elective hernia repair. It should be kept in mind, that in this group of predominantly frail and elderly patients with a very high postoperative mortality risk, the primary objective of the operation is to stop the vicious cycle of strangulation, and only secondary to repair the hernia defect.
The risk of an acute groin hernia episode is of particular relevance, when discussing indication for operation of painless or minimally symptomatic hernias. A sensible approach in groin hernias would be, in accordance with the guidelines from the European Hernia Society to advise a male patient, that the risk of an acute operation, with an easily reducible (“disappears when lying down”) inguinal hernia with little or no symptoms, is low and that the indication for operation in this instance is not absolute, but also inform, that usually the hernia after some time will cause symptoms, eventually leading to an operation. In contrast, female patients with a groin hernia, due to the high frequency of femoral hernias and a relatively high risk of acute hernia episodes, should usually be recommended an operation.
The incidence of choledocholithiasis in patients undergoing cholecystectomy is estimated to be 10 %. The presence of common bile duct stones is associated with several known complications including cholangitis, gallstone pancreatitis, obstructive jaundice, and hepatic abscess. Making the diagnosis early and prompt management is crucial. Traditionally, when choledocholithiasis is identified with intraoperative cholangiography during the cholecystectomy, it has been managed surgically by open choledochotomy and place- ment of a T-tube. This open surgical approach has a morbidity rate of 10–15 %, mortality rate of <1 %, with a <6 % incidence of retained stones. Patients who fail endoscopic retrieval of CBD stones, as well as cases in which an endoscopic approach is not appropriate, should be explored surgically.
Acute obstruction of the bile duct by a stone causes a rapid distension of the biliary tree and activation of local pain fibers. Pain is the most common presenting symptom for choledocholithiasis and is localized to either the right upper quadrant or to the epigastrium. The obstruction will also cause bile stasis which is a risk factor for bacterial over- growth. The bacteria may originate from the duodenum or the stone itself. The combination of biliary obstruction and colo- nization of the biliary tree will lead to the development of fevers, the second most common presenting symptom of cho- ledocholithiasis. Biliary obstruction, if unrelieved, will lead to jaundice. When these three symptoms (pain, fever, and jaundice) are found simultaneously, it is known as Charcot’s triad. This triad suggests the diagnosis of acute ascending cholangitis, a potentially life-threatening condition. If not treated promptly, this can lead to hypotension and decreased metal status, both signs of severe sepsis. When combined with Charcot’s triad, this constellation of symptoms is commonly referred to as Reynolds pentad.
Laparoscopic common bile duct exploration
Laparoscopic common bile duct exploration (LCBDE) allows for single stage treatment of gallstone disease, reducing overall hospital stay, improving safety and cost-effectiveness when compared to the two-stage approach of ERCP and laparoscopic cholecystectomy. Bile duct clearance can be confirmed by direct visualization with a choledochoscope. But, before the advent of choledochoscope, bile duct clearance was uncertain, and blind instrumentation of the duct resulted in accentuated edema and inflammation. Due to advancement in instruments, optical magnification, and direct visualization, laparoscopic exploration of the CBD results in fewer traumas to the bile duct. This has led to an increasing tendency to close the duct primarily, reducing the need for placement of T-tubes. Still, laparoscopic bile duct exploration is being done in only a few centers. Apart from the need for special instruments, there is also a significant learning curve to acquire expertise to be able to perform a laparoscopic bile duct surgery.
Morbidity and mortality rates of laparoscopic exploration are comparable to ERCP (2–17 and 1–5 %), and there is no clear difference in primary success rates between the two approaches. However, the endoscopic approach may be preferable for elderly and frail patients, who are at higher risk with surgery. Patients older than 70–80 years of age have a 4–10 % mortality rate with open duct exploration. It may be as high as 20 % in elderly patients undergoing urgent procedures. In comparison, advanced age and comor- bidities do not have a significant impact on overall complication rates for ERCP. A success rate of over 90 % has been reported with laparoscopic CBD exploration. Availability of surgical expertise and appropriate equipment affect the success rate of laparoscopic exploration, as does the size, number of the CBD stones, as well as biliary anatomy. Over the years, laparoscopic exploration has become efficient, safe, and cost effective. Complications include CBD laceration, stricture formation, bile leak, abscess, pancreatitis, and retained stones.
In cases of failure of laparoscopic CBD exploration, a guidewire or stent can be passed through the cystic duct, common bile duct, and through the ampulla into the duodenum followed by cholecystectomy. This makes the identification and cannulation of the ampulla easier during the post- operative ERCP. Laparoscopic common bile duct exploration is traditionally performed through a transcystic or transductal approach. The transcystic approach is appropriate under certain circumstances. These include a small stone (<10 mm) located in the CBD, presence of small common bile duct (<6 mm), or if there is poor access to the common duct. The transductal approach is preferable in cases of large stones, stones in proximal ducts (hepatic ducts), large occluding stones in a large duct, presence of multiple stones, or if the cystic duct is small (<4 mm) or tortuous. Contraindications for laparoscopic approach include lack of training, and severe inflammation in the porta hepatis making the exploration difficult and risky.
With advancement in imaging technology, laparoscopic and endoscopic techniques, management of common bile duct stone has changed drasti- cally in recent years. This has made the treatment of this condition safe and more efficient. Many options are now available to manage this condition, and any particular modality for treatment should be chosen carefully based on the patient related factors, institutional protocol, available expertise, resources, and cost-effectiveness.
Patients with acute appendicitis can present at different stages of the disease process, ranging from mild mucosal inflammation to frank perforation with abscess formation. The reported overall incidence of acute appendicitis varies with age, gender, and geographical differences. Interestingly, while the incidence of non-perforated appendicitis in the United States decreased between 1970 and 2004, no significant decline in the rate of perforated appendicitis was observed despite the increasng use of computed tomography (CT) and fewer negative appendectomies.
Of 32,683 appendectomies sampled from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) hospitals between 2005 and 2008, 5,405 patients (16.5%) had a preoperative diagnosis of acute appendicitis with peritonitis/abscess.
The definition of complicated appendicitis varies slightly in the literature. Clinicopathological diagnoses (gangrenous, perforated, appendiceal abscess/phlegmon) of acute appendicitis are commonly used for its definition. Classically, patients at the extremes of age are more likely to present with complicated appendicitis. Similarly, pre-morbid conditions including diabetes and type of medical insurance are significantly associated with the risk of perforation.
The importance of early appendectomy has also been emphasized to prevent perforation of the appendix and the sub- sequent negative impact on patient outcomes. However, more recent meta-analysis data supports the safety of a relatively short (12–24 h) delay before appendectomy, which was not significantly associated with increased rate of complicated appendicitis. Teixeira et al. also showed that the time to appendectomy was not a significant risk factor for perforated appendicitis but did result in a significantly increased risk of surgical site infection.
The outcome of patients with complicated appendicitis is significantly worse than patients with uncomplicated appendicitis. A population-based study from Sweden showed that, in a risk-adjusted model, patients with perforated appendicitis were 2.34 times more likely to die after appendectomy than non- perforated appendicitis patients. Because of its higher mortality and morbidity in patients with complicated appendicitis, the management of complicated appendicitis has evolved significantly over the last few decades.
Open or Laparoscopic Surgery
Since the first laparoscopic appendectomy was described by Semm in 1983, multiple studies have compared operative time, complication rates, length of hospital stay, hospital cost, and other outcomes between open and laparoscopic appendectomy for acute appendicitis. The most recent Cochrane review included 67 studies showing that laparoscopic appendectomy was associated with a lower incidence of wound infection, reduced postoperative pain, shorter postoperative length of hospital stay, and faster recovery to daily activity. In contrast, reduced risk of intra-abdominal abscesses and shorter operative time were found as the advantages of open appendectomy.
Due to increased surgeon experience in uncomplicated appendicitis, laparoscopic appendectomy is more frequently attempted even in complicated appendicitis cases as an alternative approach to open appendectomy. Although the general surgical steps for complicated appendicitis are similar to those for uncomplicated appendicitis, the laparoscopic procedure can be more technically demanding. Therefore, conversion from laparoscopic appendectomy to open appendectomy can be expected.
Despite these concerns, the laparoscopic approach in patients with com- plicated appendicitis has been proven to be safe and comparable to open appendectomy. Retrospective studies using a large database in the United States uniformly showed more favorable clinical outcomes (mortality, morbidity, length of hospital stay, readmission rate) and hospital costs in patients who underwent laparoscopic appendectomy when compared to open appendectomy. The real risk of developing an intra- abdominal abscess after laparoscopic appendectomy remains unclear. A meta-analysis by Markides et al. found no significant difference in the intra-abdominal abscess rate between laparoscopic and open appendectomy for complicated appendicitis, whereas Ingraham et al. showed a higher likelihood of developing an organ-space surgical site infection in patients undergoing laparoscopic appendectomy.
Estima-se que atualmente 90% das colecistectomias sejam realizadas pela técnica laparoscópica, percentual este atingido nos Estados Unidos da América no ano de 1992. Os motivos para tal preferência na escolha da técnica cirúrgica aplicada são claros: menor dor no pós-operatório, recuperação pós-cirúrgica mais rápida, menor número de dias de trabalho perdidos e menor tempo de permanência hospitalar. A colecistectomia laparoscópica foi claramente estabelecida como padrão-ouro para o tratamento cirúrgico da litíase biliar, no entanto 2 a 15% das colecistectomias vídeolaparoscópicas necessitam de conversão para cirurgia convencional, sendo as razões mais comuns a inabilidade para se identificar corretamente a anatomia, suspeita de lesão da árvore biliar e sangramento. A identificação dos fatores associados a um maior índice de conversão possibilita à equipe cirúrgica estimar o grau de dificuldade do procedimento, preparando melhor o paciente para o risco de conversão e permitindo a participação de um cirurgião mais experiente num procedimento de maior risco.
Relacionados ao Paciente: 1. Obesidade (IMC > 35), 2. Sexo Masculino, 3. Idade > 65 anos, 4. Diabetes Mellitus e 5. ASA > 2.
Relacionadas a Doença: 1. Colecistite Aguda, 2. Líquido Pericolecístico, 3. Pós – CPRE, 4. Síndrome de Mirizzi e 5. Edema da parede da vesícula > 5 mm.
Relacionadas a Cirurgia: 1. Hemorragia, 2. Aderências firmes, 3. Anatomia obscura, 4. Fístulas internas e 5. Cirurgia abdominal prévia.
The morbid obesity epidemic continues to spread throughout industrialized nations. It is a condition with a heterogeneous etiology, including genetic, psychosocial, and environmental factors. Prevention methods have currently been unable to halt the further spread of this disease. Obesity has been linked to increased healthcare costs, common physiologic derangements, reduced quality of life, and increased overall mortality. More than one third of adults and almost 17% of children in the United States are obese.
Medical therapy that can cause sustained significant weight loss may be years away. Bariatric surgery, when combined with a multidisciplinary team, continues to be the only proven method to achieve sustained weight loss in most patients. Bariatric procedures modify gastrointestinal anatomy and, in some cases, enteric hormone release to reduce caloric intake, reduce absorption, and alter metabolism to achieve weight loss. Currently, the three most common bariatric operations in the United States are Roux-en-Y gastric bypass, adjustable gastric band, and the vertical sleeve gastrectomy.
O objetivo do cirurgião ao realizar qualquer intervenção é que esta seja segura e eficiente. O procedimento deve ser o mais rápido possível, com o menor trauma tecidual, restaurando a função, e conseqüentemente diminuindo ao máximo as possibilidades de intercorrências no pós-operatório. A moderna cirurgia atinge estes objetivos de forma bastante satisfatória, porém, as complicações relacionadas às suturas ainda ocorrem com alguma freqüência. Foi somente no final do século XIX, que as suturas gastrointestinais adquiriram confiabilidade, com o conhecimento básico dos princípios da cicatrização dos tecidos. Os fatores envolvidos no reparo tecidual relacionam-se não só à técnica, mas também ao paciente individualmente, e à área a ser operada. A presença de isquemia, edema, infecção e desnutrição são alguns dos elementos que retardam e prejudicam a cicatrização. A variação na habilidade dos cirurgiões serviu de motivação para o desenvolvimento de dispositivos, que superando as diferenças individuais, permitissem que as técnicas fossem executadas adequadamente, e cujo resultado final fosse o melhor possível. Toda técnica deve ser reproduzida de forma confiável pelo maior número de cirurgiões para que seus resultados sejam adotados e reconhecidos como eficazes.
With the introduction of laparoscopic colectomy nearly 20 years ago, a relatively slow adoption of laparoscopic colorectal surgery into surgical practice has taken place. It is estimated that 10% to 25% of all colorectal resections are performed utilizing laparoscopy. The persistent steep learning curve, the lack of high-volume colorectal surgery by general surgeons (who perform the bulk of colonic resection in the United States), and the modest advantages reported are but a few of the reasons that the percentage of laparoscopic colorectal procedures has not dramatically risen. With the publication of several large, prospective randomized trials for colon cancer, along with the interest in single-port surgery and natural orifice surgery, there appears to be a renewed interest in minimally invasive procedures for the colon and rectum. This chapter will provide an overview of these issues and offer a current assessment of the common diseases to which minimally invasive techniques have been applied.
Numerous previous studies have evaluated the learning curve involved in laparoscopic colectomy. It is estimated by conventional laparoscopic techniques that the learning curve for laparoscopic colectomy is at least 20 cases but more likely 50 cases. The need to work in multiple quadrants of the abdomen, the need for a skilled laparoscopic assistant, and the lack of yearly volume has kept the learning curve relatively steep. The surgeon may also need to work in reverse angles to the camera. All of these combined add to the complexity of the procedure and result in the need to perform a number of cases before the surgeon and surgical team become proficient. More recent publications have suggested the learning curve is more than 20 cases. In a prospective randomized study of colorectal cancer in the United Kingdom, the CLASICC trial, surgeons had to perform at least 20 laparoscopic resections before they were allowed to enter the study. The study began in July 1996 and was completed in July 2002. Despite the surgeons’ prior experience, the rate of conversion dropped from 38% to 16% over the course of the study, suggesting that a minimum of 20 cases may not be enough to overcome the learning curve. In the COLOR trial from Europe, another prospective randomized study for colon cancer that required a prerequisite experience in laparoscopic colon resection before surgeons could enter patients in the study, surgeon and hospital volume were directly related to a number of operative and postoperative outcomes. The median operative time for high-volume hospitals (>10 cases/year) was 188 minutes, compared to 241 minutes for low-volume hospitals (<5 cases/year); likewise, conversion rates were 9% versus 24% for the two groups. High-volume groups also had more lymph nodes in the resected specimens, fewer complications, and shortened hospital stays. These two relatively recent multicenter studies suggest that the learning curve is clearly greater than 20 cases and that surgeons need to perform a minimum yearly number of procedures to maintain their skills.
There may not be another area in recent surgical history that has been more heavily scrutinized than laparoscopic colorectal surgery. The plethora of accumulated data allows a careful assessment of all outcome measures for nearly every colorectal disease and procedure. In comparison to conventional colorectal surgery, the benefits of laparoscopy for colorectal procedures compared to open techniques include a reduction in postoperative ileus, postoperative pain, and a concomitant reduction in the need for analgesics; an earlier tolerance of diet; a shortened hospital stay; a quicker resumption of normal activities; improved cosmesis; and possibly preservation of immune function. This is offset by a prolongation in operative time, the cost of laparoscopic equipment, and the learning curve for these technically challenging procedures. When reporting the outcomes of laparoscopic colectomy, a natural selection bias applies when comparing conventional and laparoscopic cases. The most complex cases are generally not suitable for a laparoscopic approach and therefore are performed via an open approach. Also, in many series the results of the successfully completed laparoscopic cases are compared to conventional cases, and the cases converted from a laparoscopic to a conventional procedure may be analyzed separately. Few studies, with the exception of the larger prospective randomized studies, leave the converted cases in the laparoscopic group as part of the “intention to treat” laparoscopic group. This clearly introduces selection bias.
Although the results of prospective randomized trials are available for almost every disease process requiring colorectal resection, the majority of studies of laparoscopic colectomy are retrospective case-control series or noncomparative reports. The conclusions regarding patient outcomes must therefore come from the repetitiveness of the results rather than the superiority of the study design. For any one study, the evidence may be weak; but collectively, because of the reproducibility of results by a large number of institutions, even with different operative techniques and postoperative management parameters, the preponderance of evidence favors a minimally invasive approach with respect to postoperative outcomes.
Nearly all the comparative studies provide information regarding operative times. The definition of the operative time may vary with each series, and there may be different groups of surgeons performing the laparoscopic and conventional procedures. With the exception of a few reports, nearly all studies demonstrated a prolonged operative time associated with laparoscopic procedures. In prospective randomized trials, the procedure was roughly 40 to 60 minutes longer in the laparoscopic groups. As the surgeon and team gain experience with laparoscopic colectomy, the operating times do reliably fall, but rarely do they return to the comparable time for a conventional approach.
Return of Bowel Activity and Resumption of Diet
Reduction in postoperative ileus is one of the proposed major advantages of minimally invasive surgery. Nearly all of the retrospective and prospective studies comparing open and laparoscopic colectomy have shown a statistically significant reduction in the time to passage of flatus and stool. Most series demonstrate a 1- to 2-day advantage for the laparoscopic group. Whether the reduction of ileus relates to less bowel manipulation or less intestinal exposure to air during minimally invasive surgery remains unknown. With the reduction in postoperative ileus, the tolerance by the patient of both liquids and solid foods is quicker following laparoscopic resection. The time to resumption of diet varies from 2 days to 7 days, but in the majority of comparative studies, this is still 1 to 2 days sooner than in patients undergoing conventional surgery. Again, the physician and patient were not blinded in nearly all studies, which may have altered patient expectations. However, the overwhelming reproducible data reported in both retrospective and prospective studies of laparoscopic procedures does likely favor a reduction of postoperative ileus and tolerance of liquid and solid diets.
To measure postoperative pain, a variety of assessments have been performed to demonstrate a significant reduction in pain following minimally invasive surgery; some studies utilize an analog pain scale, and others measure narcotic requirements. Physician bias and psychologic conditioning of patients may interfere with the evaluation of postoperative pain. There are also cultural variations in the response to pain. Three of the early prospective randomized trials have evaluated pain postoperatively, and all three have found a reduction in narcotic requirements in patients undergoing laparoscopic colectomy. In the COST study, the need both for intravenous and oral analgesics was less in patients undergoing successfully completed laparoscopic resections. Numerous other nonrandomized studies have shown a reduction in postoperative pain and narcotic usage.
Length of Stay
The quicker resolution of ileus, earlier resumption of diet, and reduced postoperative pain has resulted in a shortened length of stay for patients after laparoscopic resection when compared to traditional procedures. Recovery after conventional surgery has also been shortened, but in the absence of minimally invasive techniques, it would seem unlikely that the length of stay could be further reduced. In nearly all comparative studies, the length of hospitalization was 1 to 6 days less for the laparoscopic group. Although psychological conditioning of the patient cannot be helped and likely has a desirable effect, the benefits of minimally invasive procedures on the overall length of stay cannot be discounted. The benefit, however, is more likely a 1 to 2 day advantage only. The more recent introduction of clinical pathways, both in conventional and laparoscopic surgery, has also narrowed the gap but appears to be more reliable in patients undergoing a minimally invasive approach.
One of the disadvantages of laparoscopy is the higher cost related to longer operative times and increased expenditures in disposable equipment. Whether the total cost of the hospitalization (operative and hospital costs) is higher following laparoscopic colectomy is debatable. A case-control study from the Mayo Clinic looked at total costs following laparoscopic and open ileocolic resection for Crohn’s disease (CD). In this study, 66 patients underwent laparoscopic or conventional ileocolic resection and were well matched. Patients in the laparoscopic group had less postoperative pain, tolerated a regular diet 1 to 2 days sooner, and had a shorter length of stay (4 vs. 7 days). In the cost analysis, despite higher operative costs, the overall mean cost was $3273 less in the laparoscopic group. The procedures were performed by different groups of surgeons at the institution, and although the surgeons may have introduced biases, this study was undertaken during the current era of cost containment, in which all physicians are encouraged to reduce hospital stays. The results are similar for elective sigmoid diverticular resection with a mean cost savings of $700 to $800. Clearly, if operative times and equipment expenditure are minimized, the overall cost of a laparoscopic resection should not exceed a conventional approach.
O aumento da prevalência de doença diverticular fez o seu adequado manuseio mais um assunto de debate constante. Especialmente para os casos de diverticulite, progresso considerável tem sido feito em termos de diagnóstico e tratamento. Diagnóstico apropriado em TC e técnicas intervencionistas são agora amplamente disponíveis, bem como agentes antimicrobianos eficazes. Finalmente, como a ressecção cirúrgica do cólon envolvido é a única maneira de erradicar definitivamente essa condição, a colectomia eletiva laparoscópica surgiu como uma opção segura e interessante entre as opções de tratamento. Embora tenha sido recentemente contestada sobre a sua progressão, a história natural da diverticulite é assumida como sendo a de recorrência ao longo do tempo, pelo menos, em um terço dos pacientes. O medo das complicações desta doença benigna e prevalente tem motivado sociedades médicas e cirúrgicas para produzir orientações e consensos sobre o assunto. A mortalidade geralmente vem de sepse recorrente e/ou operações de emergência para casos mais complicados. Como resultado, o procedimento cirúrgico mais realizado, a sigmoidectomia eletiva, é normalmente indicada para todos os casos complicados e muitos dos não-complicados. A abordagem laparoscópica para a colectomia esquerda tem evoluído e condições seguras são oferecidas aos pacientes, quando realizado por cirurgiões experientes em laparoscopia.
A via laparoscópica tem sido reconhecida como padrão de excelência para a colecistectomias. Phillipe Mouret foi quem primeiro a realizou em 1987, mas outros procedimentos já haviam sido realizados por laparoscopia e foram descritos por ginecologistas. Desenvolvida no final da década de 80 e início dos anos 90, a videolaparoscopia mudou os conceitos de acesso cirúrgico e campo operatório, introduzindo a concepção de “cirurgia minimamente invasiva”.A colecistectomia é um dos procedimentos cirúrgicos mais realizados no mundo. Com o advento da videolaparoscopia, tornou-se uma cirurgia menos traumática, mais estética, com períodos mais curtos de internação. Em contrapartida, observou-se o aumento da incidência de lesões de via biliar extra-hepática quando comparado ao procedimento aberto, fato preocupante devido à morbidade elevada desse tipo de lesão, cuja mortalidade não é desprezível.