Arquivos de Tag: DigestiveSurgery

Gallstone Ileus

por Ozimo Gama (PhD) em 26 de fevereiro de 2023 | Deixe um comentário

INTRODUCTION

Gallstone ileus is a misnomer: this condition is not a physiologic ileus at all, but a mechanical obstruction of the intestinal lumen (most commonly the small bowel) by a large gallstone that has passed through a cholecystoenteric fistula. Cholecystoenteric fistulae may occur from the gallbladder to the adjacent luminal viscera-duodenum (most common), stomach, or colon. Gallstone obstruction of the stomach at the pylorus is known as Bouveret’s syndrome. Cholecystocolic fistula is less common. Colonic obstruction in this situation typically occurs at the sigmoid colon. Most common is cholecystoduodenal fistula, with a large (usually >2 cm) gallstone passing through the small bowel and becoming lodged in the terminal ileum. Cholecystoenteric fistula is felt to be caused by a combination of pressure, necrosis, and inflammation with chronic longstanding gallstone disease. Up to 25% of patients who develop gallstone ileus will harbor multiple stones in the alimentary tract; therefore, a close inspection of the entire intestine is important at the time of operation.

CLINICAL PRESENTATION

Over the past few years, however, the incidence of gallstone ileus has been shown to be greater than previously thought. Several recent large population-based series have found that gallstone ileus accounts for approximately 0.1% of all small bowel obstructions. The disease usually affects women (70%) and those in the seventh or eighth decade of life. Most patients present with bloating, crampy abdominal pain, and vomiting, symptoms typical of mechanical small bowel obstruction. A careful history may reveal earlier episodic colicky right upper quadrant abdominal pain consistent with gallstone disease. The classic finding on plain abdominal radiograph is that of Rigler’s triad (pneumobilia, dilated small bowel loops with air-fluid levels, and a large, calcified gallstone in the lumen of the small bowel). Currently, computed tomography (CT) is used ubiquitously. CT has 99% accuracy for diagnosing gallstone ileus. Typical CT findings include pneumobilia, dilated loops of small bowel with air-fluid levels consistent with small bowel obstruction, and transition point with the ectopic stone always visible radiologically.

MANAGEMENT

Operation is required for all patients with gallstone ileus, as spontaneous passage of these large stones is rare once the patient has become symptomatic. It is crucial to optimize the patient physiologically as much as possible in this semi urgent situation, with the understanding that most gallstone ileus patients are elderly and commonly have numerous medical comorbidities. Two contemporary series of registry data have expanded our understanding of gallstone ileus. This condition was once thought to be relatively rare; however, the National Inpatient Sample study identified 3268 gallstone ileus patients, which accounts for approximately 0.1% of all patients admitted to the hospital with mechanical small bowel obstruction during this time period. In this series, overall hospital mortality was substantial at 6.7%. Mortality was significantly higher in patients who underwent cholecystectomy and closure of the biliary fistula compared to those who simply had small bowel obstruction addressed by cholecystolithotomy. Overall, 77% of the 3268 patients had small bowel obstruction pathology treated and the remaining 23% had biliary fistula closed and cholecystectomy at the same operation. An interesting finding was the substantial incidence of postoperative renal insufficiency, or approximately 30% in the entire group of patients. The latter finding highlights the need for preoperative resuscitation and close attention to postoperative fluid management. The surgeon must consider carefully feasibility of same operation intervention to repair biliary pathology: It is safe to defer biliary operation to a later date with a second staged operation. When this strategy of two stage operation is selected, surgeons should consider and counsel their patient regarding the substantial incidence of recurrent biliary symptoms.

Publicado em: Cirurgia do Aparelho Digestivo, Técnica Cirúrgica | Marcado:DigestiveSurgery, Galsstone Ileus, ozimo gama

Laparoscopic Liver Resection

por Ozimo Gama (PhD) em 16 de junho de 2020 | 1 comentário

INTRODUCTION

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.

THECNICAL ASPECTS

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%.

Laparoscopic Left Hepatectomy

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.

COST ANALYSIS

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.

SURGICAL MARGINS

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.

SURVIVAL OUTCOMES

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.

CONCLUSION

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.