Thursday 29 May 2003
11:00–12:30
Free Papers
Session I
Liver Transplantation – I
(DOI 10.1080/16515320310001291)
1
A STUDY ON HUMAN LIVER ICAM-1 EXPRESSION AND ITS CORRELATION WITH POST-TRANSPLANT ACUTE CELLULAR REJECTION
El-Wahsh M, Fuller B, Rolles K and Davidson B
Liver Transplant Unit, University Department of Surgery, Royal Free and University College Medical School, University College London, The Royal Free Hospital, London, UK
Aim: To investigate a correlation between ICAM-1 expression with early (ACR1) and delayed (ACR2) post-transplant acute cellular rejection (ACR).
Methods: Biopsies were taken 90 min post-reperfusion (85 allografts). Routine postoperative biopsy at day 7 was taken, additional biopsy was taken at the end of week 2 or 3 when there is a suspicion of ongoing rejection. Rejection was graded according to the Royal Free novel scoring system. ICAM-1 expression was demonstrated by immuonocytochemistry technique.
Results: In post-reperfusion biopsies, 44/85 had mild ICAM-1 expression, of these only 14% developed moderate-severe ACR1 that required medical intervention. 23/85 had moderate ICAM-1 expression, of these 57% had moderate-severe ACR1. 18/85 had intense expression, in this group all allografts (100%) had moderate-severe ACR1. There was a significant correlation between post-reperfusion ICAM-1 expression and the development of early acute 0.0001. In delayed rejection 44/85 allografts had mild ICAM-1 rejection, p expression, of these 9/44 had no post- transplant biopsy as the patients were doing well and 15/44 (34%) had moderate-severe ACR2. 23/85 allografts had moderate ICAM-1 expression, of these 3/23 had no post-transplant biopsy and 13/23 (57%) had moderate-severe ACR2. 18/85 had intense ICAM-1 expression, of these 4/18 had no post-transplant biopsy and 13/18 (72%) had moderate-severe ACR2. There was a significant correlation between post-reperfusion ICAM-1 0.05.
Conclusion: ICAM-1 expression (as expression and late acute rejection, p early as 90 minutes post-reperfusion) correlates significantly with early and late rejection episodes. Perhaps this can lead the way to prophylactic treatment to prevent ACR before it becomes fully manifested.
2
EFFECT OF ISCHAEMIC PRECONDITIONING ON HEPATIC MICROCIRCULATION DURING ISCHAEMIA-REPERFUSION INJURY IN A RABBIT MODEL OF MODERATE AND SEVERE HEPATIC STEATOSIS
Yang WX, Glantzounis GK, Winslet MC, Seifalian AM, Davidson BR
University Department of Surgery, Royal Free and University College Medical School, London, UK
Background/aims: Impaired microcirculation in fatty liver has been proposed as an important factor in decreased tolerance of the liver to ischaemia-reperfusion injury. The present study aimed to investigate the effect of ischaemic preconditioning (IPC) on hepatic microcirculation (HM) in a rabbit model of hepatic steatosis.
Methods: NZ female rabbits were fed a 2% cholesterol diet for 8 and 12 weeks to induce moderate and severe hepatic steatosis. All animals were subjected to 60 min of liver lobar ischaemia followed by 7 h of reperfusion with (IPC, n = 12) or without IPC (Control, n = 12). Arterial blood pressure, oxygen saturation and heart rate were monitored continuously. HM was assessed by laser Doppler flowmeter. At the end of the reperfusion, indocyanine green (ICG, 0.5 mg/kg) clearance was measured directly by near infrared spectroscopy.
Results: In moderate steatosis, HM in the control group decreased significantly after 7 h of reperfusion (94.0±5.0 vs 73.3±3.3 flux unit, p < 0.01, baseline vs 7 h), while there was no significant deterioration in HM during the reperfusion period in the IPC group. There were significant differences in HM between control and IPC groups at the 7th hour of reperfusion (73.3±3.3 vs 118.3±16.2 flux unit, p < 0.05). The rates of ICG clearance were 57.8±13.5% and 44.4±4.0% in control and IPC groups, respectively. In severe steatosis, HM in the IPC group remained unchanged as compared with baseline, but it decreased significantly in the control group at the end of reperfusion (85.6±4.2 vs 65.8±4.3 flux unit, p < 0.05). The IPC group showed better ICG clearance as compared with control group (66.2±3.9% vs 46.3±11.6%), but the differences were not statistically significant.
Conclusions: The data suggest that IPC has a protective effect on the hepatic microcirculation in fatty liver during ischaemia-reperfusion injury.
3
IS THE USE OF ISCHAEMIC PRECONDITIONING WORTHWHILE IN LIVER TRANSPLANTATION?
Berrevoet F, Schäfer T, Vollmar B, Menger M
University Hospital Ghent, Laarne, Belgium
Aim: Ischaemic preconditioning (IP) is a process whereby a brief ischaemic episode confers a state of protection against subsequent long-term ischaemia-reperfusion injury. The current experimental study was designed to evaluate the ability of IP to protect liver grafts from injury after cold storage and reperfusion.
Methods: Sprague Dawley rats (weight range 200–300 g) were used as donors and treated with ischaemic preconditioning (group 1). Female age-matched untreated animals served as controls (group 2). After laparotomy with cannulation of the common bile duct and intra-arterial application of bis-benzimide, portal vein and hepatic artery were clamped for 10 min in group 1. Reflow was initiated by removal of the clamps for another 10 min. Livers were harvested via aortal perfusion with 100 ml of 4 °C HTK solution and stored in cold HTK solution for 24 h. In anaesthetised, sham-treated animals, the abdomen was opened for 20 min and the livers were harvested in a similar fashion. After 24 h of cold storage the livers were rinsed with 10 ml of Ringer's lactate solution and then reperfused at 10 ml/ min for 3 h through the portal vein using a Krebs-Henseleit-bicarbonate buffer solution. Quantitative histological examination of apoptosis and necrosis was performed with H&E staining and ex vivo fluorescence microscopy.
Results: Bile flow improved significantly from 0.27±0.05 (µl/min/100 g body weight in controls to 0.61±0.04 (µl/min/100 g body weight in the preconditioned animals (p < 0.001). The portal pressure in group 2 after 1 min, 15 min and lh after reperfusion was 11.2±0.6 mmHg, 9.2±0.6 mmHg and 7.6±0.8 mmHg respectively and, therefore, significantly (p < 0.01) higher than in the animals treated with IP (8.0±0.3 mmHg, 6.0±0.3 mmHg and 4.8±0.4 mmHg respectively). Parenchymal necrosis was minimal in the pretreated group, while livers of control animals showed up to 20% of hepatocellular necrosis.
Conclusion: Ischaemic preconditioning protects donor livers from injury after cold storage and reperfusion, maintaining parenchymal cell integrity as well as hepatocellular and vascular function. As in liver resections, our experimental data suggest a benefit of IP in liver preservation and transplantation.
4
p53 INHIBITION PROTECTS RAT LIVER FROM COLD PRESERVATION-INDUCED APOPTOTIC CELL INJURY
Berrevoet F, Schäfer T, Vollmar B, Scheuer C, Menger M
University Hospital Ghent, Laarne, Belgium
Aim: By histology, recent studies on cold and warm preservation of porcine and human livers demonstrated that apoptotic hepatocytes and detachment of sinusoidal endothelial cells may be responsible for early graft failure after transplantation. We analysed the kinetics of hepatocellular apoptosis using a novel fluorescence microscopic technique in cold-stored livers and evaluated the impact of the p53-inhibiting factor Pifithrin-alpha on apoptotic tissue injury.
Methods: Sprague Dawley rats (weight range 250–300 g) were treated with Pifithrin-alpha (2.2 mg/kg body weight, intraperitoneally) 30 min before liver harvesting. Male age-matched, vehicle-treated (DMSO, 100 µl/100 g body weight, i.p.) animals served as controls. After laparotomy and intra-arterial application of bisbenzimide, livers were harvested via portal venous flushing with 100 ml of 4 °C HTK solution and stored in 4 °C HTK solution for 24 h. Using fluorescence microscopy and UV epi-illumination, grafts were analysed for apoptotic cell death, as assessed by nuclear chromatin condensation and fragmentation of hepatocytes. After the 24-h period of cold storage the livers were flushed with 10 ml of 4 °C Ringer's lactate solution. Liver tissue was processed for routine histology and immunohis-tochemistry.
Results: UV epi-illumination microscopy revealed a progressive increase in the number of apoptotic hepatocytes from 1.2%±0.3 to 1.6%±1.2 and 10.8%±2.1 at 1 h, 6 h and 24 h of cold storage in the DMSO-treated controls. Importantly, Pifithrin-alpha significantly reduced the number of apoptotic cells by c. 50% at all time points. Concomitantly tissue injury, as assessed by semiquantitive scoring of hepatocellular vacuolisation, necrosis and sinusoidal detachment, was found to be significantly attenuated by p53 inhibition using Pifithrin-alpha.
Conclusion: p53 is known as one of the factors that regulate cell cycle response after DNA damage. Pifithrin-alpha treatment seems to be a promising novel approach to reduce apoptosis of both hepatocytes and sinusoidal endothelial cells after cold preservation of the rat liver.
5
SUPERCOOLING PRESERVATION UNDER HIGH PRESSURE OF RAT LIVERS
Ueno T, Omura T, Matsumoto H, Takahashi Y, Takahashi T, Kakita A
Department of Surgery, Kitasato University School of Medicine, Kanagawa, Japan
Background: Low temperature has been utilised as the basic method for extension of organ preservation time. From the enzymological and energetic viewpoints, the lower the temperature is in cold storage, the longer the organs could be preserved. However, in the past organ preservation experiments at subzero temperatures have all ended in failure for various reasons. We took note of the existence of unfrozen state of water at subzero temperatures under high pressure, and came to the idea that livers could be stored in the preservation solution maintained in the supercooling (non-freezing) state under certain conditions.
Methods: Livers removed from rats were stored in UW solution, pressurised until the prescribed pressure. After the termination of preservation, orthotopic liver transplantation was done at room temperature under ordinary pressure. The transplantability of the liver was evaluated from the survival rate in these rats. Histological examination of grafted livers was also performed. We performed the following four sets of experiment. Experiment 1: Liver grafts were pressurised up to 30, 40, 50, or 70 MPa, respectively, at the compression rate of 0.5 MPa/s. Grafts were preserved for 60 min at 0 Åé under these pressures. Experiment 2: We chose two rates by setting the compressor power at 80% of full in group A and 3% in group B. Liver grafts were pressurised up to 35 MPa and were preserved for 60 min at 0 Åé. Experiment 3: We preserved liver grafts at pressures up to 5, 10, 20 or 30 MPa for 5 h (total ischaemic time was about 6 h), at −2 Åé. The compression rate was 0.05 MPa/s. Experiment 4: Liver grafts were preserved at 0, 5 or 10 MPa at −3 or −4 Åé for 5 h (total ischaemic time was about 6 h). The compression rate was 0.05 MPa/s.
Results: All rats transplanted with liver grafts pressurized up to 30 MPa in experiment 1, 1 rat in group B (1/6) of experiment 2, all rats in the 5 MPa and control groups of experiment 3, and all rats in the 5 MPa (at −3) of experiment 4 survived for 2 weeks after liver transplantation. Under light microscopy, morphological changes observed in all groups were diffuse haemorrhage and vacuolar degeneration in the liver.
Conclusion: Liver grafts preserved in a pressurised, subzero non-frozen condition had enough function to sustain the life of rats after orthotopic transplantation. It was also suggested that factors causing cell injury due to pressurising include 1) intensity of pressure, 2) pressurising-depressurising velocity, and 3) length of preservation.
6
PROTECTIVE EFFECT OF ISCHAEMIC PRECONDITIONING AGAINST INTERMITTENT WARM ISCHAEMIA-INDUCED LIVER INJURY
Iwasaki Y, Tagaya N, Hamada K, Shimoda M, Kubota K Dokkyo
University School of Medicine, Tochigi, Japan
Aims: Although ischaemic preconditioning (IPC) has been reported to protect the liver from injury when subjected to continuous hepatic ischaemia, whether IPC protects rat livers against ischaemia-reperfusion (I/R) injury after intermittent ischaemia has not been elucidated.
Methods: Five groups of Wistar rats were subjected to intermittent hepatic ischaemia (I) comprising 15-min ischaemia and 5-min reperfusion three times with or without prior IPC (10-min ischaemia and 10-min reperfusion), 45-min continuous ischaemia (C) with or without IPC, and sham operation. Serum transaminase and lactic acid levels, hepatic tissue energy charges and hepatic blood perfusion were measured after reperfusion. Plasma tumour necrosis factor-alpha (TNF-α) levels were determined after reperfusion for 120 min. Histological and apoptotic findings were evaluated after reperfusion for 180 min.
Results: IPC significantly reduced serum transaminase levels after continuous and intermittent ischaemia (IPC + C: 1107 vs C: 2684I U/1, IPC + I: 708 vs I: 1859 IU/m). After hepatic ischaemia without IPC, apoptosis and necrosis with increased plasma TNF-α levels were observed. IPC protected livers from injury by interfering with the increase in plasma TNF-α (IPC + I: 27.6 vs I: 64.8 pg/ml, IPC + C: 21.6 vs C: 49.3 pg/ml). This resulted in attenuation of hepatic necrosis after continuous ischaemia and significantly reduced necrosis and apoptosis after intermittent ischaemia.
Conclusion: IPC exerts a greater protective effect against hepatic I/R injury after intermittent hepatic ischaemia than after continuous hepatic ischaemia.
7
EFFECTS OF TERLIPRESSIN ADMINISTRATION WITH HYDROXYETHYLSTARCH IN PATIENTS WITH HEPATORENAL SYNDROME
Saner FH, Fruhauf NR, Lang H, Stavrou G, Malago M, Broelsch CE
Klinik fur Allgemein- und Transplantationschirurgie, Uni-Klinik Essen, Essen, Germany
Background: The outcome in liver transplant patients with a hepatorenal syndrome (HRS) is worse compared with those without kidney impairment. Preliminary results suggest that terlipressin, a vasopressin analogue, plus volume challenge could improve and preserve the kidney function in patients with end-stage liver disease (ESLD).
Methods: Eleven patients with ESLD and HRS before liver transplantation and one patient with hepatocellular carcinoma (HCC), who developed HRS after extended liver resection, were treated with 6 mg terlipressin and 500 ml hydroxyethylstarch 10% (Mw 200,000 D, 0.5 substitution). Terlipressin was given until a complete response was achieved (serum creatinine <1.4 mg/dl) or for an 8-day period.
Results: Eight patients showed a significant response to this therapy; serum creatinine and blood urea nitrogen were halved, ascites and peripheral oedema diminished. One patient showed no improvement of the kidney failure. In three patients liver and simultaneously kidney function worsened, requiring a kidney replacement therapy.
Conclusion: The use of terlipressin and hydroxyethylstarch was shown to be effective in reversing HRS in an early phase; the initial condition for later liver transplantation is very much better.
Session 2
Resection – I
(DOI 10.1080/16515320310000788)
8
A CONSECUTIVE SERIES OF 107 HEPATIC RESECTIONS WITHOUT MORTALITY
Chiappa A, Biffi R, Luca F, Bertani E, Zbar AP, Crotti C, Pace U, Bellomi M, Andreoni B
European Institute of Oncology and University of Milan, Milan, Italy
Aims: A consecutive series of 107 hepatectomies was analysed to identify the risk factors for significant postoperative complications.
Methods: Among the 107 patients operated on between April 1996 and November 2002, there were 54 male and 53 female (mean age 60 years±10 years; range 27–79 years). Sixty-nine patients (64%) were affected by colorectal cancer metastases, 15 by HCC (14%) and 18 patients (17%) by other maligniancies. Five patients (5%) were resected for benign disease. A comparative study of postoperative complications after hepatectomy was conducted for the different patient groups.
Results: There were several major postoperative complications, with bile leakage in 5 patients (5%), severe hepatic failure in 1 patient (1%), pneumonia in 2 patients (2%), peritonitis due to bowel perforation or anastomotic dehiscence in 4 patients (4%) (three of them underwent concomitant bowel resection at first operation), and pulmonary embolism in one patient (1%). Peroperative mortality was nil. The median postoperative hospital stay was 12 days (range 6–140 days).
Conclusions: Formal hepatic resection is a safe procedure providing that patients are well selected. The peroperative care of those cases has greater impact on outcome then either the type of resection or the pre-existing liver function.
9
EXTENDED LIVER RESECTION FOR LOCALLY ADVANCED INTRAHEPATIC CHOLANGIOCELLULAR CARCINOMA
Lang H, Fruhauf NR, Sotiropoulos G, Kaiser G, Domland M, Paul A, Malago M, Broelsch CE
University of Essen, Klinik fur Allgemein- und Transplantations Chirurgie, Essen, Germany
Aim: Intrahepatic cholangiocarcinoma (IHC) is associated with an extremely poor prognosis. Locoregional extension is usually advanced at the time of diagnosis, accounting for low resectability rates. As IHC is currently considered a contraindication for liver transplantation, surgical resection remains the only chance for cure.
Methods: Between April 1998 and July 2002 a total of 41 patients with locally advanced IHC of UICC stage III/IV underwent surgical exploration.
Results: Resection with curative intention was performed in 24/41 (60%); in 17 cases only an explorative laparoscopy or laparotomy was possible due to disseminated intrahepatic or extrahepatic tumour. There were 16 extended right hepatectomy (Seg IV–VIII + I), 6 extended left hepatectomy (Seg I–V, VIII) and two bisegmentectomies. In addition, the following procedures were performed: resection of hilar bifurcation (n = 10), resection of diaphragm (n = 6), partial resection of vena cava (n = 4), resection and reinsertion of left liver vein (n = 1), portal vein resection (n = 5). There were 17 R0 and 7 Rl resections. 30-day mortality was 2/24 (8%), operative morbidity leading to reoperation was 20%. Median survival after Rl resection was 10 months (range 2–20 months) and after exploratory laparotomy was 5 months (0–11 months). After R0 resection the median survival was 20 months (range: 2–41 months). Currently, one patient is alive after Rl resection and 11 after R0 resection. So far, there has been tumour recurrence in 6/17 patients.
Conclusions: These results support an aggressive surgical approach to patients with locally advanced intrahepatic cholangiocarcinoma. As regards the high operative morbidity and the poor results in case of Rl resection, an improved preoperative assessment of resectability is of utmost importance.
10
COMPARISON OF TWO DIFFERENT TECHNIQUES IN HEPATIC PARENCHYMAL TRANSECTION
Gruttadauria S, Marino IR, Vitale CH, Arcadipane A, Magnone M, Doria C
Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy and Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
Aims: We performed a retrospective analysis of perioperative mortality, length of hospitalisation and blood transfused during surgery in two patient groups who underwent liver resection. In group A, we developed a new technique to resect hepatic parenchyma, using an ultrasonic surgical aspirator in association with monopolar floating ball cautery, while in group B, the crushing clamp technique was utilised.
Methods: 30 liver resections were enrolled in group A, while 107 liver resections represented group B. All patients had hepatic neoplasm except four living donors for transplant (group A). Mean age was 49.29 years in group A and 52.2 years in group B. The male:female ratio was 1:1 in both group A and B. In group A, 39.29% of resections involved3 3 segments and 60.71% involved £ 2 segments; in Group B, 36.40% involved 3 3 segments and 63.6% consisted of £ 2 segments. Statistical analysis utilised independent T square (Pearson χ2).
Results: In group A, 3.57% of patients died perioperatively while 3.7% died in group B. Average length of hospitalisation was 10.71 days in group B and 8.16 days in group A (p = 0.677). An average of 0.75 U of blood was utilised intraoperatively in group A while 1.60 U was used in group B; 19/30 (63.33%) in group A did not undergo blood transfusion while 42/107 (39.25%) received blood intraoperatively in group B.
Conclusion: The association of these two tools in liver resection reduces length of stay and the need for intraoperative blood transfusion.
11
LIVER RESECTION FOR COLORECTAL CANCER METASTASES WITH INVOLVEMENT OF ADJACENT STRUCTURES: IS IT SAFE OR HAZARDOUS SURGERY?
Gardini A, Ercolani G, Cescon M, Ravaioli M, Vetrone G, Del Gaudio M, Grazi GL, Cavallari A
Department of Surgery, S Orsola Hospital, Bologna University, Bologna, Italy
Aims: The effectiveness of liver resection extended to adjacent structures for metastases from colorectal cancer is still controversial. The involvement of inferior vena cava (IVC) or diaphragm is no longer considered an absolute contraindication to resection. We evaluate early and late results of this extended surgery.
Methods: From 1981 to 2001, 300 patients with liver metastases from colorectal cancer underwent hepatic resections at our institution. Among these patients, 11 cases (3.3%) underwent combined IVC resection and 19 (6.3%) cases had diaphragm resection. In the first group (Gl), involvement of the IVC was evidenced preoperatively in 2 cases and in 6 patients total hepatic vascular occlusion was required. In 7 cases, a direct suture of IVC was performed; in 1 patient a pericardium bovine 'patch' was applied; in 3 patients, a PTFE (polytetratluorethylene) prosthesis was used. In the second group (G2), a direct suture of the diaphragm was performed in all cases. In 4 cases pleural drainage was necessary.
Results: Operative mortality rate was 3.3%. Postoperative morbidity rate was 20%. The median follow-up time was 32.5 months in the first group and 20.9 in the second group. In Gl patients, the 1-, 3- and 5-year survival was 72.7%, 51.9% and 50%, respectively. Tumour recurrence occurred in 8 (72.7%) cases, and it was the main cause of death (4, 50%). In G2 patients the 1-, 3- and 5-year survival was 52.7%, 35.1% and 25.11% respectively. Seven patients developed recurrence (58%).
Conclusions: Liver resection combined with diaphragm or IVC resection and reconstruction is a feasible procedure, which can be performed with an acceptable operative risk leading to satisfactory results in highly selected patients. Different types of IVC repair should be applied on the basis of the extension of IVC invasion.
12
LIVER RESECTIONS FOR COLORECTAL CANCER SECONDARIES
Karamarkovic AR, Djukic V, Stefanovic B, Mihailovic V
University Center for Emergency Surgery, Belgrade, Yugoslavia
Introduction: Hepatic secondaries are the main cause of death in colorectal cancer (CRC) and surgery remains the only potentially curative treatment for those patients. This is why efficient resectional treatment of liver metastases is crucial for long-term survival.
Methods: This prospective study includes patients with colorectal liver secondaries, surgically treated by anatomic liver resections, at the University Center for Emergency Surgery in Belgrade.
Results: Since 1999, 106 hepatic metastases were resected in 42 patients (synchr. 8 patients, metachr. 34 pts). We performed 1 right hepatectomy, 3 left hepatectomies, 10 monosegmentectomies (S2–S8), 10 sectorectomies (right anterior, right posterior, left paramedian, left lateral), 3 trisegmen-tectomies (S4b, S5, S6), 10 bilateral sectionectomies (S2, S3 and S6, S7) and in 5 cases plurisegmentectomies. Unresectable colorectal metastases were downstaged by transcatheter HAI (Implantofix®), and after that were successfully resected, in 4 cases. The complication rate was 8.9% (postoperative bleeding, bile fistula, abscess colection). No method-related lethality occurred. During the follow-up period we registered a tumour recurrence rate of 19.1% (8 pts), of which two patients were subjected to liver re-resection. Overall 3-year survival rate (Kaplan-Meier) is 32.7%. Univariate analysis shows a significant corelation between 3-year survival and solitary (43.6 vs 11.2%; p < 0.03) and unilobar metastases (45.7 vs 8.7%; p < 0.003).
Conclusions: Liver resection of metastatic colorectal cancer is the only therapeutic procedure that offers reasonable chance of cure in up to a third of patients who are potentially resectable. Other treatment modalities should be performed only when resection is not possible or as a complement to resection, to improve survival rates.
13
SURGICAL TREATMENT OF PATIENTS WITH HEPATOCELLULAR CANCER
Krawczyk M, Kornasiewivcz O, Zieniewic K, Nyckowski P, Patkowski W, Najnigier B, Hevelke P, Smotr P, Remiszewski P, Korba M, Dudek K, Skwarek A
Department of General, Transplantation and Liver Surgery, Warsaw Medical University, Warsaw, Poland
Aim: Analyses of surgical treatment of 322 cases of hepatocellular cancer (HCC).
Methods: In the period 1995–2002, a total of 1542 cases of liver tumours was treated in this department, which consisted of 322 cases (20.1%) of HCC and 1220 cases (79.9%) of other liver tumours. The group of HCC comprised 228 (70.8%) patients with and 94 (29.2%) patients without liver cirrhosis. 71 (31.1%) HCC patients with cirrhosis underwent surgery – among these 67 (94.3%) underwent liver resection and 4 (5.7%) qualified for liver transplantation. The majority of patients with cirrhosis (n = 43, 60.51%) were referred for treatment by outpatient departments. In 38 cases (53.5%), the tumour was initially an incidental finding on routine check-up ultrasound scans. In 4 patients (5.7%) elevated alpha-fe to-protein (AFP) level was established as an incidental finding. The key marker of the neoplastic condition in this study was AFP.
Results: In the group of HCC patients with cirrhosis, 53 (79.1%) anatomical and 14 (20.9 %) non-anatomical (tumorectomies) resections were mostly limited to less than two segments. In HCC patients without cirrhosis, resections were decisively larger and included more than two segments. In only 4 cases, hepatocellular cancer was an indication for liver transplantations.
Conclusion: Patients with cirrhosis usually underwent small-size liver resection, whereas the patients without cirrhosis underwent large-size ones. Most of the patients with cirrhosis and HCC were admitted in an asymptomatic period. Thanks to a system of regular check-ups, liver surgery was possible in up to 30% of diagnosed patients in the cirrhotic group.
14
EFFECT OF HEPATIC RESECTION FOR HEPATOCELLULAR CARCINOMA WITH LIVER CIRRHOSIS
Kim SB, Choi DW, Bae TS, Lee JI, Paik NS
Department of Surgery, Korea Cancer Center Hospital, Seoul, Korea
Aim: Although various treatment modalities for hepatocellular carcinoma (HCC) with cirrhosis were introduced recently and applied even for resectable cases, partial hepatic resection has been considered as the best treatment option for selected HCC patients with liver cirrhosis. However, many investigators have reported postoperative mortality and high recurrence rates after hepatic resection. This study was conducted to investigate the outcomes of hepatic resection of HCC combined with liver cirrhosis and to identify prognostic factors.
Methods: From September 1987 to July 2001, 201 hepatic resections for HCC patients were performed in this hospital. Among them, 115 cases were combined with liver cirrhosis by pathological confirmation. They consisted of 96 male and 19 female patients and the median age was 51 years (24–75 years). The median follow-up period was 30 months (1–178 months). Most of them were categorised as Child-Pugh classification A (95.7%) and were related to hepatitis B viral infection in 86 cases (74.8%).
Results: The in-hospital mortality rate was 0.87% (1 case); 5-year overall and disease-free survival rates were 59.4% and 44.6%, respectively. Recurrence occurred in 53 cases and remnant liver was most common (45 cases). The 3-year survival rate after recurrence was 33.4%. In multivariate analysis, stage (p = 0.042), multiplicity (p = 0.044) and venous invasion (p = 0.035) were identified as independent prognostic factors.
Conclusions: Hepatic resection is regarded as the effective treatment modality with acceptable mortality for selected. HCC patients with cirrhosis. For high risk patients, further study including adjuvant treatment should be followed to reduce the recurrence after hepatic resection.
15
LIVER RESECTION FOR HEPATOCELLULAR CARCINOMA IN CIRRHOTICS AND NON-CIRRHOTICS: EVALUATION OF CLINICOPATHOLOGICAL FEATURES AND COMPARISON OF RISK FACTORS FOR LONG-TERM SURVIVAL AND TUMOUR RECURRENCE IN A SINGLE CENTRE
Cescon M, Grazi GL, Ravaioli M, Ercolani G, Gardini A, Vetrone G, Cavallari A
Department of Surgery and Transplantation, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
Aims: To review a single-centre experience of curative liver resections for HCC in order to evaluate clinicopathological features and outcome of cirrhotic and non-cirrhotic patients.
Methods: From 1981 to 2002, 308 curative hepatectomies for HCC on cirrhosis (group 1) and 135 for HCC without cirrhosis (group 2) were performed. Clinicopathological data, operative parameters, early results, overall and disease-free survival, and prognostic factors for survival and tumour recurrence were analysed and compared.
Results: Group 1 had worse hepatic function and higher prevalence of HCV infection. In group 2, HCC showed larger diameter (p < 0.001), poorer differentiation (p < 0.05), and more frequent macrovascular invasion (p < 0.05). Although more extended resections were required in group 2 (p < 0.001), there were no differences in blood transfusions. Postoperative complication rate was higher in group 1 (p < 0.005). After 1992, in-hospital mortality was 2.9% in group 1 and 1.1% in group 2 (p = NS). The 3- and 5-year overall survival was 63.7% and 42.2% in group 1, and 67.9% and 51% in group 2 (p < 0.05). The 3- and 5-year disease-free survival was 49.3% and 27.8% in group 1, and 58% and 45.6% in group 2 (p < 0.005). Serum bilirubin level >1.2mg/dl, multiple nodules, micro- and macro-vascular invasion, diaphragm infiltration and blood transfusions independently affected survival in group 1. Blood replacement was the only negative prognostic factor in group 2. Independent risk factors for tumour recurrence were satellite nodules and resection performed before 1992 in group 1, and age <60 years in group 2.
Conclusions: Despite a more aggressive tumour behaviour, resections for HCC without cirrhosis led to better results compared with HCC on cirrhosis. Age and intraoperative blood transfusions are the only predictors of outcome in non-cirrhotic patients. The impact of the latter in both these groups outlines the importance of surgical technique.
Session 3
Liver – Experimental
(DOI 10.1080/16515320310000797)
16
PORTOSYSTEMIC SHUNT PREVENTS APOPTOSIS OF RAT INTESTINAL EPITHELIAL CELLS CAUSED BY TOTAL HEPATIC ISCHEMIA
Bedirli A, Muhtaroglu S, Sakrak O, Guler I, Ince O, Soyuer I, Aritas Y
Erciyes University, Department of General Surgery, Kayseri, Turkey
Background: Total hepatic ischaemia (THI) is a useful manoeuvre to reduce haemorrhage from liver trauma and major hepatic resection.
However, prolonged splanchnic congestion has been shown to induce damage to the intestinal mucosa. The present study was conducted to examine whether the protective effect of the portosystemic shunt (PSS) can be seen on lipid peroxidation and apoptosis of intestinal epithelial cells in a rat model of THI.
Methods: Adult male Wistar rats weighing 200–250 g were used in all experiments. Animals were divided into four groups: control, partial hepatic ischaemia (PHI), THI alone and THI with PSS. PHI or THI was induced in rats for 60 min and was followed by a period of reperfusion of 2 h. Serum levels of aspartate transaminase (AST), alanine transaminase (ALT) and lactate dehydrogenase (LDH), tissue malondialdehyde (MDA) levels and apoptosis, liver and ileum histopathology were evaluated. Apoptosis was detected by measuring p53 and Bcl-2 levels in tissues.
Results: The serum levels of AST, ALT and LDH were significantly higher in PHI and especially THI groups (p < 0.01). There was no significant difference between the rats undergoing PHI and THI rats as regards ischaemic hepatic tissue MDA levels and apoptosis (p > 0.05). However, high levels of MDA and apoptosis in intestinal tissue were observed in the THI alone group (p < 0.05). Histological findings of ischaemic lobes in the PHI group were similar to THI groups with or without PSS. Histological examination of ileum from rats that had PHI or THI with PSS was completely normal.
Conclusions: Splanchnic congestion due to portal occlusion increased apoptosis and lipid peroxidation in intestinal epithelial cells. PSS is very effective in counteracting the principal negative effects of THI.
17
A NOVEL ANTIOXIDANT NON-STEROIDAL ANTI-INFLAMMATORY AGENT PROTECTS THE RAT LIVER AGAINST ISCHAEMIA-REPERFUSION INJURY
Leventis I, Papalois A, Andreadou I, Pousios D, Sfmiadakis I, Rekka E, Kourounakis PN, Fotiadis C, Papadimitriou I, Sechas MN
Department of Surgery, University of Athens, Experimental-Research Unit, Elpen Pharma, Department of Medicinal Chemistry, University of Thessaloniki, Department of Pathology, Navy Hospital, Athens, Greece
Aims: Liver ischaemia followed by reperfusion is an important and common clinical event. A major mechanism is leukocyte adhesion to endothelium followed by release of reactive oxygen metabolites. The aim of this study was to determine the effects of a novel antioxidant ethylenediamide derivative (compound A: C.A.) with anti-inflammatory properties on hepatic ischaemia-reperfusion injury.
Methods: 48 Wistar rats were used and divided into 8 groups (n = 6 in each group). Group 1: sham-operated. Group 2: 30 min ischaemia (control). Group 3: 30 min ischaemia followed by 60 min of reperfusion (control). Group 4: 30 min ischaemia followed by 24 h of reperfusion (control). Group 5: Laparotomy (C.A.). Group 6: 30 min ischaemia + C.A. Group 7: 30 min ischaemia followed by 60 min of reperfusion + C.A. Group 8: 30 min ischaemia followed by 24 h of reperfusion + C.A. Hepatic ischaemia was produced by occluding the portal vein and the hepatic artery. At the end of ischaemia C.A. was administered intravenously and the clamp was removed allowing reperfusion. The effect of C.A. was evaluated by histopathological examination, plasma levels of liver enzymes, lipids and biochemical parameters and lipid peroxidation measured by malondialdehyde.
Results: Ischaemia followed by 60 min of reperfusion promoted an increase in lipid peroxidation when compared with the sham-operated group and the non-ischaemic group. This increase was attenuated in the group treated with C.A. Serum enzyme levels were significantly higher in the reperfusion groups compared with the non-ischaemic groups and were diminished after the treatments.
Conclusion: C.A. exerted a protective effect on hepatic reperfusion injury in rats. The mechanism of C.A. is considered to be through its potent antioxidant and free radical scavenging activities.
18
THE NECROTIZING EFFECT OF PULSE CRYOCYCLING ON LIVER TISSUE
Kopelman D, Gaitini D, Shpoliansky G, Zaretzki A, Ben-Itzhak O, Hashmonai M
Department of Surgery B, Haemek Medical Center1, Departments of Radiology and Pathology, Rambam Medical Center2 and Faculty of Medicine, Technion-Israel Institute of Technology, Afula1 and Haifa2, Israel
Aim: Freezing is not assumed to achieve total cell destruction within the iceball. Repeated freezing and thawing (cryocycling) improves cryonecrosis. The present study investigated the effect of 'pulse' cryocycling (repeated very short cycles of freezing and thawing) on normal liver tissue.
Methods: The experiment was carried out on three groups of rabbits: controls – 5′ cycles, pulse cryocycling – 15′′ cycles, and pulse cryocycling -30′′ cycles. Freezing of liver parenchyma was performed with a Medical Cryohit 1 apparatus, using argon and helium. Freezing was applied twice for 5 min followed each time by 5 min spontaneous thawing. In the experimental groups, during the 5′ freezing periods, repeated 15′′/30′′ freezing alternated with 15“/30” active thawing. The edges of the frozen lesion were marked. On the following day, the liver was harvested.
Results: In all groups, the histological picture of the cryolesion showed a central area of total destruction, and a thin, sharply delineated outer layer (0.98±0.44 mm) in which the liver cells were completely destroyed, but some blood vessels and bile ducts were preserved. The outer border of the lesions always coincided with the edge of the frozen tissue. The only difference between the three groups was the significantly smaller size of the lesions obtained by the 15′′ pulse freezing technique.
Conclusion: In our experimental model, total destruction of liver cells was obtained up to the borders of the cryolesion by all methods of cycling. Pulse cryocycling was not superior in achieving liver cell demise within the cryolesion of normal liver tissue.
19
CATALYTIC BINARY THERAPY IN EXPERIMENTAL LIVER TUMOUR
Galperine E, Dyuzheva T, Kaliya O, Raihlin N, Mogirev S
Moscow Medical Academy & State Scientific Centre “NIOPIC”, Moscow, Russia
Aim: The aim of the study is the development of treatment for rat liver mucous cancer (MC-1) by selective occlusive injection of Teraphtal (T) + ascorbic acid (AA).
Methods: An injection of 0.1 ml of 20% tumour cell suspension was implanted into the central liver lobe of unbred male rats (n = 38, average weight = 120 g). At 12 days after tumour implantation a laparotomy with tumour measuring was performed. T was injected into the lobar branch of a portal vein at doses of 0.06 mg (group I, n = 12) and 0.3 mg (group II, n= 12) by a selective occlusive method. AA was injected at the reperfusion stage. Control animals (group III) did not receive treatment. The results were evaluated at 18 days after treatment.
Results: In group I the average tumour size before treatment was 18.1±7.5 mm3, and 67.2±46.2 mm3 (g >0.05) after treatment; in group II, tumour size was 19.9±12.4 mm3 and 101.0±35.7 mm3, respectively (g <0.05); in group III, tumour size was 31.5±7.6 mm3 and 1337.0±505.4 mm3 (g <0.05). Inhibition of tumour growth was 94% (group I) and 92% (group II). Histological studies revealed that necrosis constituted 50–80% of a tumour.
Conclusion: Binary catalytic therapy (O + AA), conducted by selective occlusive injection, leads to significant inhibition of liver tumor growth in rats. (The study is sponsored by Moscow Government.)
20
SELECTTVE-OCCLUSTVE METHOD FOR LIVER TUMOUR THERAPY
Galperine E, Dyuzheva T, Zimakova N, Mogirev S
Moscow Sechenov Medical Academy, Moscow, Russia
Aim: To elaborate a method for attaining high drug concentrations in the affected hepatic lobe with decreasing dose and concentration in plasma.
Method: The hepatic artery/portal vein or its lobar branch is catheterised, and the afferent and efferent hepatic vessels are clamped. The drug is injected through the catheter into the 'closed vascular space'. Clamping is stopped after the necessary exposition time. The method can be used intraoperatively or by balloon occlusion without laparotomy. Experiments were conducted on 48 unbred rats. Teraphtal (T; NIOPIC, Russia) was injected by SOM into the lobar branch of the portal vein (0.06 mg/rat; n = 24). Occlusion lasted for 5 min. Rats in the control group were treated by injection of T (1 mg/rat; n = 24) into the portal vein without occlusion. The concentration of T was determined by spectrophotometry.
Results: In SOM-treated rats the concentration of T at 5, 30 and 240 min after injection was 30, 33 and 48 µg/gram in the affected lobe, and 5, 7 and 9 0 µg/g in the intact lobe, respectively. The concentration of T in plasma was 3, 0 and 0 µg/ml, respectively. No T was found in lungs. In control rats the concentration of T in affected and intact lobes was 15, 60 and 51 µg/g, in plasma it was 92.4, 39.6 and 14.4 µg/ml, in lungs it was 46, 28 and 57 µg/g, respectively.
Conclusion: Selective-occlusive injection of T at smaller doses in comparison with regional injection allows most of the drug to concentrate in the affected hepatic lobe and prevents accumulation in other tissues.
21
INTRAVITAL ANALYSIS OF MICROCIRCULATION IN THE REGENERATING MOUSE LIVER
Vogten JM, Smakman N, Voest E, Borel Rinkes IHM
Department of Surgery, UMC Utrecht, The Netherlands
Aims: Liver tissue remodelling after surgery includes the development of new hepatic microvasculature. Although various endothelial growth factors have been shown to play a role in liver tissue repair, the functional consequences of rapid endothelial cell proliferation are unknown. To determine the influence of endothelial cell proliferation on vessel functionality, we have analysed the in vivo morphology of microvasculature in the regenerating liver.
Methods: Mice were subjected to 70% partial hepatectomy (PH). At 24, 48, 96 h, 7 and 14 days post-PH they underwent intravital microscopy of the exposed liver remnant. Intrahepatic micro-vessels were visualised with fluorescein-labelled dextran. Recorded parameters were:: functional vessel length (VL), functional vessel diameter (VD), hepatic cell plate width (PW) and functional vessel surface area (FVSA).
Results: VL showed a transient decrease (17–31%) after PH. PW was significantly increased in the regenerating liver. VD significantly increased on days 1 and 2 post-PH. On days 4, 7, and 14, VD returned to normal. In contrast, FVSA remained within normal range until day 14 post-PH.
Conclusions: Despite changes in vessel length and hepatic cell plate width in the early regenerating liver, functional vessel surface area remains normal until day 14 post-PH. These changes may indicate compensatory vascular growth mechanisms to ensure adequate hepatocyte perfusion during liver regeneration. Better understanding of functional variations during physiological liver regeneration may be of use in liver conditions characterised by defective regeneration, e.g. cirrhosis.
22
EFFECT OF RADIOTHERAPY AND ISCHAEMIA ON RAT LIVER
Szijarta A, Kupcsulik P, Vigvary Z, Hahn O
1st Department of Surgery, Semmelweis University, Budapest, Hungary
Aim: To model liver resection combined with intraoperative irradiation for micrometastases. This type of combined ischaemic-reperfusion and irradiation injury of the liver have not been investigated yet.
Methods: Normothermic segmental liver ischaemia (using a model that avoids splanchnic stasis) was created in 250–280-g male Wistar rats. Animals were divided into groups for 30, 45, 60 or 90 min of ischaemia. Hepatic microcirculation was studied by laser Doppler flowmetry using MOOR DRT 4 equipment with on-line computer monitoring and processing. Reperfusion was assesed by post-ischaemic flux plate maximum (PM), by area under the curve (RA) and by the time to maximum flux level (RMT). I, II, IV lobes of liver were exposed to 0, 25, or 50 Gy of gamma-radiation. Histological alterations were recorded. Plasma ALP, ALT, AST, LDH, bilirubin and TNF-α tests were performed before and after ischaemia-reperfusion and irradiation. Statistical analysis was performed with the STATISTICA computer program.
Results: Groups of rats undergoing 60–90 min ischaemia or 50 Gy irradiation showed significant histological abnormalities, increased TNF-α levels and elevated liver enzymes. Flowmetry showed a non-linear fashion of reperfusion according to ischaemic period. After 90 min rapid deterioration of flux was observed; 60 min of ischaemia represents an intermediate lesion in terms of recovery. PM, RT, RMI after 30 and 45 min of ischaemia-reperfusion do not differ significantly from normal. Complete restitution occurs in 15 min. After 60 and 90 min restitution is significantly slower and the baseline of perfusion will not settle. Survival is determined by the length of the ischaemic period, rather than the irradiation dose. Irradiation (25–50 Gy) with short-term ischaemia (30 min) did not result in increased liver enzymes and only minimal histological changes occurred.
Conclusion: Liver tolerates irradiation injury suprisingly well, preconditioning promotes restitution of liver circulation after ischaemic lesion. Low dose irradiation (25 Gy) with normothermic, short-term ischaemia (30 min) seems to be tolerable for the tumour-free liver.
23
METHYLPREDNISOLONE ATTENUATES NFκB BINDING ACTIVITY IN POST-ISCHAEMIC LIVER TISSUE, THEREBY REDUCING APOPTOSIS AND INFLAMMATION DURING ISCHAEMIA/ REPERFUSION INJURY IN THE RAT LIVER
Glanemann M, Nussler AK, Strenziok R, Munchow S, Langrehr JM, Neuhaus P
Department of General, Visceral and Transplant Surgery, Charite, Virchow-Klinikum, Humboldt University, Berlin, Germany
Aim: During hepatectomy, temporary hilar occlusion is sometimes necessary to reduce the risk of intraoperative bleeding. Hereafter, the associated is chae mi a/rep er fusion (IR) injury may lead to hepatocellular damage, which might result in organ dysfunction. The aim of our study was to evaluate the protective efficacy of steroid administration, and the potential underlying mechanisms.
Methods: After midline laparotomy male Wistar rats (250–300 g) underwent total vascular occlusion for 45 min. One group of animals received methylprednisolone (MP; 30 mg/kg BW), whereas one group served as ischaemic controls. We compared both groups with regard to the extent of IR injury using AST/ALT/ GLDH levels and histological changes. We measured the apoptotic (cytochrom C/RT-PCR, caspase 3/Western blot) and inflammatory (ICAM-1 expression/Western blot, leukocyte tissue infiltration) activity, as well as the NFicB-binding activity (EMSA) in post-ischaemic liver tissue.
Results: All parameters indicating IR injury revealed significant protection by MP treatment before liver ischaemia when compared to non-treated animals within 24 h following ischaemia. The post-ischaemic apoptotic and inflammatory activity was reduced in MP-treated animals, when compared to non-treated animals, as was the expression of NFκB-binding activity in post-ischaemic liver tissue.
Discussion: Administration of MP significantly reduced hepatocellular injury after warm ischaemia. The apoptotic and inflammatory activity was significantly reduced in the post-ischaemic liver tissue, which we judged to be a result of steroid-related suppression of transcription factor NFκB.
Conclusion: In surgical situations requiring temporary vascular inflow occlusion administration of MP might help to minimise postoperative complications caused by ischaemia-related organ dysfunction.
24
CYCLOOXYGENASE-2 EXPRESSION IN LIVER METASTASES OF COLORECTAL CANCER: AN EXPERIMENTAL STUDY
Rao M, Yang WX, Seifalian AM, Winslet MC
University Department of Surgery, Royal Free and University College Medical School, London, UK
Aim: Cyclooxygenase-2 (COX-2) has been reported to be involved in the development of colorectal carcinoma but its role in liver metastases is not established. This study aimed to investigate COX-2 expression and its possible role in the development of liver metastases.
Methods: An experimental model of liver metastases of colorectal cancer was established in syngenic BD1X rats. The animals (n = 6) were inoculated with DHD/K12 colorectal cancer cell line (1×107) through intra-portal injection and metastases were examined 3 weeks after inoculation. The growth of metastatic tumour in the liver was examined macroscopically and microscopically. COX-2 expression in metastatic tumour and liver tissue was detected by conventional and fluorescent immunohistochemistry observed under confocal microscope.
Results: Liver metastases developed in 5 of 6 rats (83%). No metastases was seen anywhere outside the liver. COX-2 was expressed in both metastatic tumour cells and the hepatocytes adjacent to the metastatic tumour. COX-2 expression in hepatocytes was mainly distributed around the central vein and in those around the vicinity of the tumour. No COX-2 expression was seen in the stoma of the tumour. With fluorescent staining, COX-2 expression was located in cytoplasm of metastatic tumour cells, while it mainly presented in the nuclei of the hepatocytes.
Conclusions: COX-2 is expressed in the liver with metastases arising from colorectal carcinoma. Further studies are necessary to clarify its role in the development of the metastases.
Session 4
Acute Pancreatitis – I
(DOI 10.1080/16515320310000805)
25
ACUTE NECROTISING PANCREATITIS – MANAGEMENT BY PLANNED STAGED REOPERATIONS USING THE ZIPPER TECHNIQUE
Radenkovic DV, Bajec DJD, Ivancevic NDJ, Karamarkovic AR, Mihailovic VK, Greopic PM, Sijacki A
Emergency Center, Medical Faculty of Belgrade, Belgrade, Yugoslavia
Aims: In an effort to improve the outcome of patients with necrotising pancreatitis (NP) and infected pancreatic necrosis, we started to use planned staged repeated necrosectomy using the zipper technique. This report describes our experience with this operative approach.
Methods: 41 patients were treated by this technique from 1996 to 2000. Data are presented according to treatment outcome (survivors vs non-survivors) .
Results: Procedure-related morbidity was 63% and overall mortality was 37%. Intra-abdominal abscesses developed in 5 patients but 3 of them did not need surgery. Fistulas developed in 14 patients (8 patients) and 57% were treated conservatively. In 7 patients haemorrhage required reopera-tion. The mean number of planned staged re-laparotomies was 3 (range 1–9). There was a significant difference between group D and S in the incidence of organ failure, sepsis, MOF, APACHE II score on admission, extension of the necrosis and intra-abdominal bleeding. In multivariate analysis only an APACHE II score >13 and extension of necrosis maintained significance as prognostic factors for mortality.
Conclusion: The fulminant or infected type of NP has a high morbidity and mortality rate. An APACHE II score > 13 and extension of necrosis behind both paracolic gutters predict poor outcome. Planned staged reoperative necrosectomy with the zipper technique provides for better control of pancreatic infection and prevents the risk of recurrent intra-abdominal sepsis.
26
RELATIONSHIP OF NECROSIS TO ORGAN FAILURE IN PATIENTS WITH ACUTE PANCREATITIS
Radenkovic DV, Bajec DJD, Ivancevic NDJ, Karamarkovic AR
Emergency Center, Medical Faculty of Belgrade, Belgrade, Yugoslavia
Aims: Pancreatic necrosis and organ failure (OF) are determinants of severity in acute pancreatitis. The relationship between the necrosis and organ failure and multiple organ failure was analysed.
Methods: A prospective study included 71 patients suffering from severe necrotising pancreatitis (SNP). The diagnosis of SNP was established by clinical and laboratory findings, contrast-enhanced CT and/or intraoperative findings. Percutaneous and/or intraoperative sampling assessed the microbiological status of necrosis. The occurrence of OF was defined according to the Atlanta classification system. Multiple organ failure (MOF) was defined by the simultaneous occurrence of 3 organ failures. Surgical treatment was performed in patients with infected necrosis, whereas sterile necrosis was treated conservatively (except 6 patients with deterioriation despite ICU treatment for at least 3 days).
Results: Twenty-nine (41%) patients had infected necrosis, whereas 42 (59%) had sterile necrosis. The incidence of OF was greater in patients with infected necrosis (79% vs 55%; p = 0.033). Distinct differences were found in the prevalence of MOF in patients with infected necrosis and those with sterile necrosis (38% vs 17%; p = 0.043).
Conclusion: Bacterial infection of necrosis has a strong impact on the occurrence of OF and MOF in patients with SNP. Organ failures increase the severity of illness and have a strong impact on the outcome of patients with SNP. Prevention of pancreatic infection is the major goal in the treatment of patients with necrotising pancreatitis.
27
TREATMENT OF INFECTIOUS COMPLICATIONS OF ACUTE NECROTISING PANCREATITIS
Shapovalyants SG, Mylnikov AG, Pankov AG, Tsarev IV, Freidovich DA, Semenov AV
Russian State Medical University, Moscow, Russia
During 1999–October 2002 we treated 163 patients with acute necrotising pancreatitis (ANP); pancreatic infection was confirmed microbiologically in 40 of them (percutaneous fine-needle aspiration, 24 patients; operation specimen, 14; autopsy, 2). 3 patients with infectious complications of ANP were treated conservatevely, 2 died. Pancreatic abscess was revealed in 7 patients, 4 were cured only by percutaneous catheter drainage; the other 3 were operated on with 1 death. 6 patients with infected pancreatic necrosis (IPN) and extensive fluid collections were initially treated by multiple percutaneous fluid aspiration, 4 survived. Another 5 patients with IPN were treated by percutaneous US-guided catheter drainage followed by surgical debridement. Surgical necrosectomy is the principal method of treatment of IPN employed by the authors, and it was performed in 26 patients. One-stage necrosectomy with postoperative lavage of retro-peritoneum was possible in 9 patients after 43.9 days (average) from the onset of pancreatitis, in 4 of them after percutaneous interventions, all survived. In 17 cases surgical necrosectomy had to be carried out much earlier due to patients deterioration, using the 'open packing' technique, in 9 of them this was carried out after an average 21.3 days from disease attack; 5 patients died. The other 8 patients with very early development of IPN were operated on at an average of 9.4 days from the onset of pancreatitis, all died with incomplete debridement of necrotic tissues. Total mortality was 16 (40%).
Conclusion: In patients with infectious complications of ANP percutaneous interventions may be the definitive treatment or can delay surgical operation. It is preferable to perform surgical necrosectomy after > 1 month from the disease attack.
28
RESULTS OF ANTIBIOTHERAPY AND SURGERY IN PATIENTS WITH NECROTISING PANCREATITIS
Otto W, Komorzycki K, Krawczyk M
Medical University of Warsaw, Department of General & Liver Surgery, Warsaw, Poland
Aim: The aim of the study was to evaluate the results of antibiotherapy and surgery in patients with necrotising pancreatitis.
Methods: The diagnosis of the disease and indications for surgery were based on clinical evaluation and USG, CT monitoring. There were 92 patients (male 55, female 37, mean age = 48 years), treated between 1996 and 2002. The treatment started with TPN, intensive care and antibiotherapy: 45 patients received piperacyline/tazobactam (group A) and 47 received cefalosporin/metronidazole (group B) initially. Surgery was indicated for peritonitis, suppurative complications and inflammatory pancreatic/biliary remnants.
Results: There were 8 patients in group A and 10 patients in group B presenting in extremis who died soon after admission due to multiple organ failure (NS). There were 20 and 37 patients in group A and B, respectively, who required emergency operation for peritonitis within 72 h of the commencement of treatment (p < 0.01). In 7 of them (35%) in group A and 8 (21%) in group B, aseptic necrosis was confirmed by bacteriological examination (p < 0.05). All these patients survived, but 2 (28%) in group A and 6 (75%) in group B required second-look surgery for peripancreatic abscesses (p < 0.001). The other patients were primarily infected. 4 patients (31%) in group A and 10 patients (34%) in group B died soon after operation due to toxaemia (NS), but 5 (38%) in group A and 15 (55%) in group B developed suppurative complications and required secondary operations (p < 0.01). The complications resulted in the death of 50% of these patients additionally. Conservative treatment appeared to be successful in 17 patients (38%) in group A but in none of the patients in group B (p < 0.001). All these patients required elective operation for inflammatory remnants. Two of them (12%) died.
Conclusion: We conclude that initial antibiotherapy with piperacyline/ tazobactam provides better protection against the primary endogenous infection, with less complications and better outcome in necrotising pancreatitis. Surgery remains an irreplaceable method in the treatment of infected necrosis and inflammatory pancreatic remnants.
29
ROLE OF C-REACTIVE PROTEIN FOR EARLY PREDICTION OF PANCREATIC NECROSIS
Barauskas G, Maleckas A, Svagzdys S, Pundzius J
Department of Surgery, Kaunas Medical University, Kaunas, Lithuania
Aim: The aim of the study was to evaluate the prognostic value of C-reactive protein (CRP) in the early diagnosis of pancreatic necrosis.
Methods: 78 patients with acute pancreatitis were included in the study. Clinical data, diagnostic procedures and laboratory values were analysed. Patients were divided into two groups. Group I consisted of 17 patients with necrotic pancreatitis, group II consisted of 61 patients with pancreatic oedema. Contrast-enhanced CT scan was used to diagnose pancreatic necrosis with subsequent fine-needle aspiration (FNA) for microbiological evaluation. CRP in serum was evaluated on days 1, 2, 3, 5, 7 and 9 after admission. Average CRP values were compared between groups by t test. The sensitivity, specificity, positive and negative predictive value for CRP concentration cut-off from 100 mg/l to 150 mg/l was calculated.
Results: There was no significant difference in demographic data between groups. Necrosis of the pancreas was demonstrated on CT scan and/or at surgery in 17 cases. The highest CRP values were detected on day 3 in group I patients. The difference of average CRP concentration was significant between groups on all days except day 7. The highest sensitivity and negative predictive value (94.1% and 95.7%, respectively) was obtained for CRP cut-off at 110 mg/l. CRP cut-off at 150 mg/l revealed the highest specificity and positive predictive value (76.5% and 60.0%, respectively).
Conclusions: CRP is an important prognostic marker of pancreatic necrosis with the highest sensitivity and negative prognostic value when the cut-off is 110 mg/l. The patients with CRP values <110 mg/l are at low risk of developing pancreatic necrosis.
30
SCHEDULED RE-LAPAROTOMIES IN THE TREATMENT OF INFECTED NECROTIC PANCREATITIS
Stefanovic B, Karamarkovic A, Djukic V, Jeremic V, Loncar Z, Savic P
University Center for Emergency Surgery, Belgrade, Yugoslavia
Aim: As infected acute necrotic pancreatitis is a dynamic and progressive process, surgical treatment of this serious disease is also planned and systematic. Massive necrotic changes of pancreas with consecutive infection are irreversible, and at the same time they are the source of both local and systematic septic complications accompanying the disease. As it is impossible to interrupt autodigestion process, necrosis and infection with phlegmonous and abscess changes, within a single surgical procedure, scheduled reoperation with temporary abdominal closure has become a practically unavoidable step in the surgical treatment of infected acute necrotic pancreatitis (ANP). Placement of abdominal glider (ETZIP) and planned re-laparotomy every 24–48 h enabled permanent control of infected and necrotic processes, by daily lavage, debridement and evacuation of necrotic and septic material.
Methods/Results: During the period from June 1996 to September 2000 137 scheduled reoperations were performed on 47 patients with confirmed diagnosis of ANP. Decompression gastrostomy and feeding jejunostomy was standard procedure in 84%. Observed mortality rate in the group treated by the scheduled reoperations approach was 25%. In the group of patients treated by single operation, the mortality rate was 36% (p 0.03) Conclusions: Scheduled reoperations enable the permanent monitoring of necrotic septic focus and prompt recongition and sanitation of complications. Feeding jejunostomy prevents bacterial translocation from the gut into the necrotic pancreatic tissue, and supports nutritive status. The immediate therapeutic results of the method and its associated mortality rate are encouraging when compared with the group treated by a single operation.
31
NECROSECTOMY AND PANCREATIC FUNCTION AFTER SEVERE ACUTE BILIARY PANCREATITIS
Calvete J, Pareja E, Sabater L, Aparisi L, Camps B, Sastre J, Artigues E, Trullenque R, Lledo S
Departments of Surgery, Digestive Diseases and Physiology, Hospital Clinico and Hospital General, University of Valencia School of Medicine, Valencia, Spain.
Aim: To investigate how necrosectomy influences endocrine and exocrine functions in patients with severe acute biliary pancreatitis (SAP).
Methods: This was a prospective cohort study including 39 patients with SAP. Severity of the episode was classified in agreement with the Atlanta criteria, but Ranson criteria and morphological Balthazar CT classification (CT after 72 h: score, severity index and amount of necrosis) were also evaluated. Patients were further subdivided into 2 groups according to whether they needed surgical necrosectomy or not. Functional pancreatic evaluation was carried out at least 12 months after the episode of SAP. Endocrine function was evaluated by oral glucose tolerance test and exocrine function by faecal fat excretion, faecal chymotrypsin (FCHY) and secretin-carulein test (SCT) (this latter was done in all patients without necrosectomy and half of the cases with necrosectomy).
Results: Pancreatic function evaluation was completed in 12 (6 male, 6 female, mean age = 64 i 11 years) of 16 patients who required necro-sectomy. Mean Ranson score in this group was 4.6±1, extension of necrosis was >50% in 8 (66.7%) and mean severity index was 8±2. After exclusion of 8 cases in the group without necrosectomy, 15 patients completed the study (6 male, 9 female, mean age = 61±14 years). Mean Ranson score was 4.3±1, mean severity index was 7±1 and extension of necrosis >50% was detected in 3 (20%) (p < 0.05 vs necrosectomy). In patients with necrosectomy the rate of endocrine dysfunction varied from 16.7% preoperatively to 75% after surgery. In the group without necrosectomy endocrine function did not change before and after the episode of SAP. In this regard the comparison of both groups was statistically significant. FCHY was pathologic in 50% of cases requiring necrosectomy vs 25% in the group without surgery. In the surgical group 25% of cases had steatorrhea vs 0% in the group without surgery. Eventually, SCT found a mild-moderate and severe pancreatic insufficiency in 33.3% and 16.7% of the operated cases, while in the non-operated group these figures were 16.7% and 0,% respectively.
Conclusions: In this series, necrosectomy impaired pancreatic endocrine function when compared with the preoperative status. The comparison between metabolic dysfunction in patients with and without necrosectomy was statistically significant. As regards exocrine function there were no significant variations, but a tendency towards pancreatic insufficiency with steatorrhea.
Session 5
Laparoscopic Cholecystectomy – I
(DOI 10.1080/16515320310000814)
32
LAPAROSCOPIC CHOLECYSTECTOMY: 12 YEARS' EXPERIENCE
Papavramidis S, Kesisoglou I, Giatas N, Gamvros O.
Third Surgical Department, AHEPA Hospital, University of Thessaloniki, Thessaloniki, Greece
Aim: Laparsocopic cholecystectomy is a well-accepted method for the treatment of symptomatic cholelithiasis. The aim of this study is to present the last 12 years' experience of our department as regards laparoscopic cholecystectomy.
Methods: From January 1991 to December 2002, 625 patients underwent laparoscopic cholecystectomy performed by the same group of surgeons. 212 patients were male (34%) and 413 female (66%). Their mean age was 42.8 years (19–83 years). The cause of the operation was symptomatic cholelithiasis in all patients. Patients with known choledocholithiasis and a history of pancreatitis or cholangitis were excluded from this series. The mean postoperative stay was 2.4 days (1–14 days).
Results: In 12 patients (1.92%) in this series the operation was converted to open. The causes of conversion were (a) leakage of multiple gallstones during the dissection of the gallbladder in 3 patients, (b) the presence of firm adhesions that made the recognition of the anatomic structures impossible in 3 patients, (c) massive bleeding from the gallbladder bed in 4 patients, and (d) the presence of severe necrotic cholecystitis in 2 patients. Four patients were reoperated: one on the second postoperative day, due to leakage from the cystic duct stump and the other on the fifth postoperative day for choleperitoneum due to bile duct injury. The two remaining patients were reoperated on the first postoperative day due to severe bleeding from the the trocar insertion site under the umbilicus. Twelve patients (1.92%) showed myocardial ischaemic changes immediately after the operation. Five of them were transferred to the ICU and one of them died from myocardial infarction. In 7 of these 12 patients the postoperative stay was extended. In 552 patients (88.4%) there were changes of chronic cholecystitis, in 43 (6.9%) gallbladder hydrops, in 13 (2.1%) gallbladder empyema and in 15 patients (2.6%) necrotic cholecystitis was found.
Conclusions: Laparoscopic cholecystectomy is a safe operation with no mortality and minimal morbidity. We recommend it as the operation of choice for symptomatic cholelithiasis.
33
COST ANALYSIS OF LAPAROSCOPIC CHOLECYSTECTOMY VS OPEN CHOLECYSTECTOMY IN A UNIVERSITY TEACHING HOSPITAL IN GREECE
Alexakis N, Antonakis PT, Kosmadakis N, Konstadoulakis MM, Leandros E, Androulakis G
First Department of Propaedeutic Surgery, University of Athens, Hippokration Hospital, Athens, Greece
Aims: This study was organised to evaluate the cost-effectiveness of laparoscopic cholecystectomy (LC) in comparison to open cholecystectomy (OC) in the setting of a single university teaching hospital in Greece.
Methods: LC was attempted in 5539 patients in the department from 1990 to 2000, while open cholecystectomy (OC) was performed in 810 patients. Eventually 5440 LCs were performed and 99 patients were converted (conversion rate 1.8%). Financial data were provided by the administrative services of our hospital and our department's providing services.
Results: The mean equipment cost was 951.14_ for LC and only 97.14_ for OC. Conversely, due to the increased hospital stay in the OC group (mean = 7.3 days, range = 5–92) in comparison with the LC group (mean = 1.8, range = 1–12), the mean total cost for OC was significantly higher (mean cost of OC = 2132.10_, mean cost of LC = 1452.97_, p < 0.01). Interestingly, the percentage of social security coverage was 100.1% for the LC and 100% for the OC group.
Conclusions: OC is significantly more expensive than LC in Greece, while LC is profitable to the hospital in contrast to the OC.
34
FINGERPORT IN LAPAROSCOPIC CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS
Sinha R
MLB Medical College, Jhansi, India
Aim: Adhesions in acute cholecystitis tax even the more experienced operator during laparoscopic cholecystectomy. Blunt and sharp dissection, electrocautery, laser, hydrodissection and ultrasonic dissection may all have their limitations. Thus there is a need for an alternative more effective method.
Method: The separation of the gallbladder from the adherent structures was done in 13 patients with acute cholecystitis, using the forefinger of the left hand introduced through the hypochondrial port. In two patients a second finger was introduced through the epigastric port.
Results: The finger dissection failed in 3 patients because of dense adhesions and high subcostal position of the gallbladder. The average time required was 7.9 min.
Conclusion: The finger dissection is easy, fast and limits injury because of the direct vision and the tactile sensation, which are missing in other methods of laparoscopic dissection.
35
A SINGLE CENTRE'S EXPERIENCE IN LAPAROSCOPIC CHOLECYSTECTOMY: REVIEW OF 8 YEARS AND 3575 CONSECUTIVE PATIENTS
Bostanci B, Yol S, Akbaba S, Ulas M, Kayaalp C, Ozogul Y, Atalay F, Akoglu M
Department of Gastrointestinal Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
Background: The first laparoscopic cholecystectomy (LC) at our department was performed in 1993 and both techniques (French and American) have been routinely used since its introduction. This paper retrospectively reviews 3575 consecutive patients operated during the last 8 years and the details of our experience are discussed.
Methods: The data of all patients who underwent LC between January 1995 and January 2003 were collected retrospectively. Patients, including 2463 females (68.9%) and 1112 males (30.1%), had a median age of 52 years (range 15–82 years). 2921 patients (81.7%) had the procedure with American technique by staff surgeons and/or fellows and the rest (18.3%) underwent the French technique, mostly performed by a single surgeon (M.A.) with the participation of fellows.
Results: Laparoscopic operation was converted to open cholecystectomy in 170 patients (4.8%). The conversion rate did not changed during the years (the conversion rates were 6.1%, 4.1% and 5.0% for sequential thousand cases, respectively). The most common reason for conversion was the presence of severe inflammation and adhesions to Callot triangle and obscure anatomy (n = 151). The overall mortality rate was 0.14%. Unfortunately five patients were lost because of bleeding (n = 2), bile duct injury (n = 2), and bile leak and sepsis (n = 1). The overall morbidity rate was 2.0%. The incidence of major bile duct injury was 0.36% and all cases except two were diagnosed intraoperatively. The incidence of postoperative bile leak was 0.25%. Nasobiliary or endoscopic stents were applied in seven cases. One patient was managed by observation and one required surgical intervention. 88% of the patients were discharged within 24 h after the operation. Other patients stayed an average of 3 days (range 2–5) in hospital.
Discussion: LC is a safe and effective procedure, however, it is not a benign procedure and is associated with minor and major complications. The key factor for the success of these results was the deliberate, meticulous surgical technique and the surgeons' desire to perform laparoscopy.
36
REASONS FOR CONVERSION IN EIGHT YEARS OF LAPAROSCOPIC CHOLECYSTECTOMY EXPERIENCE
Yol S, Bostanci B, Kayaalp C, Ozogul Y, Ozer I, Ulas M, Akoglu M
Department of Gastrointestinal Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
Aim: To evaluate the incidence and the reasons for conversion during laparoscopic cholecystectomy (LC) in our 8 years of experience.
Methods: The data for all patients who underwent LC between January 1995 and January 2003 were collected retrospectively. Reasons for conversion were divided into two groups. Group 1 comprised technical reasons such as obscure anatomy, adhesions and unexpected findings, and group 2 comprised accidental reasons such as biliary injury and hemorrhage. The conversion rate for each year was compared using chi-square test and the reasons were discussed.
Results: During this period, 170 patients encountered conversion to laparotomy (the overall rate was 4.8%).
| Year | n | Conversion rate (%) | Group 1 | Group 2 |
|---|---|---|---|---|
| 1995 | 270 | 26 (9.6)* | 25 | 1 |
| 1996 | 375 | 16(4.3) | 13 | 3 |
| 1997 | 570 | 28 (4.9) | 27 | 1 |
| 1998 | 493 | 12 (2.4)* | 12 | 0 |
| 1999 | 504 | 27 (5.4) | 24 | 3 |
| 2000 | 473 | 27 (5.7) | 23 | 4 |
| 2001 | 455 | 20 (4.4) | 18 | 2 |
| 2002 | 435 | 14 (3.3) | 13 | 1 |
| Total | 3575 | 170 (4.8) | 155 | 15 |
There was no mortality after conversion. * Only the difference between the conversion rate in 1995 (9.6%) and that of 1998 (2.4%) was statistically significant.
Conclusion: Our conversion rate has not decreased. This may be attributed to our standard meticulous operative technique and the surgeons' desire to perform laparoscopy.
37
PREDICTIVE FACTORS FOR CONVERSION OF LAPAROSCOPIC CHOLECYSTECTOMY
Akin M, Akyurek N, Sare M, Dalgic A, Tatlicioglu E
Department of Genaral Surgery, Gazi University Medical School, Ankara, Turkey
Aim: The aim of this study was to investigate the reasons for conversion to open surgery (OS) and to evaluate the predictive factors for conversion in patients who were underwent laparoscopic cholecystectomy (LC).
Methods: From January 2000 to December 2002, a total of 327 elective laparoscopic cholecystectomies was performed at the Medical School of Gazi University. A retrospective analysis of 33 parameters included patients' demographic details, laboratory data, clinical history, ultrasound results, operation time, intraoperative details, body mass index (BMI), sex, American Society of Anesthesiology (ASA) classification score, previos abdominal surgery, preoperative need for ERCP and PTC, peroperative antibiotic prophylaxis.
Results: The mean age was 48.7 years (range 17–86); 86 patients were male and 240 patients were female. 37 patients (11.3%) were converted to open surgery. Multivariate analysis revealed that for all cases, operation time longer than 61 min, patients who needed peroperative antibiotic prophylaxis, adhesions in area two, adhesion score higher >1, adhesions near the gallbladder, difficulty in callot dissection, bleeding, performing peroperative cholangiography and the use of abdominal drain predicted conversion to open cholecystectomy.
Conclusion: Conversion from laparoscopic to open cholecystectomy was required in 11.3% of our patients. This compares favorably with results reported in the literature. We believe that it is imperative to view conversion to an open procedure as a sign of experience in order to avoid catastrophic ductal injuries and not as a complication. The risk factors determined in this study can help in counseling patients undergoing LC with regards to the probability of conversion to an open procedure.
38
TIMING OF URGENT LAPAROSCOPIC CHOLECYSTECTOMY DOES NOT INFLUENCE CONVERSION RATE
Mercer S, Knight J, Jancewicz S, Walters M, Sadek S, Toh S, Somers S
Solent Department for Digestive Diseases, Queen Alexandra Hospital, Portsmouth, UK
Aims: The 'gold standard' treatment of acute gallstone disease is urgent laparoscopic cholecystectomy, but there is confusion about the effect of delay in operation on conversion rates. Most reports suggest that delay beyond 3 or 4 days leads to a higher conversion rate.
Methods: Our institution operates a specialist-led protocol for the urgent management of all admissions with acute cholecystitis (AC) and biliary colic (BC). Data were collected prospectively over a 6-month period.
Results: From March to August 2002, there were 110 admissions to our institution with AC or BC. 74 (67%) underwent cholecystectomy at the index admission with an overall conversion rate of 12%. 4 of 38 (11%) carried out within 3 days of admission were converted, compared with 5 of 36 (14%) after 3 days. 5 of 44 (11%) carried out within 4 days of admission were converted, compared with 4 of 30 (13%) after 4 days. There were no deaths or major complications.
Conclusion: So long as the procedure is carried out by experienced upper GI surgeons working within a specialist-led protocol, the conversion rate for laparoscopic cholecystectomy can be as low as 12%, and the timing of urgent laparoscopic cholecystectomy has no impact on the conversion rate.
14:00–15:30
Session 6
Liver Transplantation – 2
(DOI 10.1080/16515320310000823)
39
SURGICAL ANATOMY IN 96 CONSECUTIVE RIGHT LIVER LIVING DONOR TRANSPLANTS
Varotti G, Gondolesi G, Waine M, Artis T, Fishbein T, Emre S, Schwartz M, Miller C
Mount Sinai School of Medicine, New York, USA
Aim: To assess the surgical anatomy of the right lobe living donors (RLLD).
Methods: We reviewed 96 RLLD. For arterial and portal anatomy we included patients with preoperative MRI or angiogram and surgical report (SR) (96/96); intraoperative cholangiogram and SR for biliary anatomy (72/96); MRI and SR for hepatic venous (HV) anatomy (51/96).
Results: Hepatic artery (HA): 68 RLLD (70.8%) had classic anatomy; 12 had a left HA arising from the left gastric artery (12.5%); 13 had a right HA arising from the superior mesenteric artery (SMA) (13.5%); two (2.1%) had a double replaced left HA and right HA, and in a single case (1.0%) the common HA arose from the SMA. Portal vein (PV): 83 RLLD (86.4%) had classic anatomy; 6 (6.3%) had a trifurcated PV, 7 (7.3%) had a right paramedian PV taken off the left PV. Biliary tree: 43 RLLD (59.7%) had a normal anatomy; 9 (12.5%) had a trifurcated biliary anatomy; in 8 (11.1%) the right paramedian bile duct and in 12 (16.6%) the right lateral bile duct opened into the left bile duct. HV: S5 and S8 accessory HV were found in 19 (37.3%) and 14 cases (27.4%) respectively; 8 RLLD had both (15.7%). S6 or S7 short HV were found in 22 cases (43.1%).
Conclusions: Anatomical variations in RLLD grafts are more common in the biliary system; HA and PV are the most constant structures. Commonly at least one accessory HV needs to be reconstructed. No variations constitute a contraindication to donation.
40
DONOR AND RECIPIENT FACTORS INFLUENCING EARLY GRAFT FUNCTION AFTER LIVER TRANSPLANTATION
Belina F, Ryska M
Transplant Surgery Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
One of the main postoperative complications after liver transplantation (OLTx) is poor early graft function (PEGP), leading to significant morbidity and mortality.
Aim: We evaluated several donors, perioperative and recipient parameters and their correlation to PEGP, morbidity and mortality after OLTx.
Methods: From April 1995 to September 2002, 269 OLTx were performed in 257 patients. We identified and analysed retrospectively 36 donor and recipient characteristics and risk factors associated with PEGF or primary non-function (PNF). We observed the incidence of postoperative complications. PEGF was defined as the peak AST >1500 U/l and ALT > 1000 U/l during the first postoperative week. Data analysis was performed by Student's t test, chi-squared analysis and logistic regression analysis.
Results: The incidence of the PEGF was 25% and PNF was 3%. The most important donor factors were identified as age (p = 0.0018) and body mass index (p = 0.025). The main recipient factors were the pretransplant medical status (UNOS p = 0.01) and Child Pough score (p = 0.01). The rewarming time and number of the blood products used during transplantation were identified as the most important perioperative risk factors.
Conclusion: PEGF and PNF were probably most often caused by the presence of multiple risk factors. Rates of early dysfunction of the liver graft might be reduced by avoidance of combinations of the risk factors.
41
LONG-TERM SURVIVAL AFTER LIVER TRANSPLANTATION FOR BILIARY ATRESIA: A SINGLE CENTER EXPERIENCE WITH 280 PATIENTS
Fouquet V, Alves A, Branchereau S, Grabar S, Houssin D, Gauthier F, Bernard O, Soubrane O
Hospital le Kremlin Bicêtre, 78 rue du Général Leclerc, 94375 le Kremlin Bicêtre, France
Aim: We present the results of 280 children with biliary atresia (BA) who have undergone orthotopic liver transplantation (OLT) at a single institution.
Methods: Among 601 OLT performed between April 1986 and December 2000 by the Bicetre-Cochin Liver transplant group, 332 OLT were performed in 280 children with BA. The prognostic factors for survival were investigated among the recipients, donors and transplantation characteristics. We performed univariate and multivariate analysis using Cox proportional hazards models. Patient and graft survival was determined at 1, 5 and 10 years.
Results: Overall patient survival at 1, 5 and 10 years was 85%, 82% and 82%, respectively. The corresponding overall graft survival was 77%, 73% and 71%. The multivariate analysis identified 4 independent risk factors for failure including: the polysplenia syndrome, the UNOS status at the time of OLT (p = 0.05), donor's age over 25 (p = 0.01) and perioperative complications (p = 0.03). On the other hand, patient age, gender, indication of OLT, liver graft type and retransplantation did not influence results.
Conclusions: The long-term outcome after OLT for BA in a pediatric liver transplant reached an 82% survival rate at 10 years. Four independent factors, including polysplenia syndrome, UNOS status, donor's age and perioperative complications significantly predicted patient survival. Improvement of overall results could arise from an optimal management of these four factors.
42
SPLIT LIVER TRANSPLANTATION: THE MOUNT SINAI EXPERIENCE
Artis T, Gondolesi G, Artis S, Florman S, Roayaie S, Krieger N, Shneider B, Fishbein T, Schwartz M, Miller C, Emre S
Mount Sinai Medical Center, New York, USA
Aim: Split liver transplantation (SLT) is an innovative technique to increase the number of donor livers. It is our policy to split every suitable liver to provide allografts for 2 recipients. We report our experience with SLT comparing outcomes of ex vivo and in situ grafts.
Methods: Between February 1994 and January 2003, 31 livers were split to provide 62 (43 ex vivo and 19 in situ) allografts. On 22 occasions, ex vivo splitting was performed on the back table and 10 livers were split in situ; 2 livers were shared with other centers.
Results: 24 adults (mean age 50.95±13.22 years, range 22–68) and 38 children (mean age 3.66±4.58 years, range 1 month-15 years) received split grafts. Right lobe grafts were placed in 23 adults and 6 children; 1 left lobe graft was used for a child, left lateral segment grafts were received by 31 children and 1 adult. 25 livers were shared by adult-child pairs, 1 liver was shared by 2 adults, 5 livers were shared by 2 children. Seventeen patients were UNOS status 1, 29 were UNOS status 2 and 16 were UNOS status 3. Total ischemia time (TIT) was 637±181.34 min for the ex vivo SLT vs 588 i 229,41 min for in situ SLT (p = NS). Incidences, of overall surgical complications were not significant. Four (6.4%) cases of primary non-function (PNF) occurred overall, 3 (6.9%) in ex vivo SLT vs 1 (5.2%) in in situ SLT. Hepatic artery thrombosis occurred in only 1 of the adult patients who received in situ right lobe graft, overall (1.6%). Two children recieving ex vivo left lateral grafts had portal vein thrombosis, overall (3.2%). Biliary complications occurred in 5 (11.6%) ex vivo SLT vs 1 (5.2%) in the in situ SLT. Eight patients (12.9%) had retransplants overall, 6 (13.9%) from ex vivo SLT vs 2 (10.5%) from in situ SLT. 1-year and 5-year actual graft survival rates of overall ex vivo and in situ SLT were 84.1% and 63.6%, 80.3% and 64%, 93.7% and 56.2%, respectively. 1-year and 5-year actual patient survival rates were 87.7% and 75.7%, 85.3% and 71.9%, 94.1% and 94.1%, respectively.
Conclusions: These encouraging results, which represent the experience of a single center over 9 years, suggest that SLT can be performed with good overall outcome and all suitable livers should be considered for splitting.
43
PEDIATRIC LIVER TRANSPLANTATION WITH SEGMENTAL GRAFTS: OUTCOME ANALYSIS OF LIVING DONOR VS CADAVERIC SPLIT GRAFTS
Artis T, Artis S, Gondolesi G, Roayaie S, Florman S, Krieger N, Fishbein T, Schwartz M, Miller C, Emre S
Mount Sinai Hospital, New York, USA
Aim: To compare short- and long-term outcomes of pediatric liver transplantation (LT) with segmental grafts from living donors (LD) vs cadaveric (CAD) split grafts.
Methods: Between July 1993 and January 2003, 79 LD and 38 cadaveric split (25 ex vivo and 13 in situ) liver transplantations were performed in 117 children at our center. We analysed demographic data, pretransplant patient status, warm ischemia time (WIT) and total ischemia time (TIT), surgical complications and graft and patient survival in both groups.
Results: LD grafts comprised 67 left lateral segments, 7 left lobes and 5 right lobes. CAD grafts comprised 31 left lateral segments (9 in situ and 22 ex vivo split), 1 left lobe (in situ split) and 6 right lobes (3 in situ, 3 ex vivo split). The mean age of LD recipients was 3.45±4.70 years vs 3.66±4.58 years in the CAD group. 16 patients were UNOS status 1 in the LD group vs 12 in the CAD group and 19 were UNOS status 2 in the LD vs 11 in the CAD group. Mean TIT was 96.08±56.38 min in LD vs 600.13±219.88 min in CAD group (p < 0.001). Primary non-function was seen in 2 patients in each group (2.5% in LD vs 5.2% in CAD, p = NS). The incidence of vascular complications was not significantly different between the groups (in the LD group, 4 (5%) hepatic artery thrombosis (HAT) and 4 (5%) portal vein thrombosis (PVT) vs 0 (0%) HAT and 2 (5.2%) PVT in the CAD group). Biliary complications occurred in 11.3% (n = 3) and 7.8% (n = 9) of patients in the LD and CAD groups, respectively (p = NS). Patient survival at 3 months and 1 and 5 years was 95.3%, 92.1% and 92.1%, respectively in LD recipients vs 94.6%, 88% and 88% in CAD graft recipients (p = NS). Graft survival at 3 months and 1 and 5 years was 93.7%, 92.1% and 89.6%, respectively in LD recipients vs 88.7%, 85.3% and 80.3% in CAD graft recipients (p = NS).
Conclusion: These innovative techniques had excellent, comparable graft and patient survival. LDLT and SLT are complimentary procedures to decrease waiting list mortality and should be part of a centers' armamentarium.
44
PIGGY-BACK TECHNIQUE IN ORTHOTOPIC LIVER TRANSPLANTATION: A SINGLE-CENTER EXPERIENCE OF 423 CASES
Cescon M, Grazi GL, Ercolani G, Gardini A, Ravaioli M, Vetrone G, Cavallari A
Department of Surgery and Transplantation, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
Aims: We have already demonstrated the superiority of the piggy-back technique (PB) vs the conventional technique in orthotopic liver transplantation (OLT). We therefore reviewed our series of OLTs performed with the PB.
Methods: From January 1992 to October 2002, 423 of 646 OLTs (65%) were performed with the PB, with increasing utilization over time (>90% after 1998). The complications related to PB were analysed, with specific reference to the orifice used for the anastomosis with the donor vena cava (cuff of recipient left and middle hepatic veins (LM), LM with a >1 cm opening of the adjacent caval wall (LM + ), or including the right hepatic vein (LMR) as well).
Results: 30-day mortality was 5.7%. Twenty-two patients (5.2%) experienced complications related to PB (stenosis or torsion), as follows: 14/122 (11.5%) with LM, 4/226 (1.8%) with LM+, and 4/75 (5.3%) with LMR (LM vs LM+, p < 0.0001; LM vs LMR, p = NS; LM+ vs LMR, p = NS). Balloon dilation or additional side-to-side caval anastomosis were successful in 12 (54%) and 3 (13.6%) patients, respectively. Retransplantation was required in 7 cases (32%). Two patients (0.5%) died from causes linked to PB stenosis. Actuarial 3- and 5-year survival of patients with or without PB complications was 74% and 74%, and 82% and 78%, respectively (p = NS); 3- and 5-year graft survival was 47% and 47%, and 77% and 72% in the two groups (p < 0.005).
Conclusions: PB is feasible in almost all cases of OLT. The use of the single orifice formed by left and middle hepatic veins does not provide an adequate width for a safe anastomosis.
45
COMBINED HEART AND LIVER TRANSPLANTATION FOR FAMILIAL AMYLOIDOTIC POLYNEUROPATHY. EXPERIENCE WITH 3 CASES
Ercolani G, Grazi GL, Cescon M, Ravaioli M, Gardini A, Cavallari A
Department of Surgery and Transplantation, Ospedale Sant'Orsola, University of Bologna, Bologna, Italy
Aim: Few cases of combined heart and liver transplantation (CHLT) for familial amyloidotic polyneuropathy (FAP) have been reported; therefore, the exact timing for indication and technique for the operation are far from being consolidated.
Methods: Three patients with severe cardiomyopathy secondary to FAP underwent CHLT. Patient 1 had no serious involvement of other organs, whereas patients 2 and 3 had evident peripheral neuropathy and gastrointestinal motility alterations. Patient 3 also had high-grade ortho-static hypotension.
Results: All 3 patients underwent cardiac and sequential hepatic transplantation in the same session with organs procured from the same donor. Veno-venous bypass was used only in patient 1, with an uncomplicated procedure. After transplant, his cardiac performance remained normal and no progression of FAP was observed. Patient 2 had no intraoperative complications, but he experienced postoperative bleeding, renal failure, sepsis and heart failure, and died due to multi-organ failure 2 months after transplant. In patient 3, soon after CHLT, right hemicolectomy was required intraoperatively due to intestinal ischemia, without significant hemodynamic alterations. In this last patient, extra-cardiac symptoms of FAP gradually worsened postoperatively. Two patients (patients 1 and 3) are currently alive after 38 and 20 months, respectively. None of the patients experienced acute rejection in the postoperative period.
Conclusions: CHLT for FAP can be performed successfully even in patients with advanced disease. However, the most compromised patients are more exposed to intraoperative risks, postoperative complications and worsening of extra-cardiac, extrahepatic symptoms. Candidates for CHLT for FAP should have priority in the waiting list. Protection against acute rejection of combined transplantations needs further evaluation.
Session 7
Liver Resection – 2
(DOI 10.1080/16515320310000832)
46
MAJOR LIVER RESECTION FOR GIANT HEPATIC TUMORS IN CHILDREN AND ADULTS: A STEP FOR LIVER TRANSPLANTATION FROM LIVING DONOR
Marwan I, El Sefi T, Gad H, Hamaad E, Sadek A, Shawky A, Ibrahim T, Abd Eldayem H, Abou Ela K, Osman M, Soliman S, Helmy A
Department of Surgery, National Liver Institute, Menoufeya University, Cairo, Egypt
Aim: To evaluate our experience retrospectively gained from successful formal or extended hepatectomy for giant liver tumors as a mandatory step for liver transplantation from a living donor in children and adults.
Methods: Right or extended right hepatectomy was done in 15 patients and left or extended left hepatectomy was done in 13 cases, those 28 giant liver tumors out of 147 were resected between September 1991 and September 2002. The tumor diameter ranged from 8 to 27 cm and ultrasonic dissector and bipolar coagulation irrigation were used in 21 cases.
Results: Patients included 7 children (aged 7 months to 13 years) and 21 adults (aged 26–65 years). There were 6 patients (21%) with HCC on top of liver cirrhosis. Hospital mortality (1 month) occurred in 3 cases, 2 of them were emergency laparotomies to control bleeding after needle biopsy. One case with haemangio-endothelioma on top of chronic liver disease died 1 week after surgery from liver failure. Postoperative complications were minor biliary leak (2 cases) and wound infection (3). Two patients were re-explored for microscopic malignant involvement at the surgical edge.
Conclusion: Major liver resection is a safe procedure, especially when performed on normal liver under elective conditions. Experience gained in hepatectomies is needed in any program for liver transplantation from living donor.
47
EXTRAHEPATIC BILE DUCT RESECTION IN COMBINATION WITH LIVER RESECTION FOR HILAR CHOLANGIOCARCINOMA
IJtsma AJC, Appeltans BMG, Peeters PMJG, de Jong KP, Porte RJ, Slooff MJH
Department of HPB Surgery & Liver Transplantation, University Hospital Groningen, Groningen, The Netherlands
Hilar cholangiocarcinoma (HC) is a rare tumor and surgery offers the only chance for cure. From September 1986 to December 2001, 42 patients (20 males, 22 females) underwent a combined extrahepatic bile duct resection (EHBDR) and liver resection (LR) for HC. The aim of the study was to analyse outcome in terms of patient survival, morbidity and mortality and to look for predictive factors for this outcome. Median observation time was 59 months. 1-, 3- and 5-year actuarial patient survival was 72%, 37% and 22%, respectively. Median survival was 19 months. Hospital mortality, all due to septic complications, was 12%. Morbidity was observed in 32 (76%) patients. Infections were the most dominant complication. Patients without the need for vascular reconstruction (n = 33) showed a trend to a better survival compared with patients (n = 9) needing such a reconstruction (p = 0.068). Patients (n = 11) with AJCC stage I or II tumors had a superior survival compared with patients (n = 31) with stage III or IV tumors (p = 0.023). Patients with tumor-free lymph nodes (n = 26) showed a better survival compared with patients with tumor-positive lymph nodes (n = 16) (p = 0.004). Over 20% of patients with hilar cholangiocarcinoma can survive >5 years after a combined EHBDR and LR at the cost of 12% perioperative mortality and a 76% morbidity. Results can be improved by prevention of infectious complications, better selection of patients in order to avoid vascular reconstructions and predicting a negative nodal state.
48
PATIENTS WITH SMALL HEPATOCELLULAR CARCINOMA ON CIRRHOSIS: SHORT- AND LONG-TERM RESULTS OF LIVER RESECTION
Muratore A, Vigano L, Zorzi D, Ribero D, Ferrero A, Capussotti L
Istitudo Per La Ricerca e La Cura Del Cancro, Candiolo, Torino, Italy
Background: Closer follow-up and better imaging studies have allowed early detection of small hepatocellular carcinomas (HCC). Liver transplantation is the treatment of choice for patients with small, single HCC on cirrhosis but its main drawback is the scarcity of donors. Therefore, liver resection is the gold standard approach in patients with good liver function.
Methods: A retrospective study was carried out from January 1985 to December 2001. 96 Child-Pugh A patients underwent curative liver resection for a single, <5 cm HCC on cirrhosis. 72 patients had an anatomic resection. Primary end-points of this study were in-hospital mortality, morbidity, overall and disease-free survival, prognostic factors.
Results: In-hospital mortality rate was 1.0% (1/96 patients). Overall morbidity was 26% (25/96 cases), mainly related to lung complications (15 cases). The overall morbidity was not significantly different between anatomic and non-anatomic resections. The overall and disease-free median and 5-year survival were 40 and 26.3 months, 54.8% and 40.4% respectively. At univariate analysis, age (≥70 years), gender, hepatitis B or C serology, transaminase levels, serum alfa-fetoprotein (≥20 ng/ml), daughter nodules (presence or absence), tumor-free margin (≥1 cm), Edmonson-Steiner grade (1–2 or 3–4) were not significant prognostic factors. Microvascular invasion was the only factor significantly correlated to survival (p = 0.04). Type of resection (anatomic vs limited) was not a prognostic factor even if there was a trend toward a better overall and disease-free survival in the limited resection group: 71.6% and 68.7% in the non-anatomic group vs 51.1% and 38.7% in the anatomic group (p = 0.3 and p = 0.5). Similar results were found when analysing the subset of higher-risk patients with microvascular invasion. At multivariate analysis, no clinicopathologic characteristics were independent predictors of survival.
Conclusions: Liver resection is a safe procedure with good long-term results, especially in the subset of patients with small, single hepatocellular carcinomas. Anatomic resections do not achieve better results than non-anatomic ones.
49
LAPAROSCOPIC LIVER RESECTION FOR BENIGN AND MALIGNANT LIVER DISEASES
Lee SK, Kim KH, You YK, Park IY, Kim DG, Kim EK
St.Mary's Hospital, The Catholic University of Korea, Seoul, Korea
Aims: Laparoscopic surgery is considered the standard method for many kinds of pathologies, including gallbladder and splenic disease. However, in liver disease, the application of laparoscopic methods has been limited due to technical difficulties and the risk of bleeding and air embolism. The objective of this study was to analyse the feasibility of the laparoscopic approach in liver disease and to present different laparoscopic methods of treatment.
Methods: A retrospective analysis of 45 patients who underwent laparoscopic liver resection for benign and malignant liver diseases between Nov. 1995 and Sept. 2002 was carried out. Laparoscopic-assisted liver resections were performed in 41 patients, hand-assisted laparoscopic resections in 3, and totally laparoscopic resection in 1. 18 patients had benign liver disease and 27 patients had malignant disease, including hepatocellular carcinoma and metastatic liver tumor.
Results: The mean age of the patients was 55.8 years, and there were 28 men and 17 women. Resection ranged from wedge resection to hemihepatectomy, left lateral sectionectomy was the most frequent type of resection. Mean operative time was 261.5 min and mean hospital stay was 10.7 days. Complications occurred in 10 (22.2%) patients, including bile leaks, acute fluid collections, pulmonary problems and hepatic failure. One patient died of postoperative liver failure.
Conclusion: Laparoscopic liver resection is feasible and relatively safe for benign and carefully selected malignant liver tumors, especially for those who are not good candidate for a formal liver resection. Accurate preoperative evaluation and meticulous surgical technique are essential for successful surgery.
50
SURGICAL TREATMENT OF HEPATIC METASTASES OF NON-COLORECTAL ORIGIN
Pantoflicek J, Ryska M, Kucera M, Belina F
Transplant Surgery Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
Aim: Surgical resection is the only potentially curative treatment for metastatic cancer to the liver. Therapeutic guidelines for treatment of colorectal liver metastases are well defined, but it is difficult to establish therapeutic guidelines for heterogeneous group of non-colorectal liver metastases.
Methods: 20 patients with liver metastases of different origin were preoperatively indicated for multimodal therapy and were operated between 1998 and 2002 at our department. All patients could be divided into 4 homogenous groups according to origin of primary tumour: metastatic Grawitz tumour, breast carcinoma, digestive tumours and a group of different tumours. Peroperative assessing of metastatic extent allowed application of multimodal strategies to each patient.
Results: 28 multimodal procedures (5 implantation of port catheter, 6 non-anatomical resections, 6 hemihepatectomies, 4 segmentectomies and bisegmentectomies, 6 cytodestructive procedures) were performed in 20 patients. There were no perioperative deaths. Postoperative complications were seen in 20% of patients. Actuarial survival rates were 65 %, 35 % and 15 % at 1, 2 and 3 years.
Conclusion: Low morbidity and satisfactory survival rates justify a multi-modal approach to the surgical management of non-colorectal liver metastases.
51
SYNCHRONOUS SURGERY FOR COLORECTAL HEPATIC METASTASES
Djukic V, Karamarkovic D, Stefanovic B, Stepic D, Culafic DJ, Loncar Z
University Center for Emergency Surgery, Belgrade, Yugoslavia
Background: Over the last 5 years 16 patients have had synchronous hepatic metastases for colorectal cancer treated at our HBP unit. As a general policy the metastases were resected if colorectal resection made no technical difficulties and vice versa.
Methods: 6 patients underwent major liver resection (>3 segments), either left or right hemiliver according to the Brisbane classiffication; 7 patients had so-called left sectionectomy/resection of segments 2,3 Couinaud; 3 patients had metastasectomy/atypical liver resection of two segments. All our patients were followed at 3-day intervals using ultrasonography and CEA determination. The operative mortality was zero. The most frequent complication was bile leakage in 6 patients (37.2%) and pleural effusion in 4 (25%). We perform parenchymal resection using just clamps and scissors under a Pringle maneuver upgraded by preconditioning.
Results: There was a 50% recurrence rate in the first postoperative year. We attempted to improve disappointing results by repeated resection, hepatic artery infusion catheter application or radiofrequency ablation procedures.
Conclusion: Even potentially radical liver surgery for synchronous colorectal metastases should be completed by adjuvant chemotherapy. Extrahepatic metastatic disease is a really tragic prognostic sign.
52
CHARACTERITICS OF PATIENTS WITH METASTATIC LIVER DISEASE: OUR EXPERIENCE IN A PERIPHERAL HOSPITAL
Koutsimani Th, Zandes N, Chatzimisios K, Kechagia T, Papavramidis Th, Agorastou P, Simelidis D, Patoulidis I
Department of General Surgery, General Hospital of Kozani Mamatsio, Greece
Aims: The aim of this study is to present the experience of our clinic in metastatic liver disease.
Methods: In this retrospective study, during the last 5 years (1997–2002) 55 patients with metastatic liver disease were described. Diagnosis was made by ultrasonography, CT or intraoperatively. These patients were operated in our clinic or only visit our clinic for the chemotherapy. The only treatment for metastasis was chemotherapy. 26 patients were males and 29 females; the mean age was 68.2 with SD (10.6).
Results: Tumors of the large intestine were observed in 21 patients (38.1%), breast in 10 patients (18.1%), stomach in 6 (10%), billiary tract in 5 (9%), pancreas in 6 (10%), kidney in 2 (3.6), carcinoid in 1 (1.8%), myosarcoma in 1 (1.8%) and APUDOMA. in 1 (1.8%). The liver metastases were from 1 (8 patients), 2 (5 patients), 3 (4 patients), 4 (1 patient) to multiple (37 patients) sites. The type of operation ranged from curative resection to palliative procedures.
Conclusions: Cancer of colon gives rise to liver metastasis more commonly than the other tumors. By the time that the metastasis has been diagnosed the maximum period of survival was from days to a maximum of 1 year depending on the number of metastases. The psychological condition and the patient's life situation influence the outcome. The mean age of the population studied (68 years), and coexisting conditions such as diabetes and cardiovascular disease, influence the aggressiveness of the surgery and the outcome of treatment.
53
HAS LONG-TERM SURVIVAL FOLLOWING HEPATIC RESECTION FOR LIVER COLORECTAL METASTASES IMPROVED?
Chen JWC, Tang A, Padbury RTA
Department of Surgery, Flinders Medical Centre, Flinders University of South Australia, Adelaide, Australia
Aim: Long-term survival has been achieved after resection of colorectal metastases confined to the liver. The aim of this study is to examine trends in outcomes of patients undergoing liver resection for colorectal metastases by a single surgeon over a 10-year period.
Methods: A retrospective review of records of all patients from March 1992 to December 2002 was performed. Data from 61 patients undergoing potentially curable liver resection for colorectal metastases were analysed. Survival outcome related to prognostic determinants were analysed using the log-rank test.
Results: The median survival for this cohort was 7.01 years, with 2- and 5-year survival rates of 94% and 57%, respectively. Disease-free survival at 2 and 5 years was 77% and 41%, respectively. Of the determinants affecting disease-free survival, initial colorectal tumour staging (p < 0.04) and age at time of liver surgery (p < 0.02) were significant, whereas sex, tumour size, resection type and margins of clearance showed no significance. Of the determinants affecting overall survival, only age <70 years (p = 0.068) approached significance, whereas sex of patient, staging of colorectal tumour, size of metastasis, resection type (segmentectomy vs lobectomy), margins of clearance and era of treatment showed no significance.
Conclusion: Patient and disease-free survival following liver resection for colorectal metastases has improved significantly in recent years, and our experience is consistent with evolving international standards. Although the reasons for improved survival are not clear, contributing factors may include better selection with newer preoperative and intraoperative imaging and increased use of chemotherapy.
Session 8
Pancreas Tumour – I
(DOI 10.1080/16515320310000841)
54
REGIONAL CHEMOTHERAPY PLUS OR MINUS PROPHYLAXIS OF THROMBOEMBOLIC EVENTS WITH LOW-DOSE WARFARIN IN THE TREATMENT OF ADVANCED PANCREATIC CANCER – A RETROSPECTIVE ANALYSIS
Mueller H, Nakchbandi W, Nakchbandi I, Seiler M
Carl von Hess Hospital, Oncologic Surgery, Hammelburg, Germany
Aim: Advanced pancreas carcinoma remains a disease with dismal prognosis and a median survival of about 5–6 months using systemic chemotherapy with Gemcitabine. In a retrospective study we have analysed the efficacy of four different regimens of regional chemotherapy with and without accompanying prophylaxis of thromboembolic events with low-dose warfarin.
Methods: This was a retrospective analysis of data obtained on 281 patients with a mean age of 59.4 years and a mean survival with therapy of 16.09 +/ − 0.5 months and a median survival of 10.23 months. These patients received one of four regimens of chemotherapy: Rl: Gemcitabine, mitomycin C (MMC); R2: bleomycin, MMC, Venorelbine/Metoxantron; R3: Paclitaxel, CDDP, Treosulfan; R4: CDDP, MMC, Melphalan/ Metoxantron with intraperitoneal chemotherapy (in the case of peritoneal metastases). In addition, 170 pts received warfarin at a dose of 1.25 mg daily. 203/281 pts were pretreated by operation (92), systemic chemotherapy (75) or radiochemotherapy (13). In 148 pts metastases were documented in the liver (148), lymph nodes (106), peritoneum (47) or the lung (32).
Results: 83 pts who received the combination Rl at any time during their hospital stay had a mean survival rate of 12.2 +/− 1.1 months (median 10.5 months) as compared to those who did not receive this combination with a mean survival of 9.4 +/− 0.5 months (median 7.7 months) (p < 0.05). The most important variable was the use of the regimen Rl at any time during therapy. In addition, we found that patients who received warfarin had a mean survival rate of 20.31 months (median = 11.28 months, n = 170) as compared with 10.89 months (median = 7.99 months, n = 111), p = 0.03. There was no significant difference in the number of thrombotic events or bleeding episodes with or without this low-dose warfarin therapy. In a regression analysis the combination of R1 therapy and warfarin kept its significance, suggesting an additional benefit using the combination of R1 regimen and warfarin.
Conclusion: In summary, in a retrospective analysis patients who received the combination of Gemcitabine and mitomycin C regionally had a survival benefit that was even further maximized by the addition of warfarin therapy. A prospective study comparing systemic therapy with Gemcitabine with regional therapy consisting of Gemcitabine plus mitomycin, with and without warfarin is thus warranted.
55
THE USEFULNESS OF STAGING LAPAROSCOPY IN PANCREATIC CANCER
Yoshimura N, Coldham C, Mirza DF, Bramhall S, Whiting J
Queen Elizabeth Hospital, Birmingham, UK
Aims: The manual for improving cancer services 'Improving Outcomes in Upper Gastrointestinal Surgery' states that laparoscopy should be performed before radical surgery for pancreatic cancer, a practice that is not widespread. The aim of this study was to examine the potential benefits of laparoscopy.
Methods: Between September 1997 and April 2002, data were collected prospectively on 230 consecutive patients with CT resectable pancreatic and ampullary cancers. Two patients underwent laparoscopy, the remaining 228 had laparotomy with curative intent. The number of patients found to have inoperable disease and the reasons for inoperability were recorded.
Results: 137 patients had pancreatic resections. 36 were unresectable because of peritoneal or liver metastasis. 53 had locally advanced disease. In 4 cases pancreatitis precluded resection. Ampullary tumours (n = 52) are associated with much fewer metastasis (n = 2) and after excluding this group 178 non-ampullary tumours remained of which 87 had unresectable disease. In this subgroup 34 patients had liver or peritoneal metastasis.
Conclusions: In non-ampullary cancers laparoscopy could have prevented up to 19% (34/178) of laparotomies. The survival for patients with metastatic disease is so poor (median 128 days) that patients are ill served by palliative bypass. In non-ampullary cancer staging laparoscopy should be performed as stated by the guidelines.
56
STAGING AND SURGICAL TREATMENT OF PANCREATIC CARCINOMA
Moustafellos P, Gourgiotis S, Alfaras P, Niakas E, Papakonstantinou A, Germanos S, Baratsis S
Athens Medical Center, 1st Surgical Department & Transplant Unit, Evangelismos Hospital, Athens, Greece
Aim: To present our results in the staging and surgical management of pancreatic cancer and discuss the indications of the existing methods of surgical treatment and their results.
Methods: During a 9-year period 65 patients with pancreatic carcinoma were treated surgically. The tumor was located in the head of the pancreas in 49 (75.4%) patients, the tumor was located in the body and tail in 8 (12.3%) patients, and in 8 (12.3%) patients the tumor arose from the ampulla of Vater. In 14 cases (21.5%), a pancreaticoduodenectomy (Whipple resection) was performed, in 2 (3%) cases total pancreatectomy and in 3 (4.61%) cases distal pancreatectomy was performed. 30 patients (46.15%) were treated with some kind of palliative operation (cholecys-tojejunostomy or choledochojejunostomy with or without gastrojejunost-omy). In 16 cases (24.6%) biopsy only was carried out. The selection of the operative method was dependent on the spread of the lesion. 26 patients were treated with supplementary chemotherapy with satisfactory results.
Results: 3 patients (4.61%) required re-operation due to complications and 2 (3%) patients died.
Conclusion: 29.23% of our cases were treated with pancreatic resection, and Whipple resection was found to be the procedure with the most satisfactory results and low morbidity. Palliative operations offered the patients a good quality of life for a short period of time.
57
LOCALLY ADVANCED PANCREATIC CANCER TREATED WITH RADIATION AND 5-FLUOROURACIL: A FIRST STEP TO NEOADJUVANT TREATMENT?
Smeenk HG, Jeekel J, Gouma DJ, Eijck van CHJ
Erasmus Medical Center, Rotterdam, The Netherlands
Aims: In this study, an analysis was performed in 85 patients with histologically proven pancreatic cancer without distant metastases. 47 patients were treated with chemoradiation. To evaluate the effect of this therapy, this group was compared to a non-selected group of 38 patients that did not receive chemoradiation.
Methods: Radiotherapy consisted of 50 Gy external upper abdomen radiation in two courses, concomitant with intravenous 5-fluoreouracil (5-FU) 25 mg/kg/24 h continuously on the first 4 days of each treatment course.
Results: The treatment protocol was completed in 40 patients without complications. Tumor response was seen in 13 patients, stable disease in 11 and progressive disease in 16 patients. The median survival time for the treated group was 10 months, which was significantly better than the 8 months median survival (of the non-treatment group) when treatment was not given (p < 0.015). A second-look operation was performed in 10 patients after completion of radiotherapy. In five patients (11%) the tumor could be resected without postoperative mortality. Median survival time in this group (n = 5) was 83 months (range 11–149 months).
Conclusion: Treatment of pancreatic cancer patients with 5-FU chemotherapy and radiotherapy is associated with prolonged survival. In some cases, neoadjuvant therapy led to resection of pancreatic cancer, which was not possible at an earlier stage.
58
EARLY RESULTS OF TOTAL PANCREATECTOMY FOR CHRONIC PANCREATITIS AND CANCER
Fronek, J, Ryska M, Belina F, Strnad R
Transplant Surgery Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
Aim: Total pancreatectomy (TP) is the most extensive treatment modality for patients with pancreatic cancer (PC) and chronic pancreatitis (ChP). This retrospective study aimed to define the morbidity and mortality of TP. The advantages and disadvantages of TP have crystalised during the last 10 years. Nowadays the indications are multicentre ductal pancreatic cancer, positive resection margins and certain indications in ChP.
Methods: During April 1998–November 2002 169 patients underwent surgery in this institute for PC, 11 of them were treated by TP. R0 resection was carried out in 10 patients. Morbidity was 45.5% and mortality was 0%. 184 patients underwent TP for ChP, 7 (3.80%, 5 men, 2 women). The indications were severe ChP with complications and symptoms resistant to conservative care and previous surgery (4), or tumour suspicion (3). Morbidity in this group was 42.9% (intra-abdominal abscess 1, wound infection 2), mortality was 0%.
Conclusions: The postoperative morbidity rate in TP was 45.5% resp. 42.9%, mortality 0%. TP is better ground for adequate lymphadenectomy, there is no risk of postoperative pancreatitis and leakage, postoperative diabetes mellitus and exocrine insufficiency is controllable in the majority of patients. In patients with ChP, TP is an operation of last resort. Early results are succesful. Late results are not available for the short postoperative period, of PC. In ChP it is difficult to collect the follow-up data.
59
OUR EXPERIENCE OF PERIAMPULLARY CARCINOMAS (20 YEARS' RESULTS)
Aktan S, Ogus M, Oygur N, Gokce G, Eser A, Alakus H, Emek K, Karpuzoglu T
University of Akdeniz, Faculty of Medicine, Department of Surgery, Antalya, Turkey
Aim: To outline our experience of periampullary carcinomas over a 20-year period.
Methods and Results: Between 1982 and 2002, a total of 204 patients were admitted to Akdeniz University Medical School, Department of General Surgery, Antalya, Turkey, with the diagnosis of pancreatic and periampullary cancer. Only 60 (29.4%) of those patients with periampullary cancer have undergone pancreaticoduodenal resection. 39 (65%) were male and 21 (35%) were female. The youngest patient was 22 and the oldest was 86 years old. The average age of the patients was 57 years old.
The localisation of the tumors was the head of the pancreas in 40 (66.6%) patients, the ampulla ofVater in 11 (18.3%) patients, distal common bile duct in 8 (13.3%) patients and the second part of the duodenum in 1 (1.6%) patient.
In our series, even for the small size (<1 cm in diameter) tumor of the second part of duodenum and ampulla, partial duodenectomy or transduodenal ampullectomy have not been done. Of those 60 cases 47 (78.3%) had classic pancreaticoduodenectomy (PD) and 4 (6.6%) had pylorus-preserving PD. 8 (13.3%) patients who had IDDM before the surgical intervention have undergone PD resection with total pancreatectomy plus splenectomy. In one patient the distal pancreatic channel together with surrounding pancreatic tissue were ligated and left alone without pancretico-jejunal anostomosis.
All the specimens were studied histopathologically in terms of the size of the tumor, tumor histology and differantiation, regional lymph node and surgical margin involvement to stage the tumor according to TNM classification. All pathologies were adenocarcinomas except one which was malignant lymphoma of the head of the pancreas. The size of the tumors in the surgical specimen varied between 2 cm and 5 cm in diameter. Surgical margin involvement was noted in one case and there was regional lymph node invasion in 11 patients.
The most frequently seen major complication was anastomotic leakage, which appeared in 8 (13.3%) patients. Six of the leaks were from pancreatico-jejunuostomy anastomosis and two were from biliary-enteric anastomosis. There were 6 (10%) postoperative hospital deaths.
In this study, for patients with periampullary cancer treated with PD, 1-, 2-and 5-year overall survival rates were calculated to be 44%, 27% and 8%, respectively.
Conclusion: Survival rates in our series of patients with carcinoma of the ampulla of Vater treated with PD were better than those for tumors located at pancreas. 1-, 2- and 5-year overall survival rates for ampullary cancers treated with PD were 65%, 39% and 22% respectively. The results obtained from our study are similar to those in related literature.
60
LOCALIZATION AND SURGICAL TREATMENT OF OCCULT INSULINOMA
Gourgiotis S, Alfaras P, Moustafellos P, Niakas E, Baratsis S, Hadjiyannakis E
Athens Medical Center, 1st Surgical Department & Transplant Unit, Evangelismos Hospital, Athens, Greece
Aim: To present our experience concerning diagnosis, localization and surgical treatment of 12 insulinomas in the past 12 years (1991–2002).
Methods: Patients comprised 4 men and 8 women with a mean age of 47 years. The most common presenting symptoms were related to severe neuroglycopenia. Hypoglycemic seizures and confirmed weight gain were present in some patients. All patients underwent a combination of abdominal ultrasound, abdominal CT and DSA angiogram. All patients underwent evaluation during a prolonged supervised fast, by measurement of serum glucose, insulin and c-peptide levels and by measurement of HbAlC. The mean duration of symptoms before diagnosis was 25 months.
Results: Enucleation of the tumor was performed in 5 cases, Whipple procedure was performed in 3 patients, while 3 patients underwent distal pancreatectomy. The 12th patient underwent total pancreatectomy following Whipple procedure (performed elsewhere). The final pathological diagnosis was solitary islet cell adenoma in 9 patients, multiple islet cell adenoma in 2 patients and neuroendocrine carcinoma in 1 patient. There was no postoperative death. The complications were 2 pancreatic fistulae and 2 wound infections.
Conclusion: Accurate diagnosis, preoperative localization and diligent surgical exploration by experienced surgeons are the key to a successful outcome in patients with insulinomas.
Session 9
Biliary Injury
(DOI 10.1080/16515320310000850)
61
BENIGN BILIARY STRICTURES: RESULTS OF A NATIONWIDE SURVEY
Erkan M1, Coker A2, Abbasoglu O3, Ince O4, Karayalcyn K5, Yagmur O6, Alper A1
Departments of Surgery, Istanbul University1, Dokuz Eylül University2, Hacettepe University3, Erciyes University4, Ankara University5, Cukurova University6, Turkey
A questionnaire regarding the experience of the treatment of benign biliary strictures (BBS) in different centers in Turkey has been prepared to evaluate the changes in the pattern of injury and its consequential effects on treatment strategy and outcome. 328 patients with BBS have been treated in 6 different centers and all of them have been evaluated retrospectively. Average age was 50.1±11.2 and jaundice and cholangitis were the leading symptoms (n = 203). In recent years, with a gradual increase in the availability of endoscopic and radiological expertise, the bulk of patients underwent extensive preoperative diagnostic and therapeutic procedures including endoscopic retrograde cholangiopancrea-tography (n = 106), percutaneous transhepatic cholangiography (n = 181), angiography (n = 44) and magnetic resonance imaging (n = 49). Definitive surgery was performed on 301 (91.7%) patients. Roux-en-Y hepaticojejunostomy was the reconstruction most frequently performed (68.6%). 32 patients were treated satisfactorily by balloon dilatation and 13 patients were followed without any intervention. In 20 patients reoperation was performed and there was a 19.2% major complication rate (n = 63). There were 18 (2.7%) hospital mortalities. Cholecystectomy was the leading etiological factor (n = 287) and 111 of them were performed laparoscopically. Overall, successful outcome was achieved in in 92.3% patients.
62
EXTRAHEPATIC BILE DUCT INJURY DURING LAPAROSCOPIC CHOLECYSTECTOMY
Bockhorn M, Frilling A, Malago M, Testa G, Li J, Broelsch CE
Department of General and Transplantation Surgery, University Hospital Essen, Essen, Germany
Aims: Despite clear advantages of laparoscopic cholecystectomy, the injury of hilar structures, particularly of the common bile duct, remains the subject of continuous discussion.
Methods: From April 1998 until September 2002, 33 patients with damage of the extrahepatic bile duct during laparoscopic cholecystectomy were referred to our institution. All patients underwent elective surgery because of symptomatic cholelithiasis in a hospital elsewhere. In 5 of these patients, the bile duct damage was diagnosed at the time of the laparoscopic procedure, leading to conversion to open surgery. In 3 other patients the bile duct damage was recognized early postoperatively and endoscopic bile duct stenting was performed subsequently. All 33 patients underwent laparotomy at our institution.
Results: Complete transection of the common bile duct was present in 29 patients. In 2 patients iatrogenic stenosis of the common bile duct was found. 2 patients had significant tangential duct lesions. Of the patients with complete bile duct dissection, there was damage to the common hepatic artery or right hepatic artery in 4 individuals. Reconstructive surgery included Roux-en-Y bilioenteric anastomosis in 31 cases, in 3 of them over an endoluminal drain. Reconstruction of the hepatic artery was also performed in 2 patients. 2 patients required right hepatectomy. In 1 of these patients a Klatskin tumor not recognized at the time of laparoscopy was diagnosed. The postoperative outcome was uneventful in 30 patients. Intra-abdominal abscess required laparotomy in 1 patient. 2 patients with complex bile duct and arterial damage died postoperatively, one with septic organ failure and the other due to hepatic insufficiency while waiting for liver transplantation.
Conclusion: Injury of the common bile duct presents a dangerous and potentially lethal complication of laparoscopic cholecystectomy, particularly in cases with concomitant vascular injuries. Early recognition of the lesion is extremely important. It is advisable to treat these patients in specialized centers, as their management frequently requires advanced knowledge of hepatobiliary surgery.
63
COMPARISON OF BILE DUCT INJURY IN LAPARASCOPIC AND OPEN CHOLECYSTECTOMY
Inc B, Demiryurek H, Yagmur O, Alparslan A, Sonmez H
University of Cukurova, Faculty of Medicine, Balcali, Adana, Turkey
Aim: Bile duct injury is a severe complication of cholecystectomy. The aim of this study is to compare the clinical features of bile duct injury after laparascopic and open cholecystectomy.
Methods: We identified a total of 46 cases between January 1995 and December 2002. Most of patients were referred to our center. 22 patients had had open cholecystectomy (group 1) and 24 patients had undergone laparascopic cholecystectomy (group 2). Sex, age, course of operation, average hospital stay, type of injury, location of injury, morbidity and mortality were analysed for both groups. The type of injury was classified according to Olsen's classification in both groups.
Results and Conclusion: The incidence of bile duct injury was higher in female patients. There was no difference in the average postoperative stay in hospital. Common hepatic duct injury was more frequently diagnosed in both groups. However, vascular injury was seen more frequently in the laparascopic group than the open surgery group. According to Olsen's classification, type III A was the major injury type in groups 1 and 2. Hepaticojejunostomy with stent, choledococholedocostomy, choledoco-duodenostomy, choledocojejunostomy, or T-tube were used to repair bile duct injury. There was no difference in morbidity and mortality in the two groups.
64
MAJOR BILE DUCT INJURIES ASSOCIATED WITH LAPAROSCOPIC CHOLECYSTECTOMY – ESPECIALLY LATE ONSET COMPLICATIONS
Kobayashi Y, Komori T, Yamaguchi N, Takahashi T, Takada E, Sunagawa M
First Department of Surgery, Dokkyo University School of Medicine, Tochigi, Japan
Background: The incidence of bile duct injuries (BDI) or bile duct strictures has remained a major concern since the introduction and widespread use of laparoscopic cholecystectomy (LC), even with development a new equipment such as US AD (ultrasonically activated device), which makes its control safer and less invasive for organ tissues.
Methods: Between 1991 and 2002, a total of 270 patients underwent LC in our department and USAD was introduced in April 1998. LC patients were divided into two groups according to whether USAD was used or not: group A (July 1991–March 1998, n = 139); group B (April 1998–July 2002, n = 131).
Results: 245 patients had a successful LC with uneventful recovery. 16 (5.9%) of 270 patients were simultaneously converted from LC to laparotomy because of uncontrollable bleeding or severe adhesions or BDI. 9 patients (3.3%) required the second operation after LC; 5 of these patients were managed within 3 days after LC complicated with bile leakage or hemorrhagic bleeding. The overall complication rates were comparable. However, 4 patients in group B with complicated liver dysfunction at 60–90 days after LC developed to bile duct stricture and 3 of those patients were managed by hepaticojejunostomy. Histologically, the epithelium of the bile duct was completely obscured by granulation tissues in all cases.
Conclusion: Although several reasons must be considered, mechanical vibration or degeneration by USAD may cause of bile duct injury in the late onset complications.
65
CONCOMITANT VASCULAR AND BILE DUCT INJURIES DURING LAPAROSCOPIC CHOLECYSTECTOMY: MANAGEMENT AND OUTCOME
Soonawalla ZF, Orug T, Tekin K, Shah SR, Olliff SP, McMaster PM, Buckets JAC, Mirza DF
Liver Unit, Queen Elizabeth Hospital, Birmingham University, Birmingham, UK
Aims: Bile duct injuries are a serious complication of laparoscopic cholecystectomy. The incidence and consequences of associated hepatic pedicle vascular injuries have been poorly reported.
Methods: This retrospective study over 10 years evaluates 92 consecutive patients referred to a tertiary hepatobiliary unit following bile duct injuries that occurred during laparoscopic cholecystectomy. Ten (11%) of these patients had co-existent hepatic vascular pedicle injury-their presentation, management and long-term outcomes are analysed.
Results: Of the 10 patients, 7 had isolated hepatic arterial injury, 1 had portal venous injury alone, while 2 had both arterial and venous damage. The associated biliary injury was major (Strasberg d,e) in all 10 cases. None of the 7 patients with isolated hepatic arterial injury had significant bleeding; the vascular component of the injury was detected during the operation in only one of them. All 3 cases with portal venous injury had profuse bleeding at cholecystectomy. Two patients, who were referred intraoperatively, underwent immediate vascular and biliary reconstruction. Three patients required hemihepatectomy – two for liver infarction secondary to arterial and portal venous injury, and the other for sepsis from intrahepatic abscesses; 2 of these 3 died postoperatively. 4 of 6 patients have suffered long-term consequences following hepatic artery occlusion.
Conclusions: Concomitant vascular injuries are not uncommon, particularly in patients with complex bile duct injuries or severe bleeding during laparoscopic cholecystectomy. Associated vascular injuries greatly increase patient morbidity and mortality, particularly if they are not suspected and treated promptly.
66
THE EFFECT OF CONCOMITANT VASCULAR DISRUPTION IN PATIENTS WITH IATROGENIC BILIARY INJURIES
Bilge O, Bozkiran S, Ozden Y, Tekant Y, Acarli K, Alper A, Emre A, Ariogul O
Istanbul University, Istanbul Faculty of Medicine, Department of General Surgery, Hepatopancreatobiliary Unit, Istanbul, Turkey
Aim: To evaluate treatment results in iatrogenic biliary injuries with concomitant vascular injuries.
Methods: Between January 1998 and May 2002 (inclusive), angiography was performed in 45 of the 105 patients treated for iatrogenic biliary tract injury. The charts of these 45 patients and 5 other patients in whom vascular injury was diagnosed at operation were evaluated retrospectively. 29 patients had concomitant vascular injury-the biliovascular injury group (BVI); the remaining 21 patients had isolated biliary tract injury (IBTI).
Results: The most frequent initial operation was cholecystectomy. The frequency of high-level (Bismuth III or IV) strictures was 90% in the BVI group and 62% in the IBTI group (p < 0.05). Perioperative mortality was 7% in the BVI group and 5% in the IBTI group (p > 0.05). The morbidity in the BVI group was significantly higher (p < 0.05). Two patients in each group were lost to follow-up. During a median follow up of 31 months (range 5–51), in the BVI group, successful functional outcome was achieved in 96% of the BVI group and 100% of the IBTI group with a multimodal approach (p > 0.05).
Conclusions: Concomitant vascular injury had no significant effect on mortality and medium-term outcome of biliary reconstruction. However, the frequency of high-level biliary injury and morbidity were significantly higher in the BVI group.
67
AN EXPERIMENTAL MODEL OF IATROGENIC BILIARY STRICTURE IN THE RAT
Ozden I1, Cantez S2, Cevikbas U3, Sivas A4, Ariogul O1, Sanli Y2, Alper A1
Istanbul University, Istanbul Faculty of Medicine, Departments of General Surgery1, Nuclear Medicine2, Pathology3 and Biochemistry4, Istanbul, Turkey
Aim: The clinical presentation and course of iatrogenic biliary tract injury exhibit wide spectra. The aim of this study was to establish an experimental model of iatrogenic biliary stricture in the rat.
Methods: Adult, male Wistar albino rats were allocated to two groups: group 1 (sham operation, n = 6) group 2 (iatrogenic injury, n = 12). The first group underwent laparotomy only. In the second group, a 1-cm segment of the hepatic canal below the hilar confluence was skeletonized and crushed with a mosquito hemostat for 3 seconds. Bilirubin and alkaline phosphatase (ALP) levels were measured on the 11th and 31st postoperative days.
Results:
| Day 11 | Day 31 | p value | |
|---|---|---|---|
| Group 1 | |||
| ALP (U/L) | 935 (703–986) | 933 (657–1088) | >0.05 |
| Bilirubin (mg/dl) | 0.10 (0.05–0.10) | 0.05 (0.05–0.10) | >0.05 |
| Group 2 | |||
| ALP (U/L) | 1265 (589–2907) | 1259 (539–1816) | >0.05 |
| Bilirubin (mg/dl) | 0.6 (0.1–18.6) | 0.2 (0.1–9.8) | >0.05 |
The biochemical values (median (range)) of the sham operation group remained homogeneous and stable. In contrast, in group 2, the data on day 11 reflected a heterogeneous response to the injury. Although the intra-group comparisons of the values on day 11 and 31 yielded insignificant differences, actually, individual animals in group 2 showed different courses: the values remained stable in 5 animals while they were aggravated in 4 and improved in 3.
Conclusion: The proposed model simulates the diverse clinical picture of iatrogenic biliary strictures.
Session 10
HPB Imaging
(DOI 10.1080/16515320310000869)
68
VIRTUAL AND DIAGNOSTIC ASSESSMENT FOR 3-D COMPUTED TOMOGRAPHIC ANGIOGRAPHY IMAGING IN HEPATO-BILIARY-PANCREATIC DISEASES
Yamaguchi N, Kobayashi Y, Takahashi T, Komori T, Sunagawa M.
First Department of Surgery, Dokkyo University School of Medicine, Tochigi, Japan
Aim: Following the introduction of helical dynamic computed tomography (CT), three-dimensional CT angiography (3-D CTA) has been widely accepted in clinical practice. 3-D CTA, as an excellent imaging technique, is expected to detect parenchymal tumor and vascular structures. This study aimed to investigate the diagnosis and evaluation of vascular involvement using 3-D CTA in preoperative planning in abdominal disease.
Methods: 11 patients with hepato-biliary-pancreatic diseases were assessed (5 with pancreatic carcinoma, 2 with GB carcinoma, 1 with carcinoma of bile duct, 3 with HCC). In all cases, 3-D CTA imaging were compared with conventional angiography and intraoperational findings.
Results: In 2 cases with pancreatic carcinoma, 3-D CTA accurately showed the presence of vascular invasion as a preoperative finding, and the patients safely underwent operation with vascular reconstruction.
Conclusion: Understanding the detail of vascular anatomy in advance and detecting a small lesion such as micro-metastasis produced good results in surgery, and also these practices provide an educational procedure for young surgeons. 3-D display of axial images in particular makes understanding of findings easier and more accurate. In clinical applications, 3-D CTA was very useful not only for the detection, evaluation, classification and staging of abdominal masses, but also for preoperative evaluation of vascular anatomy.
69
THE PREDICTIVE VALUE OF MAGNETIC RESONANCE CHOLANGIO-PANCREATOGRAPHY IN PATIENTS WITH SUSPECTED COMMON BILE DUCT STONES: A PROSPECTIVE STUDY
Vriens PW, Warmerdam PE, Breslau PJ
Rode Kruis Ziekenhuis, Department of Surgery, Den Haag, The Netherlands
Background: Patients suspected of having common bile duct (CBD) stones used to undergo intra-operative cholangiography (IOC) after cholecys-tectomy, and CBD exploration when necessary. Endoscopic retrograde cholangio-pancreatography (ERCP) could be used to diagnose and treat potential CBD stones. Both IOC and ERCP are invasive techniques with significant morbidity. Magnetic resonance cholangio-pancreatography (MRCP) is a non-invasive modality, allowing direct visualization of the biliopancreatic system.
Aim: To evaluate the predictive value of MRCP to detect CBD stones in patients at risk for choledocholithiasis, compared to IOC in a prospective study.
Methods: Between 1999 and 2002, all patients suspect of having CBD stones were scheduled for MRCP and cholecystectomy with IOC. Suspicion was based on history of jaundice or gallstone pancreatitis, raised serum bilirubin >17 mmol/1 or CBD diameter >7 mm on ultrasonography.
Results: 67 patients underwent MRCP. Of 52 patients with a negative MRCP, 51 had no signs of CBD stones on IOC. The negative predictive value of MRCP was 98%. MRCP was positive in 15 patients, 11 had CBD stones on IOC. Positive predictive value was 73%. Of the 12 patients who underwent CBD exploration for positive IOC, 11 had a positive MRCP. The sensitivity of MRCP was 92%. IOC was negative in 55, 51 of them had a negative MRCP. Specificity was 93%.
Conclusions: Since MRCP has a high negative predictive value and high sensitivity for CBD stones in patients at risk for choledocholithiasis, diagnostic ERCP is no longer necessary. ERCP and IOC should be reserved for patients with a positive MRCP.
70
ASSESSMENT OF VASCULAR INVASION IN HILAR CHOLANGIOCARCINOMA WITH MRI
Halazun KJ, Kotru A, Ghoz A, Guthrie A, Robinson PJ, Ward J, Toogood GJ, Pollard SG, Lodge JPA, Prasad KR
St James' University Hospital, Leeds, UK
Background: Resectability in hilar cholangiocarcinoma is determined by extent of tumour along the bile ducts and local invasion of vessels in liver hilum. Preoperative assessment often includes invasive investigations like percutaneous cholangiography and angiography. However, recent reports of using magnetic resonance imaging (MRI) for non-invasive assessment have been promising.
Aims: This study aims to correlate MRI findings in patients with hilar cholangiocarcinoma with macroscopic appearances of the tumour and histopathology findings (HP).
Methods: Over an 8-year period (1994–2002), 37 patients underwent surgical resection for hilar cholangiocarcinoma. The case notes of 32 patients were reviewed retrospectively. The MRI findings were compared with the operative findings and HP reports with respect to invasion of hilar vasculature and lymph nodal involvement.
Results: 17 males and 15 females were included in the study with a median age of 57 years (28–70). The results are shown in Table 1.
Table 1. MRI vs operative and HP findings.
| MRI + | MRI + | MRI − | MRI − | |
|---|---|---|---|---|
| O & HP + | O & HP | O & HP + | O & HP | |
| RPV involvement | 3 | 1 | 4 | 24 |
| LPV involvement | 10 | 1 | 4 | 17 |
| RHA involvement | 2 | 1 | 2 | 27 |
| LHA involvement | 2 | 0 | 0 | 30 |
| Lymph nodes | 10 | 3 | 10 | 9 |
Conclusions: (1) MRI had a 50% sensitivity (10/20) and 75% specificity in detecting lymph nodal involvement. (2) MRI was very specific in detecting RPV involvement (96% specificity), but the sensitivity was only 43% (3/7). (3) LPV involvement was better detected on MRI, with sensitivity of 70% (10/14 patients). It was also highly specific, predicting negativity in 17/18 patients (95%). (4) As regards arterial involvement, the sensitivity and specificity of MRI were 67% and 98%, respectively. (5) MRI is a very useful non-invasive modality for assessment of vascular involvement.
71
SELECTION CRITERIA FOR MR CHOLANGIOGRAPHY AND/OR ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY PRIOR TO OPEN OR LAPAROSCOPIC CHOLECYSTECTOMY
Ipekci F, Yener O, Alper E, Aksoy F, Gulhan Y
SSK Goztepe Educational Hospital, 1st Department of Surgery, Istanbul, Turkey
Aims: Routine use of endoscopic retrograde cholangiography (ERC) and/or magnetic resonance cholangiography (MRC) before cholecystectomy is not cost-effective. The objective of this study was to determine precise and easily applicable criteria to select patients who should undergo MRC and/or ERC before cholecystectomy.
Methods: From January 99 to December 2001, 440 patients who were candidates for laparoscopic or open cholecystectomy were evaluated by the choledoc stones scoring system in this clinic. Initial patient evaluations consisted of history and physical examinations and serum analyses for billuribin, ALP, transaminase and amylase. In addition, right upper quadrant abdominal sonograms were obtained for the determination of cholelithiasis and common bile duct (CBD) diameter. Patients with suspected choledocholithiasis: (1) history of pancreatitis, cholangitis, jaundice; (2) CBD diameter >5 mm; (3) total billuribin >1.5 mg/dl or ALP >150 U/l or AST >100 U/l.
Results: All patients were evaluated by the scoring system, then patients were divided into two groups. Group 1, patients at high risk for common bile duct stone, n = 47;, group 2, 393 patients were operated for cholelithiasis. MRC was performed in group 1 patients; 23 of them had common bile duct stone at MRC (%48.9). Diagnoses among the patients were as follows: acute chronic cholecystitis in 15 patients (32%), biliary pancreatitis in 15 patients (32%), obstructive jaundice in 8 patients (17%), biliary colic in 6 patients (13%), choledocholithiasis in 3 patients (6%).
Conclusions: MRC is a useful imaging modality for screening patients with suspected CBDS before cholecystectomy. All patients who are candidates for cholecystectomy should be evaluated by the scoring system. The selective use of MRC based on the scoring system will minimize the need for non-therapeutic ERC.
72
PEROPERATIVE EXPLORATION FINDINGS COMPARED TO MAGNETIC RESONANCE CHOLANGIOGRAPHY RESULTS IN COMMON BILE DUCT STONES ACCORDING TO THE CHOLEDOC STONES SCORING SYSTEM
Ipekci F, Yener O, Ergun A, Gulhan Y, Balkan T
SSK Goztepe Training Hospital, 1st Department of Surgery, Istanbul, Turkey
Aims: Magnetic resonance cholangiography (MRC) appears to be the best imaging method for the diagnosis of choledocholithiasis. The aim of this prospective study was to assess the accuracy of MRC in the diagnosis of common bile duct stones (CBDS).
Methods: Between 1 January 99 and 31 Deceember 2001, a total of 440 patients underwent laparoscopic or open cholecystectomy at this clinic. We prospectively evaluated the efficacy of MRC for the identification of CBDS among patients with high risk for choledocholithiasis. history of jaundice cholangitis, biliary pancreatitis: (1) CBD size by ultrasound >5 mm in diameter; (2) serum chemistry abnormality total billirubin, ALP >100, AST >100. Patient selection was based on clinical, sonographic and laboratory criteria. Operation findings were compared to MRC results.
Results: 440 patients underwent eevaluation with preoperative labarotory criteria. MRC was performed in 47 patients. CBDS were detected in 23 patients by MRC; in 20 of them stones were detected by intraoperative exploration (86.9%). In 3 of them stones were not detected by exploration.
Conclusions: MRC is useful for the evaluation of patients with suspected choledocolithiasis. The advantages of MRC include: its noninvasive nature, ease of application, accuracy in identifying and estimating the site of CBDS. The application of MRC in this setting reduces the need for diagnostic ERCP. The selective use of MRC based on the proposed algorithm will improve utilization of this imaging modality, while minimizing the need for non-therapeutic ERC.
CBDS scoring system→2→MRC→stone + →ERCP
MRC→stone (-)→cholecystectomy (laparoscopic or open)
73
DIFFERENT SENSITIVITY OF [18F]-FLUORODEOXYGLUCOSE POSITRON EMISSION TOMOGRAPHY IN DETECTING PRIMARY AND RECURRENT HEPATOCELLULAR CARCINOMA
Liu C, Frilling A, Gorges R, Kuhl H, Broelsch EC
Department of General and Transplantation Surgery, University Hospital Essen, Essen, Germany
Aims: The mechanism of [18F]-fluorodeoxyglucose positron emission tomography (FDG-PET) is based on the enhanced glucose metabolism of tumor cells. However, its value for diagnosis of hepatocellular carcinoma (HCC) remains controversial. The reported sensitivity of FDG-PET in detecting HCC ranged from 20% to 70%. In this study, the sensitivity of FDG-PET in detecting primary and recurrent HCC, respectively, was analysed.
Methods: At the authors's hospital, 40 patients with HCC who had FDG-PET examination within last 2 years were included in this study. These comprised 29 cases of primary and 11 cases of recurrent HCC. The results of FDG-PET were compared with ultrasonography, contrast-enhanced CT, MRT, serum AFP level, and histological grading.
Results: Altogether 8 cases (20%) were detected by FDG-PET; 2 cases (6.9%) of primary and 6 cases (54.5%) of recurrent HCC. Four cases of recurrent HCC were highly suspicious (maximal SUV 8.1) and the FDG-PET hot spots were confirmed by CT or MRT. Extrahepatic metastases were found at the same time in 2 cases of recurrent HCC. All 8 positive and 3 suspicious cases of HCC were moderately or poorly differentiated, and one suspicious case was well differentiated. One positive case with primary HCC had underlying hepatitis C and liver cirrhosis.
Conclusions: FDG-PET has higher sensitivity for detecting recurrent HCC than primary HCC. This may be due to varying degrees of glucose metabolism of tumor cells. FDG-PET has value in detecting recurrence and extrahepatic metastasis of HCC, moreover, in discriminating tumor lesion and regenerating nodules in liver cirrhosis.
74
THE UTILITY OF WHOLE BODY FDG-PET IN THE ASSESSMENT OF COLORECTAL LIVER METASTASES
Bhattacharya S, Abraham AT, Hutchins RR, Desai C, McLean A, Bomanji JB
Royal London Hospital, London, UK
Aims: To assess the sensitivity, specificity and clinical value of whole-body 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) in assessing colorectal liver metastases.
Methods: Over 2 years, 54 patients were studied prospectively. They included 40 consecutive patients deemed on ultrasonography and contrast-enhanced CT/MR to have resectable liver metastases from colorectal cancer. All underwent FDG-PET as the last investigation before deciding treatment. At surgery, intra-operative ultrasound was performed. Histological findings were compared with imaging results. Also, FDG-PET was used to assess 7 patients with suspected tumour recurrence following resection, and in 7 patients to assess efficacy of radiofrequency ablation or chemotherapy.
Results: In the 40 candidates for liver resection, FDG-PET identified 103 lesions (79 hepatic, 24 extrahepatic) with 100% specificity and 95.3% sensitivity for hepatic metastases, and 83.3% specificity and 96% sensitivity for extrahepatic lesions. FDG-PET provided new information in 22 (55%) patients. It altered management in 15 (37.5%) patients – in 4 it led to surgical resection, while 11 had proposed resections cancelled. In 18 (45%) patients FDG-PET revealed additional disease and in 4 (10%) it downstaged the disease. 24 patients underwent surgery; 20 had successful liver resections. In 7 patients with suspected tumour recurrence, FDG-PET revealed the site of recurrence in 6. In 7 patients, FDG-PET proved useful in confirming successful resection/ablation of the lesions treated, but also in revealing new disease.
Conclusions: FDG-PET should be an essential part of the staging algorithm before resection of colorectal liver metastases.
75
COMPARISON OF MRCP AND ERCP IN CHOLEDOCHOLITHIASIS
Akaydin M, Akcakaya A, Kaplan R, Aydin M, Sahin M
SSK Vakif Gureba Hospital, 2 Department of Surgery, Istanbul, Turkey
Aim: The results of ERCP and MRCP in choledocholithiasis were compared in our clinic. Nowadays, MRCP is increasingly performed as a non-invasive procedure for the diagnosis of choledocholithiasis. Before ERCP, the diameter of the choledochus and the number and the diameter of stones have to be estimated, as they can affect the success of ERCP, especially in difficult choledochus cannulation cases.
Methods and Results: MRCP was performed before the procedure in 46 cases aged 25–82 years (average 57.8); the number of female and male patients was equal. Pain was the major complaint in all cases. There was mechanical jaundice in 7 cases during ERCP. There were 2 cystic dilatations. In our series 40 cases had dilatation of the choledochus and 44 choledocholithiasis cases were reported by MRCP. After performing ERCP the results were as follows: choledochus dilatation, 44 cases; choledocholithiasis, 44 cases; and cystic dilatation, 2 cases. 2 false positive and 2 false negative results were determined by MRCP before the procedure. Screening the dilatation of the choledochus by MRCP was determined to be less sensitive than ERCP. In false-negative cases stones <5 mm were found in the choledochus after ERCP examination. As the number and diameter of the stones in the choledochus rose, the positive result rate in MRCP rose proportionally.
Conclusion: We suggest that before performing ERCP as an invasive procedure, determination of the stones in the choledochus by MRCP will increase the success rate of ERCP.
16:00–17:30
Session 11
Liver Resection – 3
(DOI 10.1080/16515320310000878)
76
LIVER SECUNDARIES OF COLORECTAL CARCINOMA – CURRENT THERAPY IN THE CZECH REPUBLIC
Ryska M, Pantoflicek J, Belina F
Institute for Clinical and Experimental Medicine, Transplant Surgery Department, Prague, Czech Republic
Aim: The Czech Republic, with a colorectal carcinoma (Cr-Ca) incidence of 73.5 new cases/100,000 inhabitants, occupies the highest position in the world. Liver secondaries are found in 60–70% of patients. This study aimed to evaluate the questionnaire data obtained from surgical departments in 2000.
Methods: 10 answers regarding diagnosis, surgery and follow-up were obtained from 75 surgical departments providing 76% of operations for Cr-Ca in the Czech Republic. 51 departments perform 20–50 bowel resections annually, but liver operations exceptionally, and 24 departments perform liver resections routinely.
Results: 144 liver resections, 173 metastasectomies and 50 ablations were performed. In 99 cases a hepatic artery access system was inserted. Diagnosis was defined by US/CT in 100%, by MR in 15% and by IOUS in 9% of cases. Of 24 surgery departments, 17 performed <5 resections yearly. There was no chance for treatment in 3 (4%), surgery as the best solution in 50 (67%) and chemotherapy alone in 17 (22%) patients. Repeated resections for liver metastases was found to be suitable in 25 (33%) patients. Follow-up was provided in 82% by surgeons, in 58% by oncologists and in 16% by gastroenterologists. CEA and CA 19.9 were examined regularly in 100% of patients.
Conclusions: Resection therapy of liver secondaries of Cr-Ca is rarely provided in the Czech Republic, and is not systematic. The management of these patients should be standardised.
77
SURGICAL TREATMENT AND REGIONAL CHEMOTHERAPY OF LIVER COLORECTAL CANCER METASTASES
Severtsev A, Mischerjakova T, Volodin D, Pfaf V, Bakay I, Kuleshov I, Remizov M, Melnikov G
HPB Surgery Department, MPS-Central Clinical Hospital, Moscow, Russia
Aim: At the time of diagnosis most patients with colorectal cancer also have liver metastases (MTS). At the same time during the first year after colon or rectum cancer resection most patients develop liver MTS. There are some prospects for the use of new anti-cancer drugs and the introduction of so-called cytoreductive surgery in this situation. Unfortunately, the real situation in this direction is not clear at present. The purpose of this study was to assess the clinical results of a combination of cytoreductive surgery and new anti-cancer pharmauceutical agent – CPT-11 (irinotecan).
Methods: From December 1994 to May 2001, 45 patients with metastatic liver colorectal cancer had surgical treatment at the Surgical Dept/Liver Unit of the MCRG (Moscow, Russia). The male:female ratio was 20:25 and the mean age of patients was 62±10 years. The main site of cancer (colon or rectum) was resected. All patients had cytoreductive liver resection (some non-resectable MTS nodules were non-resected). 15 of the latter had different postoperative cytoreductive methods. All patients had intraoperative intra-arterial (a. hepatica) vascular port insertion for regional postoperative chemotherapy. 3 weeks after surgery patients had intra-arterial chemotherapy: CPT-11 at 150 mg/m2 (+i.v. 150 mg/m). The number of courses was up to 11.
Results: 5 patients (9%) died after surgery (1 month). The main cause of death was liver insufficiency. All other patients were alive with a mean time after surgery of 2.5 years: 1 year after surgery–40 patients (100%), 2 years-32 patients (80%); 3 years – 28 patients (70%); 4 years – 15 patients (37.5%); 5 years – 5 patients (12.5%). At the time of chemotherapy all patients experienced stabilization of cancer progression. From 3 months onwards there was cancer progression. The re-commencing of regional chemotherapy produced re-stabilization. Chemotherapy was stopped when the general condition of the patient was poor or there were major complications from this treatment.
Conclusion: The combination of cytoreductive surgery and regional (plus systemic) chemotherapy with new agents and regimes could be a good challenge for patients with advanced colorectal cancer even if not all liver nodules are resected.
78
SPONTANEOUS RUPTURE OF BENIGN HEPATOCELLULAR TUMOURS
Jethwa P, Lala A, Buckels JAC, Mayer AD, Mirza DF, Bramhall SR
Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
Aim: Adenoma and focal nodular hyperplasia (FNH) are rare hepatocellular tumours. Resection of adenoma is recommended because of the risk of malignant change and rupture with haemorrhage; however, as FNHs are believed to remain asymptomatic, their resection is not indicated. The aim of this study was to review the pathology of benign hepatocellular tumours presenting with rupture and assess the role of delayed surgical intervention in their management.
Methods: Data for patients who presented with benign hepatocellular tumours between January 1995 and October 2002 were obtained. Only patients presenting with spontaneous rupture of tumours were studied.
Results: 37 patients with benign hepatocellular tumours (adenoma, 17; FNH, 18; others, 2) were managed during this period. 8 females and 2 males presented with spontaneous rupture of tumours. 6 females were on oral contraceptives (OCP) when they bled. 6 were operated on during the same admission. 3 who remained haemodynamically stable later underwent elective resection. Surgical resection varied from segmental resection to extended hemi-hepatectomy. There was no postoperative mortality. Surgical resection was facilitated following resolution of subcapsular haematoma in elective resections. One patient who had multiple lesions in both lobes of liver was considered inoperable and advised to avoid the OCP and has remained well. Histology of the resected lesions showed: adenoma (7), nodular regenerative hyperplasia(l) and FNH(l).
Conclusions: Hepatic adenoma is the most common benign hepatocellular tumour to present with spontaneous rupture and bleeding; however, FNH may also rupture. There is a place for delayed surgical resection of bleeding tumour in a haemodynamically stable patient.
79
HEPATITIS VIRAL STATUS AFFECTS THE PATTERN OF INTRAHEPATIC RECURRENCE AFTER RESECTION FOR HEPATOCELLULAR CARCINOMA
Wakai T, Shirai Y, Yokoyama N, Nomura T, Nagakura S, Hatakeyama K
Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
Aim: To define whether the patterns of intrahepatic recurrence after resection for hepatocellular carcinoma differ according to hepatitis viral status.
Methods: 111 patients undergoing a curative resection for hepatocellular carcinoma were divided into three groups: the C-viral group (n = 55), which tested positive for hepatitis C antibody; the B-viral group (n = 32), which tested positive for hepatitis B surface antigen; and the non-B non-C (NBNC) group (n = 24), which tested negative for both hepatitis B surface antigen and hepatitis C antibody. The long-term outcomes were analysed retrospectively.
Results: The pattern of development of intrahepatic recurrence differed between the NBNC group and the other groups: the cumulative probability of intrahepatic recurrence reached a plateau at 2.4 years after resection in the NBNC group, while it continued to increase steadily in the hepatitis viral groups. The C-viral group showed a higher incidence of intrahepatic recurrence than the other groups by univariate (p = 0.0306) and multi-variate (relative risk = 1.69, p = 0.0429) analyses. Multiple intrahepatic recurrent lesions were more common in the C-viral group (p = 0.0457).
Conclusions: Multicentric carcinogenesis in the remnant liver was less common in the NBNC group than in hepatitis viral groups. Hepatitis C virus infection is a significant risk factor for intrahepatic recurrence after resection and is also associated with multiple intrahepatic recurrent lesions.
80
DIFFERENTIATED CATHETERISATION OF HEPATIC VEINS TO ANALYSE TUMOR CELL DISSEMINATION DURING LIVER SURGERY FOR COLORECTAL LIVER METASTASIS
Fruhauf NR, Oldhafer KJ, Kasimir-Bauer S, Gorlinger K, Lang H, Kaiser G, Broelsch CE
University of Essen, Klinik fur Allgemein- und Transplantations Chirurgie, Essen, Germany
Aim: Patients undergoing resection of colorectal liver metastasis have a high risk for tumor recurrence. Since concepts like 'no-touch surgery' are hard to obtain in liver surgery, perioperative tumor cell dissemination due to manipulation of tumor tissue might be one of the major reasons for this.
Methods: 47 patients undergoing hepatic resection due to colorectal liver metastasis were studied for cytokeratin (CK) -positive cells in blood and bone marrow (BM) samples before surgery and in blood samples from the hepatic vein during surgery of liver metastasis by immunochemistry. Normal and malignant tissue in the liver samples was studied for the expression of the urokinase plasminogen activator (uPA), the oncoprotein Her-2/neu and the epithelial growth factor receptor (EGF-r), by sandwich enzyme immunoassays.
Results: CK-positive cells were detected in the BM of 26/47 patients (55%), in blood samples before surgery in 14/47 patients (30%) and during surgery in 11/47 patients (23%). No CK-positive cells were found in 15/47 patients (32%) in any sample studied. Normal liver tissue showed a threefold higher expression for EGF-r compared to tumor tissue. A ninefold higher expression of uPA was detected in 63% of tumor tissue samples. Although the mean values for Her2/neu in normal liver tissue were comparable to those in tumor tissue, significant differences in expression were found in 47% of patients. Patient follow-up and survival rates show clear correlations to the presence of CK-positive cells.
Conclusion: Although CK-positive cells were present before surgery in some patients, an isolated perioperative spread of CK-positive cells occurs in 23% of cases. These findings, including uPA overexpression in liver metastasis, may carry an increased risk for early disease recurrence. Modification of surgical techniques may help to avoid or reduce tumor cell spread.
81
YIELD OF RESECTABLE LIVER METASTASES WITH INTENSIVE ULTRASOUND-BASED FOLLOW-UP AFTER COLORECTAL CANCER RESECTION
Mercer S, Lew-Gor S, Smith J, O'Leary D, Midwinter M
Solent Department for Digestive Diseases, Queen Alexandra Hospital, Portsmouth, UK
Aims: Intensive follow-up after curative resection for colorectal cancer improves survival, primarily through the benefit of curative resection of colorectal liver metastases. This study reviewed the experience of ultrasound-based liver surveillance in a DGH with a specialist colorectal unit.
Methods: All patients with a colorectal cancer resection between June 1996 and May 1999 who presented with or developed liver metastases were reviewed. The policy adopted was of 6-monthly ultrasound scans for 2 years following colorectal cancer resection in patients aged 75 and under.
Results: Of 646 patients undergoing colorectal cancer resections over the 3-year period, 74 had synchronous metastases, of whom 5 underwent potentially curative hepatic resection. Ultrasound-based follow-up identified a further 23 patients with metachronous metastases; of 15 patients under the age of 75, 3 underwent potentially curative hepatic resection. In 38% of cases, preoperative ultrasound failed to detect liver metastases which were palpable at surgery.
Conclusions: Ultrasound-based surveillance identified very few patients with hepatic metastases amenable to curative resection. More aggressive follow-up, including other imaging modalities, is required if UK hepatic resection rates are to approach those in mainland Europe and the USA.
82
SPONTANEOUS RUPTURE OF HEPATOCELLULAR CARCINOMA: DIFFERENT THERAPEUTIC OPTIONS
El-Sefi T, Osman M, El-Abd O, Abou El Ela K, Hammad E, Sadek A, Shawki A, Ibrahim T, Mohamed AM, Marwan I
National Liver Institute, Menoufeya University, Alexandria, Egypt
Aim: To analyse the results of the management of 24 cases with spontaneous rupture of hepatocellular carcinoma (HCC).
Methods: Between January 2000 and December 2002, 24 patients were admitted with ruptured HCC. They were divided into 3 groups according to the initial treatment modality: group I (10 patients) underwent emergency surgery; group II (8 patients) were treated by transarterial embolization (TAE); and group III (6 patients) were treated conservatively, 2 of them received additional octreotide drip infusion.
Results: In group I, non-anatomical limited resection was done in 5 patients, suture plication in 2, enucleation of the extruded ruptured tumor in 2, and pressure gauze packing in 1 patient. Three patients died within 1 month from liver failure. In group II, initial hemostasis was successful in all patients. Thereafter; 1 of them underwent delayed resection, and 3 had transarterial chemoembolization (TACE). The remaining 4 patients were continued on supportive treatment. Hospital mortality consisted of 2 patients. In group III, patients were treated by volume replacement, and correction of acidosis and coagulopathy. Two of them received additional octreotide drip infusion for 5 days. One patient had received TACE 3 weeks after admission. Two patients in this group died within 1 week of admission.
Conclusions: Treatment options should be individualized according to the patient's general condition, the hepatic reserve, the experience of the surgeon, and the availability of interventional radiology. A staged approach with non-invasive initial haemostasis (either by TAE or octreotide infusion) followed by elective liver resection or TACE was an effective modality of treatment. The administration of octreotide in such patients carries new promise, but awaits a larger group of patients to reach a conclusion.
83
SURGICAL EXPERIENCE WITH MALIGNANT LIVER TUMOURS
Oktay C, Yuney E, Tunali V, Kamali S
SSK Okmeydani Hospital-Sisli, Istanbul, Turkey
Aims: The aim of this report is to review surgical approach, morbidity and mortality rates and prognostic factors in patients with malignant liver tumours.
Methods: We evaluated 34 patients treated in this department between the 1999 and 2002. 14 patients were evaluated as inoperable by the use of advanced techniques such as colonoscopy, BT and MR and the rest of the 20 patients were operated, 6 patients with a diagnosis of primary liver tumour and 14 patients with a diagnosis of metastatic (secondary) liver tumours. Re-resection was performed for 2 patients with secondary liver tumour.
Results: While 7 of the 20 patients who were operated on developed early complications, late complications were observed in only one patient (morbidity 40%). 2 patients with hepatocellular carcinoma (HCC) and one patient with metastatic tumours died during the peroperative period (mortality 15%).
Conclusions: The results of our surgical interventions for metastatic liver tumours were similar to those in the literature and we believe that patients with primary liver tumour should be carefully selected and limited surgery should be performed for these patients.
Session 12
Liver Tumour – Local Treatment
(DOI 10.1080/16515320310000887)
84
TREATMENT STRATEGY FOR SMALL AND SINGLE HEPATOCELLULAR CARCINOMA: COMPARISON OF PERCUTANEOUS ETHANOL INJECTION THERAPY AND SURGICAL RESECTION
Shimoda M, Kubota K
Dokkyo University, Tochigi, Japan
Aim: This study was conducted to clarify the efficacy of percutaneous ethanol injection (PEI) and surgical resection for the treatment of small hepatocellular carcinoma (HCC).
Methods: From January 1994 to December 2001, 40 patients were treated by PEI (P group) and 32 patients underwent hepatic resection (Hr group) for small HCC (<5 cm and single lesion). Retrospectively, long-term patients and recurrence-free survival were compared in the two groups. Data were expressed as means. Student's t test and Kaplan-Meier methods were used for comparisons. A p value <0.05 was considered statistically significant.
Result: There were no statistically significant differences in preoperative liver function, gender or age in the groups. Mean tumor size was 2.1 cm in the P group and 3.1 cm in the Hr group, respectively. Mean patient follow-up was 44.5 months for P group and 31.3 months for the Hr group (p = 0.021). The Hr group had statistically better 1-, 3- and 5-year overall survival rates than the P group (92.5%, 74.6%, 45.7% in the P group, 93.6%, 83.9%, 74.6% in the Hr group, respectively, p = 0.047). During the follow-up period, 23 of the 40 (57.5%) and 9 of the 32 (28%) patients developed tumor recurrence after PEI and surgery. Cumulative 1-, 3- and 5-year recurrence-free survival rates in the P group were 68.4%, 46.9% and 26.2%, whereas those in the Hr group were 73.6%, 65.7% and 65.7%, respectively. The results for the Hr group were significantly better than those for the P group (p = 0.048).
Conclusion: Our overall findings show that liver resection can achieve better overall and recurrence-free survival than PEI.
85
THE LONG-TERM RESULTS OF RADIOFREQUENCY ABLATION IN PATIENTS WITH COLORECTAL LIVER METASTASES
Navarra G, Jiao L, Tysome JR, Curro' G, Habib NA
Department of Surgical Oncology and Technology, Imperial College School of Medicine, Hammersmith Hospital Campus, London, UK
Aims: To evaluate the long-term results of radiofrequency ablation of unresectable colorectal liver metastases.
Methods: This was a retrospective review of patients with unresectable colorectal liver metastases between June 1997 and April 2001 who underwent radiofrequency ablation. Postoperative morbidity and mortality were examined together with the recurrence rate and survival.
Results: 38 patients (mean age 59.5 years; range 31–83) underwent intraoperative radiofrequency ablation. A total of 203 colorectal liver metastases was recorded. Of these, ablation was achieved in 168 lesions and 35 lesions became resectable following radiofrequency ablation in 8 patients. There was no mortality. Postoperative complications occurred in 5 patients (13.2%), 3 of which happened in patients treated with radiofrequency ablation plus resection. The ablation was considered complete in 22 patients. The median follow-up period was 27.1 months (range 12–54). Among the patients with a complete ablation, of the 11 patients who had recurrences in the liver (50%) one also relapsed in the pelvis, one had local recurrence at the site of the primary, one in the bone and the lung, respectively. Kaplan-Meier survival estimates in patients with complete ablation showed a 1-year survival rate of 95%, 2-year survival rate of 79% and 3-year survival rate of 65%.
Conclusion: Radiofrequency ablation is a safe and effective option for patients with advanced colorectal liver metastases. The major advantage of this technique is that it increases resectability and improves survival. When used in association with other loco-regional or systemic treatment, it can increase the control of the disease.
86
RADIOFREQUENCY ABLATION OF HEPATIC TUMORS: PERSONAL EXPERIENCE
Filauro M, Cappato S, Marini P, Franceschi A, Papadia F, Angelini G
HBP Surgery, Galliera Hospital, Genoa, Italy
Aim: To describe the authors' experience of radiofrequency ablation (RFA) of hepatic tumors.
Methods: RFA is an ablative technique for small liver tumors that are unresectable for various reasons. Between April 1997 and May 2002, 64 patients were treated in our center for a total of 75 hepatic malignancies: 36 lesions were hepatocellular carcinoma (HCC) and 39 lesions were metastases, from colorectal and non-colorectal cancer. In 27% of cases we used a celiotomic approach, in 6% of cases a laparoscopic approach and in 67% of cases a percutaneous approach. RFA was always performed under US guidance. There was no treatment-related mortality; we observed a morbidity rate of 1.5% for major complications and 3.1% for minor complications.
Results: Mean survival after HCC was 16.0 months. Mean survival after treatment of metastasis of colorectal cancer was 15.3 months. Actuarial survival of patients with HCC was 32.6% at 24 months and 38.5% for patients with metastasis of colorectal cancer. The recurrence rate observed was 25% for HCC and 28% for metastatic lesions. HCC recurrence was observed in nine patients (25%), in 3 of them (8.3%) RFA was repeated. The mean time for appearance of local recurrence was 4 months. In five cases (13.8%) we observed multifocal and/or extrahepatic diffusion. In 1 case of multifocal recurrence the patient had TACE. No further treatment was performed in the other patients for poor general conditions, poor liver function or extrahepatic disease appearance. Recurrence of hepatic metastasis occurred in 11 patients (28%). In three cases (7.6%) recurrence could be treated with a second RFA session, in 8 patients (20.5%) recurrence presented as multifocal and/or extrahepatic disease and no additional surgical treatment could be performed. In every case of repeated ablative treatment, no additional morbidity was observed.
Conclusion: In selected cases, we consider that there is a role for RFA as complementary treatment to surgery. Waiting list for liver transplant, for HCC, and two-stage hepatectomy, for metastatic disease are interesting applications of RFA.
87
THE BIOCHEMICAL RESPONSE AFTER RADIOFREQUENCY ABLATION OR CRYOABLATION IN PATIENTS WITH LIVER TUMOURS
Roerdink WH, Peeters PMJG, Porte RJ, Bottema J, Slooff MJH, de Jong KP
Department of HPB Surgery & Liver Transplantation, University Hospital Groningen, Groningen, The Netherlands
Aim: To evaluate the biochemical response after radiofrequency ablation (RFA) or cryoablation of liver tumours.
Methods: 22 patients underwent cryoablation and 15 patients had RFA. We evaluated liver synthetic capacity (PTT, albumin), liver excretory capacity (bilirubin), liver cell damage (ALAT), thrombocytes, acute phase response (CRP), secondary injury (myoglobin, CPK) and renal function (creatinine). Serum samples were takenpreoperatively and on days 1, 2, 3, 4, 7 and 10 after the procedure. Differences in serum response between the two groups were statistically analysed.
Results: On the day of peak levels CRP and PTT were higher in the cryoablation group as compared to the RFA group. On the first 2 postoperative days median serum values of thrombocytes and albumin decreased to lower levels in the cryoablation group than in the RFA group. No differences in serum response of ALAT, CPK, myoglobin and creatinin were found in the two groups. The total serum response of bilirubin was significantly higher in the RFA group.
Conclusion: Cryoablation initially induces a more severe impairment of liver synthetic capacity than RFA. The acute phase response and the decrease of thrombocytes after cryoablation are more pronounced when compared to RFA. Thus, as far as the initial biochemical response is concerned, RFA seems to be a less harmful technique when compared to cryoablation.
88
TRANSCATHETER ARTERIAL CHEMOEMBOLISATION AS A PALLIATIVE TREATMENT FOR PATIENTS WITH INOPERABLE HEPATOCELLULAR CARCINOMA
Zieniewicz K, Remiszewski P, Grodzicki M, Kotulski M, Dudek K, Korba M, Najnigier B, Michałowicz B, Nyckowski P, Patkowski W, Rowinski O, Krawczyk M
Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
Aim: Transcatheter arterial chemoembolisation (TACE) is one of the oldest methods of treatment for patients with hepatocellular carcinoma (HCC). It was introduced to clinical practice in 1983–1984 in Japan. Still the role of TACE in the multimodal treatment of the advanced HCC is widely discussed. The aim of the study was to analyse the indications and the results of the treatment of patients with inoperable HCC by TACE.
Methods: The medical records of patients treated for HCC in this department in the period 1995–2002 were reviewed. A group of 135 patients with advanced HCC, with contraindications to surgery, because of multifocal lesions in both liver lobes and/or large size and localisation of the tumor, was indentified. Chemoembolisation with lipiodol or intra-arterial chemotherapy was proposed as a palliative method of treatment in this group of patients. There were 83 men (61.5%) and 52 women (38.5%), aged 23–84 years (mean 64±13 years). In 85 patients (63%) the tumor was detected in cirrhotic liver and in 50 patients (37%) the liver parenchyma was healthy. The most common causes of the liver cirrhosis were hepatitis C (46 patients, 54%) and hepatitis B (24 patients, 28%). The mean diameter of the lesion, if single, was 77±21 mm. The most common findings were disseminated HCC in both liver lobes (67 patients, 49.6%), in the right lobe only (36 patients, 26.7%) or in the left lobe only (8 patients, 5.9%). Extrahepatic dissemination was diagnosed in 8 patients. The mean alfafetoprotein serum concentration at the begining of the treatment was 5612±2758 ng/ml. The majority of the patients were cassified as Okuda stage I-II. The chemotherapeutic drug that has been used in our center is doxorubicin (adriamycin) suspended in lipiodol. The subsequent embolisa-tion was performed selectively with the use of gelfoam and autologous blood clots. In this group of patients 1–8 sessions of chemoembolization were performed (mean 2.7). The chemotherapy was typically repeated every 4–16weeks (mean interval 6.4 weeks), depending upon the hepatic tolerance, the response and recovery of the white blood cells and platelets and the period of clinical patient recovery. US examination and/or CT scan were obligatory as a method of follow-up every 1–2 months.
Results: The operative morbidity was 5.9% (8 patients), the majority were technical complications. 3 deaths related to the procedure were observed: in 2 patients this was due to acute liver failure and in 1 patient there was massive peritoneal hemorrhage from the huge protruding tumor. The survival time from the beginning of the treatment in the whole group was 3–4 months (mean 12 months). The most common cause of death was tumor progression and liver failure.
Conclusion: TACE is a relatively simple and safe procedure which may be offered as a palliative treatment for patients with advanced inoperable HCC. The place of TACE as an element of multimodal approach in the treatment of HCC still needs further experience.
89
LOCAL TREATMENT OF UNRECTABLE LIVER TUMORS
Shaposhnikov A, Teternikov A, Bordushkov U, Perfilov A
Rostov Research Oncology Institute, Rostov-on-Don, Russia
Aims: The purpose of this study was to examine the cytoreductive effects of local application of 96° alcohol (AA), RF ablation (RFA) and electrolysis (EA) for treatment of multifocal unrectable malignant liver tumors.
Methods: Three series of experiments were carried out on 6 pigs during laparotomy. First, 10 ml of 96° ethanol were injected into the liver tissue. In the second, a monopolar umbrella electrode (tip diameter 5 cm) was inserted into liver tissue for 5 min duration and 110 kHz alternating current was passed through the electrode. In the third series, two gold-platinum electrodes of 2 mm diameter each were placed into the liver at distances of 5 cm. Direct current (100 mA, 60 V) was passed between electrodes for 15–25 min. Local tissue temperature was measured by needle thermometry right after exposure. The destructive effects on local hepatic cells were studied histologically. These methods were performed laparoscopically or after laparotomy in the treatment of 63 patients with multifocal hepatocellular or cholangiocellular carcinomas (AA, 43 patients; RFA, 12 patients; EA, 8 patients). The follow-up results of the treatment were evaluated clinically and by sonography.
Results: Local liver tissue necrosis was found in all experiments, especially after RFA. The liver tissue temperature in the RFA zone varied between 60 and 105°C, and after EA between 55 and 82°C. There were no intraoperative or postoperative complications. 1-year survival was 92.0% after RFA, 85.0% after AA (12.5% and 8.0%, in the control groups, respectively). All 8 patients were alive 9 months after electrolysis ablation.
Conclusion: Local ablation of unresectable liver tumors is an effective method of treatment, especially RFA. Electrolytic destruction of hepatic malignancy needs further evaluation.
Session 13
Pancreas Tumour – 2
(DOI 10.1080/16515320310000896)
90
COMPARISON OF BYPASS AND PALLIATIVE RESECTION THERAPY FOR PANCREATIC CANCER
Strnad R, Fronek J, Langer D, Belina F, Ryska M
Transplant Surgery Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
Aim: Pancreatic cancer is the fifth most common cause of cancer death in Europe. 80% of cases are locally advanced or have distant metastases. Radical procedures are only suitable for a minority of patients. Palliative or symptomatic procedures are common. Bypass is usually planned according to the preoperative investigations. Palliative resection is usually indicated by peroperatively or postoperatively by the definitive histology. This study compared bypass and palliative resection therapy for pancreatic cancer.
Methods: From April 1998 to December 2002, 72 patients underwent palliative surgery and 13 resection for pancreatic cancer at this institute (3 had total pancreatectomy and 10 underwent duodenopancreatectomy). 59 patients underwent the bypass procedure. In total there were 51 hepaticojejuno-anastomoses and 17 gastroentero-anastomoses.
Results: One patient (8%) died within the early postoperative course after palliative resection. Early postoperative morbidity was 61% (8 patients); 2 patients needed surgical treatment of the complication. 1-year survival was 27%, 2-year survival was 18%. 2 patients (3.5%) died within the early postoperative course after palliative bypass. Early postoperative morbidity was 36% (21 patients); 6 patients (29%) needed surgical treatment of the complication. 1-year survival was 35%, 2-year survival was 17%.
Conclusions: No significant differences were found between the two palliative procedures described as regards early morbidity and mortality and cumulative survival. We can conclude that bypass procedures and palliative resections for pancreatic cancer have non-significant differences in morbidity, mortality and survival rate.
91
JEJUNAL LOOP DECOMPRESSION IN PANCREATICODUODENECTOMY: A PROSPECTIVE NON-RANDOMIZED STUDY
Kaman S, Bostanoglu A, Kayaalp C, Bostanci B, Ozogul Y, Yol S, Savkilioglu M, Atalay F, Akoglu M
Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
Aim: Decompression of jejunal loop used for pancreaticojejunal anastomosis may reduce the rate of pancreaticojejunal leak by preventing the distention of the anastomosis. The aim of this study was to evaluate the effect of decompression on pancreaticojejunal anastomosis.
Methods: Sixty patients who underwent pancreaticoduodenectomy operation between March 1999 and April 2002 were evaluated prospectively. Patients were divided into two groups. Decompression in Group I (n = 17) was performed by either jejunojejunostomy (n = 12) or jejunal drainage catheter (n = 5). Group II (n = 43) was the non-decompression group. Both groups were evaluated for age, gender, preoperative symptoms, preoperative biliary drainage, operative time, blood loss, and other additional procedures. The mortality, morbidity and pancreatic leak rates of both groups were compared.
Results: Both groups were similar regarding age, gender, preoperative symptoms and preoperative biliary drainage. Operative time, blood loss and additional procedures were not different (p > 0.05). The mortality, morbidity and pancreatic leak rate of Group I was not different from that of Group II (0 vs 12%, p = 0.31; 47% vs 53%, p = 0.65; 12% vs 19%, p = 0.26; respectively).
Conclusions: Performing decompression for jejunal loop in pancreaticoduodenectomy operation decreased the rate of pancreatic leak but this was not statistically significant.
92
PYLORUS-PRESERVING PANCREATODUODENECTOMY: COMPARISON WITH PANCREATODUODENECTOMY
Iwamoto M, Inoue H, Hayashi M, Toyoda M, Tanigawa N
Department of General and Gastroenterological Surgery, Osaka Medical College, Osaka, Japan
Aim: The indications for pylorus-preserving pancreatoduodenectomy (PpPD) have been expanded. At present, it is applied to both malignant and benign diseases. To date, however, few reports have been published concerning its long-term outcomes. This paper will report the results of this surgical treatment in patients followed for a long period (3 years or more).
Methods: Between 1973 and 2001, 145 patients underwent pancreatoduodenectomy at our department. 55 patients were followed for 3 years or more after surgery. Of these 55 cases, 23 underwent PpPD and 32 received ordinary pancreatoduodenectomy (PD). In these two groups of patients, we compared the frequency of postoperative stomal ulcers, morphology and patency of the pancreatic duct, residual pancreatic function, incidence of fatty liver, performance status (PS) and postoperative weight recovery.
Results: The underlying disease was carcinoma of the papilla of Vater in 23 cases, bile duct cancer in 13 cases, pancreatic cancer in 5 cases, duodenal cancer in 4 cases, chronic pancreatitis in 3 cases and other conditions in 10 cases. Stomal ulcers developed in one case from the PpPD group but improved in response to conservative treatment. When examined by CT and MRCP, one case each from the PpPD group and the PD group had pancreatic duct dilation before surgery. Of the patients for whom mucosal suture was attempted for pancreatogastrostomy during PpPD, 21 underwent endoscopy. The pancreatic duct orifice was clearly visible in 8 of these 21 cases, and excretion of pancreatic juice at a point, which appeared to be the pancreatic duct orifice, was confirmed in the remaining 13 cases. The percentage of patients in whom diabetes mellitus developed or was exacerbated after surgery was 22% (5/23) in the PpPD group and 31% (10/32) in the PD group. Deterioration of exocrine pancreatic function was seen in one case each from the two groups. The incidence of fatty liver was 12% (3/25) in the PpPD group and 28% (9/32) in the PD group. The percentage of cases where PS was rated as 0 or 1 was 96% (22/23) in the PpPD group and 73% (22/32) in the PD group. The percentage of cases showing postoperative weight recovery was 52% (12/23) in the PpPD group and 34% (11/32) in the PD group. Scintigraphy of the gastrointestinal and biliary tracts did not reveal disturbed gastric emptying in any case in the two groups.
Conclusion: In terms of the morphology and function of the residual pancreas, there was no significant difference between the PpPD group and the PD group. However, the incidence of fatty liver was lower after PpPD than after PD. The results suggest that PpPD is superior to PD in maintaining PS and promoting postoperative weight recovery.
93
CLINICAL ANALYSIS OF CA19-9 POSITIVE RATE OF HEPATOBILIARY PANCREAS DISEASE
Chae YS, Lee JI, Jeong JH, Lee WJ, Kim JY, Kim BR
Kwandong University, Korea
Aims: CA19-9 is the most widely used pancreatic tumor marker. However, the CA19-9 level is increased in conditions such as gallbladder cancer, cholangiocarcinoma, hepatocellular carcinoma, gallbladder polyp, acute cholangitis and chronic pancreatitis. Therefore, this study aimed to determine the CA19-9 positive rate of the above diseases in Korea.
Methods: A positive result was considered if the upper limit of normal was 37–40 U/ml. The CA19-9 level was measured in 53 patients with pancreatic cancer, 72 with cholangiocarcinoma, 41 with common bile duct cancer, 27 with gallbladder cancer, 35 with hepatocellular cancer, 70 with acute pancreatitis, 93 with chronic pancreatitis, and 30 with a gallbladder polyp, from September 1998 to December 2000 in the Severance Hospital.
Results: When the cut-off value was >40 U/ml, a positive result was found in 79.2% (42/53) of pancreatic cancer patients, 58.3% (42/72) of cholangiocarcinoma patients, 37% (10/27) of gallbladder cancer patients, 31.7% (13/41) of common bile duct cancer patients, 19.7% (14/70) of acute pancreatitis patients, 14.2% (5/35) of hepatocellular cancer patients, 16% (5/93) of chronic pancreatitis patients, and 3.3% (1/30) of patients with a gallbladder polyp.
Conclusion: The highest positive rate was 79.2% in the pancreatic cancer patients. We confirmed that the Lewis phenotype distribution indicates that pancreatic cancer, cholangiocarcinoma and chronic pancreatitis showed high frequency in the Le(a – b–) group when they were statistically compared with a healthy control group, but that acute pancreatitis showed a statistically higher frequency in the Le(a + b–) group than chronic pancreatitis.
94
RISK DETERMINATION OF PANCREAS-RELATED MORBIDITY FOLLOWING THE WHIPPLE PROCEDURE
Barauskas G, Gulbinas A, Pundzius J
Kaunas Medical University, Kaunas Medical University Hospital, Department of Surgery, Kaunas, Lithuania
Aim: To analyse the risk factors for development of pancreas-related morbidity following the Whipple procedure.
Methods: Prospectively collected data from 122 patients who had undergone pancreaticoduodenectomy (PD) was analysed. Fibrosis of parenchyma, diameter of pancreatic duct, exocrine function, bilirubinaemia, nature of disease, age of patient and pancreas-related morbidity were evaluated. Fibrosis of the pancreatic remnant was determined by computer-aided morphometric analysis. Exocrine function was tested by She Bo® Elastasel Stool test. Statistical analysis was carried out by two-tailed chi-squared analysis and Student's t test for independent variables. The univariate analysis was performed using non-parametric tests: Mann-Whitney U test for comparison of two groups and Spearman R for relationship between variables. Logistic regression analysis was used to identify independent risk factors.
Results: Pancreas-related morbidity was encountered in 27 (22.13%) cases as pancreatic fistula in 13 and peripancreatic sepsis in 14. There was no significant difference in age, jaundice, and benign or malignant nature of disease between the groups with and without pancreas-related complications. Univariate analysis showed that the diameter of the main pancreatic duct, postoperative amylasaemia, pancreatic exocrine function and fibrosis were significantly different in the groups (p = 0.001, p = 0.002; p = 0.003 and p = 0.026, respectively). Logistic regression analysis revealed that exocrine pancreatic function at the cut-off of Stool Elastase 100 ng/g (odds ratio 21.6, 95% CI 2.09–223.7) is the only independent risk factor.
Conclusions: Exocrine function, measured by Stool Elastase-1 test, is helpful to detect a subset of patients with minimal risk for pancreas-related morbidity after PD.
95
PANCREATICODUODENECTOMY WITH PORTAL OR SUPERIOR MESENTERIC VEIN RESECTION FOR CARCINOMA OF THE PANCREAS
Sakrak O, Bedirli A, Ince O, Aritas Y
Erciyes University, Department of General Surgery, Kayseri, Turkey
Aim: Although the prognosis of pancreatic carcinoma is poor, the only chance for cure is provided by pancreaticoduodenectomy (PD). Many surgeons still consider invasion of portal or superior mesenteric vein (PV/ SMV) by tumour as a contraindication for radical surgery. However, several recent studies have suggested low morbidity and mortality rates in patients undergoing extended PD including resection of PV/SMV. The aim of this study was to review the treatment outcomes of PD with partial resection of PV/SMV for pancreatic carcinoma.
Methods: Between 1995 and 2002, there were 36 consecutive patients who underwent PD for malignant disease. Of the patients, 4 were male and 3 were female, with a mean age of 56 (range 44–61) years. Tumor was located in the head of the pancreas in all patients. Seven patients underwent PD with en bloc resection of PV/SMV with curative intent for pancreatic carcinoma. Clinical and operative findings were reviewed. Also, morbidity, mortality and long-term survival were analysed.
Results: Five patients underwent repair with a Gore-Tex graft. End-to-end anastomosis was possible without grafts in 2 patients. All vascular anastomoses were performed with a running suture of 6.0 Prolene. Portal vein occlusion was performed for an average 16 min (range 11–26). The median operative time was 6.8 hours and median intraoperative blood loss was 800 ml. When no death occurred, the most important complication was delayed gastric emptying in one patient. Postoperative contrast-enhanced Doppler ultrasound was conducted in 4 patients and all the patients had patency of the portal vein. 1-year survival rate was 57%, with a median survival of 11.4 months. Hovewer, no 2-year survival was observed for the entire series.
Conclusions: PD with partial resection of PV/SMV can be performed with low morbidity and mortality rates in patients with pancreatic carcinoma; however, long-term survival should not be expected.
96
HEMORRHAGIC COMPLICATIONS FOLLOWING PANCREATICODUODENECTOMIES
Yoo KE, Moon HJ, Noh SI, Heo JS, Choi SH, Joh JW, Kim YI
Department of General Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
Aim: Hemorrhagic complication following pancreaticoduodenectomy has the highest mortality rate. We present here influencing factors and treatment modalities of early and delayed hemorrhage after pancreaticoduodenectomy.
Methods: From Oct. 1994 to May. 2002, 454 patients underwent pancreaticoduodenectomies for malignant or benign diseases. All patients' medical records were reviewed retrospectively. Chi-square test was used for analysis of the data.
Results: Of the 454 patients, there were 35 hemorrhagic complications. 14 were early hemorrhages within the fifth postoperative day and 21 were delayed hemorrhages. In 28 patients, hemorrhagic sites were confirmed. 17 patients (48.8%) had hemorrhage from the peripancreatic arteries, while 9 patients (25.7%) had hemorrhage from the anastomotic site and 2 from the retroperitoneal space. In early hemorrhage, the type of pancreaticoduodenectomy according to the extension of resection was an influencing factor (p = 0.040), while in delayed hemorrhage, whether the hemorrhage was benign or malignant (p = 0.035) and the existence of prior intra-abdominal complications (p = 0.017) were influencing factors. In 14 cases (40%), surgical treatments were performed first, while in 10 cases (28.6%), transarterial embolization was selected as the main treatment modality. There were 8 cases of pseudoaneurismal hemorrhage. Three patients (8.6%) died.
Conclusion: For the prevention and effective treatment of hemorrhagic complications, more meticulous bleeding control during the operation and postoperative closed observations are needed. Furthermore, hidden intra-abdominal local inflammation should be considered a factor that causes massive late hemorrhage.
Session 14
Bile Duct Stones
(DOI 10.1080/16515320310000904)
97
LAPAROSCOPIC CHOLEDOCHOTOMY WITHOUT T-TUBE PLACEMENT: A PRELIMINARY REPORT
Wan A, Griniatsos J, Karvounis E, Isla A
Upper GI and Laparoscopic Unit, Ealing Hospital, London, UK
Aim: Postoperative complications after laparoscopic choledochotomy are mainly related to the presence of the T-tube. We assessed the safety and effectiveness of laparoscopic endobiliary stent placement and primary common bile duct (CBD) closure as an alternative to T-tube placement.
Methods: Between January 1999 and November 2002, patients with jaundice, abnormal liver function tests or pancreatitis all received an intraoperative cholangiogram. All patients with proven choledocholithiasis underwent laparoscopic common bile duct exploration (LCBDE) through a choledochotomy. In the early period, a T-tube was placed at the end of the procedure. Since June 2001, biliary stent placement and primary CBD closure was chosen as the preferable approach. We compared these two groups of patients in terms of pre-, intra- and postoperative parameters.
Results: Of the 45 patients who underwent LCBDE, 30 (21F:9M) had T-tubes and 15 (10F:5M) had stent placements, with a median operative time of 120 min for both groups. They had a median age of 69 (52–75 years) in the T-tube group and 55 (51–64 years) in the stent group. The median postoperative stay was 7 (4–12) days for the T-tube group compared with 2.5 (2–3.5) days for the stent group. There were 5 complications related to the procedure in the T-tube group and none in the stent group.
Conclusions: Endobiliary stent placement is a feasible substitute for T-tube placement following lapaorosocpic choledochotomy for choledocholithiasis. Placement of endobiliary stent may produce a shorter hospital stay and fewer postoperative complications compared with the standard practice of using a T-tube for biliary drainage.
98
LAPAROSCOPIC TREATMENTS IN PATIENTS WITH CHOLEDOCHOLITHIASIS
Park IY, Hur H, Lee JH, Lee SK, Kim KH, You YK, Lee S, Kim DG
Department of Surgery, College of Medicine, Catholic University of Korea, Seoul, Korea
Aim: There are various strategies to manage common bile duct (CBD) stones. Endoscopic management of the CBD stones is associated with a high success rate. However, recently, the skills of laparoscopic surgeons has improved greatly, making the laparoscopic treatment of CBD stones feasible. We compared several laparoscopic modalities, including transcystic duct exploration, choledochotomy and primary bile duct closure only or choledochotomy with T-tube choledochostomy or choledochotomy with antegrade stent.
Methods: Between March 1998 and December 2002, 28 patients with choledocholithiasis underwent laparoscopic treatment. 10 male patients and 19 female patients had a median age of 55.6 years (range 21–79). Transcystic duct exploration was performed in 4 patients, T-tube choledochotomy was performed in 4 patients, choledocholithotomy and primary closure of bile duct was performed in 5 patients and choledochotomy with antegrade stenting in 15 patients.
Results: Antegrade stents were not visible in abdominal X-rays at 6.9±2.4 days postoperatively. Postoperative hospital stay was 16±12 days. Complication was limited to 2 cases of recurrent stone which were treated endoscopically and one bile leakage.
Conclusion: Different laparoscopic approaches in patients with choledocholithiasis are safe and effective alternatives to the open method.
99
BILIARY MANOMETRY IN PATIENTS WITH COMMON BILE DUCT STONES
Park IY, Kim TH, Hur H, Lee JH, Lee SK, Kim KH, You YK, Won JM
Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
Aim: Conventional operative treatment of patients with common bile duct (CBD) stones is to insert a T-tube via the exploring CBD after stone removal. However, the placement of the T-tube is associated with complications. So far there have been a few alternative methods such as primary closure, primary closure with antegrade stent and antegrade sphincterotomy. There is still controversy as to whether or not to drain the CBD by intraductal drainage after choledochotomy. It is mainly dependent on subjective indications such as inspection, palpation and operative cholangiogram. We performed this study using intraoperative manometry to determine an objective indication for primary closure and drainage of CBD.
Methods: The study included 15 patients who underwent CBD exploration for stone removal between March 2002 and December 2002. CBD exploration was performed laparoscopically in 7 cases, and by open surgery in 8 cases. There were 7 males and 8 females. Median age was 68 years. Basal pressure of the sphincter of Oddi and the frequency of phasic contraction were measured intraoperatively using a manometer via a working channel of the choledochoscope.
Results: We performed primary closure in cases with lower basal pressure (<35 mmHg), low frequency of phasic contraction (<7/min) and no probability of retained stones. Intraductal drainage was performed in others. There was neither bile leakage nor postoperative obstructive jaundice in the primary closure group.
Conclusion: Intraoperative biliary manometry is a simple and useful tool that suggests an objective indication for primary closure of common bile duct. However, the number of cases was small and further evaluation is needed.
100
EARLY DRAINAGE OF THE BILIARY TRACT WITH ERCP IN ACUTE CHOLANGITIS
Yanar HT, Ertekin C, Taviloglu K, Guloglu R, Gok K
Istanbul University, Istanbul Faculty of Medicine, Department of Trauma and Emergency Surgery, School of Medicine, University of Istanbul, Turkey
Aim: Acute cholangitis is a complication of biliary stasis. If early drainage cannot be achieved it may lead to septic shock and death. The aim of this report was to advocate endoscopic retrograde cholangio-pancreatography (ERCP) in patients with cholestasis.
Methods: 21 consecutive patients were admitted to the Emergency Surgery Unit of Istanbul Faculty of Medicine for the management of acute cholangitis between January 1999 and December 2002. 7 men and 14 women with a mean age of 61.7 years (range 32–79) were evaluated retrospectively. Clinical signs, laboratory findings, ultrasound and bacteriological results, treatment modality, mortality and morbidity in these patients have been reviewed.
Results: 3 of the patients had a history of previous cholecyctectomy. Charcot's triad was present in 17 (80.9%) patients. ERCP revealed cholelithiasis in 12 patients, sludge in 5 patients, hydatid cyst in 1 patient, cholangiocarcinoma in 1 patient, Oddi dysfunction in 2 patients. After initial management 16 patients (76.1%) underwent surgical treatment. Culture of blood was positive in 12 patients (57.1%). There was no complication related to ERCP. Only one patient (4.7%) died, who had septic shock.
Conclusion: Early drainage of the biliary tract with ERCP in patients with acute cholangitis can be performed with low morbidity and mortality rates. In cases of insuffiency, percutaneous transhepatic or surgical drainage of the biliary tract should be considered as alternative management.
101
AN EFFECTIVE MODIFIED RENDEZ-VOUS TECHNIQUE FOR THE LAPAROSCOPIC TREATMENT OF COMMON BILE DUCT STONES
La Greca G, Randazzo V, Di Blasi M, Di Stefano A, Di Stefano M, Greco L, Di Carlo I, Russello D
Department of Surgical Sciences, Transplantation and Advanced Technology – University of Catania, Catania, Italy
Background: In the laparoscopic era the treatment of preoperatively known common bile duct (CBD) stones in patients with gallbladder disease is still controversial because different approaches are possible.
Methods: Considering the sequential approach to be only a rescue option, we developed a modified rendez-vous technique and performed it in 15 consecutive cases. All patients with cholecystolithiasis were analysed by Hughier's score to identify those at risk of CBD stones. The preoperative diagnosis was obtained in 12 patients by ultrasonography and in 3 by magnetic resonance cholangiopancreatography (MRCP). The technical particulars of our rendez-vous procedure are as follows: the patient remains in the same supine position used for cholecystectomy, avoiding the time-consuming change in the lateral position, and the endoscopist performs ERCP without problems. The rendez-vous is performed after cholecystectomy so that endoscopic insufflation and intestinal bloating do not hinder surgery. Instead of common cholangiography catheters, a larger one, which allows the guide wire and dormia to pass inside, is used to perform cholangiography. The guide wire is introduced through this catheter and retired by the endoscopist after passing the papilla vateri. In this way time-consuming retrograde pancreatography is avoided, which also minimizes the risk of pancreatitis.
Results: The results showed 100% effectiveness in retrieval of the stones, a limited mean time of 24 min, 0% pancreatitis and 6% morbidity, with mortality (6%) occurring in an 85-year-old ASA 4 patient.
Conclusion: Our modified rendez-vous technique is simple, effective and rapid for the treatment of CBD stones but co-operation between the endoscopist and surgeon is mandatory.
102
A NEW SCORING SYSTEM TO PREDICT CHOLEDOCHOLITHIASIS AND THE NECESSITY FOR ERCP
Sener M, Celik G, Sevinc M, Basak F, Demir M, Aren A
SSK Istanbul Training Hospital, Istanbul, Turkey
Aim: In different series it was reported that there was a stone in the main duct in 7–20% of patients who have gallstones. In recent years microinvasive or non-invasive methods have been preferred, so laparoscopic cholecystectomy is now a 'gold standard' in the treatment of gallstones. However, a conclusive method could not be achieved in the treatment of choledocholithiasis. This is the cause of the difficulty in determining exactly which patient has stones in the main duct. On the other hand, determining and extracting the stones in the main duct by endoscopic retrograde cholangiopancreatography (ERCP) before laparoscopic cholecystectomy gives advantages to the surgeons and the patients in many ways. Therefore, we planned this prospective study to develop a scoring system to determine main duct stones before laparoscopic cholecystectomy.
Methods: We analysed 696 patients who had gallstones between 1 January 2001 and 31 December 2002. 67 patients who had jaundice or had normal bilirubin levels but high alkaline phosphatase (ALP) levels had magnetic resonance cholangiopancreatography (MRCP). Patients were scored by giving points for age, sex, periods of jaundice or cholangitis, ALP, gamma glutaryl transferase (GGT), blood bilirubin levels and ultrasonographic findings. Additional points were given according to MRCP findings. According to these, main duct stones were determined in 54 patients and 52 of them underwent ERCP and then laparoscopic cholecystectomy. Main duct stones were found in 36 of the patients who underwent ERCP, as well as choledochocel in one patient and Mirizzi syndrome in one patient. All these patients' scores were at least 6 when MRCP findings had not been taken into account and were at least when MRCP findings had been taken into account. As a result of this study, we are of the opinion that it is suitable for patients whose scores are 9 or more to undergo ERCP without MRCP before laparoscopic surgery.
Conclusion: When our series was scanned again according to this information it can be seen that 10 ERCP and 18 MRCP had been applied unnecessarily.
Session 15
Biliary – Miscellaneous – I
(DOI 10.1080/16515320310000913)
103
CLINICOANATOMICAL STUDIES ON THE DORSAL SUBSEGMENTAL BILE DUCT OF THE RIGHT ANTERIOR SUPERIOR SEGMENT OF THE HUMAN LIVER
Kamiya J, Nagino M, Uesaka K, Sano T, Nimura Y
Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
Background: The dorsal subsegmental intrahepatic bile duct in the right anterior superior segment (B8c) sometimes joins the posterior sectorial duct. In such cases it can be misidentified as the right posterior superior segmental duct (B7). However, there are no published studies on the confluent pattern of B8c.
Methods: We studied B8c in the resected liver of 107 patients (65 with bile duct carcinoma and 42 with gallbladder carcinoma) who had undergone right hepatectomy or more extensive right-sided liver resection.
Results: B8c was identified in all cases. It joined the right posterior sectorial duct or B7 in 18 cases (16.8%). In 12 cases B8c independently joined the posterior sectorial duct or B7. In 6 cases B8c joined the posterior sectorial duct after making the common duct with the lateral subsegmental duct in the anterior superior or anterior inferior segment (B8b or B5c).
Conclusion: B8c does not join the anterior sectorial bile duct in every 6th case.
104
INFLAMMATION AND FIBROSIS OF CHOLECYSTITIS IN MALES IS MORE SEVERE THAN IN FEMALES
Kartal A, Vatansev C, Aksoy F, Boz S, Aktan M, Golcuk M, Karahan O
Selcuk University Meram Medical Faculty, Department of General Surgery, Konya, Turkey
Aim: It has been shown that oestrogen causes less inflammation and fibrosis in women by means of effects on macrophages and fibroblasts. However, there are no studies dealing with gallbladder inflammation in males or in females. To investigate this, adhesions around the gallbladder and the gallbladder wall itself that had been removed laparoscopically were examined for macrophage infiltration and collagen (hydroxyproline-HP) deposition.
Methods: A total of 40 patients (21 women, 19 men) with symptomatic gallbladder stones were included in the study. The mean age was 39.2 (range 25–43 years). All the women were of reproductive age. Patients who were taking medicines that have side effects on wound healing, those with systemic and connective tissue diseases, and those who had undergone previous abdominal operations, smokers and alcohol consumers were excluded from this study. Adhesions taken during laparoscopic cholecystectomy were divided into two parts; one for histological study (macrophages and other cells) and the other for collagen investigation. The latter was kept in physiologic serum at −60°C. The gallbladder was opened in front of Hartmann's pouch. After evacuation and irrigation, two 1-cm pieces were excised as full thickness from Hartmann's pouch, to detect inflammatory cells and collagen deposition. HP was established by g/mg dry tissue. Results were analysed by using a modified Woessner's method as the Student t test.
Results: We found that macrophage infiltration was twofold higher in men than in women both in gallbladder wall and in adhesive bands. There was a statistical difference between men and women. Mean values of HP in women g/mg dry 8.1, 9.4 and 14.5 gallbladder wall and fibrotic band was 13.1, 13.1 1.49 and 25.2 tissue, respectively. The same values in men were 23.4 g/mg dry tissue, respectively. The difference was meaningful between the two sexes.
Conclusion: Macrophage infiltration and collagen deposition of the inflammed gallbladder wall and its peripheral adhesion is more severe in males than in females.
105
VALUABLE MARKERS OF THE ORGANISM RESPONSE IN ACUTE DIFFUSE PERITONITIS – C5a AND Cl INHIBITOR
Ivancevic NDJ, Bajec DJD, Radenkovic DV
Clinical Center of Serbia, Emergency Center, Belgrade, Yugoslavia
Aim: Changes in the concentration of the C5a and Cl inhibitors are markers of the organism response to infection. The aim of the study was to assess the survival predictive value of these markers in acute diffuse peritonitis.
Methods: The study group included 40 patients (age range 19–87 years). All patients were operated on for acute diffuse peritonitis.
Results: 8 patients died. The C5a and Cl inhibitors were determined before the operation and every day after the operation for at least 7 days, or until the patient's demise. In the survivors postoperative C5a concentrations decreased and normalized, while in the non-survivors these concentrations increased. The Cl inhibitor significantly decreased in the non-survivors.
Conclusion: Both C5a and Cl inhibitors are valuable markers for the survival prediction of patients with acute diffuse peritonitis.
106
PREDICTIVE VALUES OF AT III, Cl INHIBITOR AND a2-MACROGLOBULIN IN ACUTE DIFFUSE PERITONITIS
Ivancevic NDJ, Bajec DJD, Radenkovic DV
Clinical Center of Serbia, Center for Emergency Surgery, Belgrade, Yugoslavia
Aim: Changes in AT III, Cl inhibitor and a2-macroglobulin levels are known to be important predictors of survival in septic patients. The aim of the study was to determine an optimal time for sampling of AT III, Cl inhibitor and a2-macroglobulin in order to maximize survival prediction.
Methods: The study group included 40 patients (age range 19–87 years). All patients were operated on for acute diffuse peritonitis.
Results: 8 patients died. The AT III, Cl inhibitor and a2-macroglobulin levels were determined before the operation and every day after the operation for at least 7 days, or until the patient's demise. The critical period was the second postoperative day, as the values of the measured parameters normalized in the survivors, while they decreased in the other patients. In the following days values of the measured parameters stayed within normal limits in the survivors, while in the other patients they decreased, reaching the minimum values in the final sample.
Conclusion: Optimal sampling time for the AT III, Cl inhibitor and a-2macroglobulin for the prediction of survival in acute diffuse peritonitis is the second postoperative day, thus identifying a high-risk patient that might benefit from more aggressive therapy.
107
THE OUTCOME OF SURGERY FOR 77 CASES OF BILIARY ATRESIA: A SINGLE INSTITUTIONAL EXPERIENCE IN EGYPT
Marwan I, Saleh A, El-Sefi T, Osman M, Ibrahim T, Galal A, Sadek A, Abou Ela K, Gad H, Abd Edaim H, Marwan A-M
Surgery Departement, National Liver Institute, Menoufeya University, Cairo, Egypt
Aim: Retrospective evaluation of the outcome for 77 cases of biliary atresia who underwent surgical treatment. A liver transplantation program has not started yet at our institution.
Methods: Between June 1995 and December 2002, 77 cases of biliary atresia were operated, 38 females and 39 males, with mean age at surgery 83.25 days (range 43–155). Hepatecojejunostomy was done for type I (4 cases), hepatic portocholecystostomy was performed for type II (8c ases). For type III, Kasai procedure was done in 39 cases, interposition jejunal loop with an intussusceptive anti-reflux valve in 16 cases, and hepatic portojejunostomy with valve in 10 cases.
Results: The mean age for type I was 111 days (range 80–155), all are still alive, one for 5.5 years, 2 for 3.6 years and one for 2.7 years. Type II was observed in 8 cases with a mean age of 79.66 days (range 45–102), 2 of them were identical twins. The procedure failed in 2 and was converted to portoenterostomy, 4 of them are alive, one for 2 years and 3 for 1 year. The remaining 65 cases were type III with a mean age of 83.41 days (range 43–149). 9 patients underwent the operation below the age of 60 days, 41 cases were aged 61–90 days, and 27 cases were above the age of 91 days. There are 40 overall survivors (52%), 14 of them are clinically jaundice-free, hospital mortality was 24 cases and 13 lost in the follow-up.
Conclusions: Close long-term care, follow-up and elevation of the medical awareness of the family are essential to achieve good results, especially in centers where liver transplantation has not started yet.
108
ROUX-EN-Y PROCEDURE IN PAEDIATRIC SURGERY
Gardikis S1, Antypas S2, Kambouri K2, Perente S3, Lainakis N2, Botaitis S1, Dolatzas Th2, Simopoulos C3
1Department of Pediatric Surgery and 32nd Surgery Department, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, 2First Department of Pediatric Surgery, “Agia Sophia” Children's Hospital, Athens, Greece
Aims: Roux-en-Y in paediatric surgery is limited. In this study we present our experience of Roux-en-Y in hepatobiliary disorders in childhood.
Methods: 28 children (18 girls and 10 boys) with hepatobiliary disorders (range 25 days to 12 years) were treated in our clinics between 1986 and 2002. 20 suffered from biliary atresia (female:male ratio 0.81) and 8 from choledochal cyst (female:male ratio 0.14). All the patients underwent surgery after the diagnosis. The operative approach in biliary atresia was excision of the bile duct remnants followed by Roux-en-Y portoenterostomy (Kasai's procedure) (average 1.1 months) and in choledochal cyst, cyst cholocystectomy followed by Roux-en-Y hepaticojejunostomy (average 7.2 years). The mean length of follow-up was 9.3 years.
Results: Among the children with biliary atresia, 12 developed postoperative cholangitis, 6 portal hypertension and 5 hepatic cirrhosis. 6 of them died, 3 underwent liver transplantation, and 5 are on a waiting list for transplantation. Of the children with choledochal cysts, 2 presented postoperative cholangitis that was treated conservatively and one developed anastomotic stricture and underwent redo operative reconstruction. All of them are alive without sequelae.
Conclusions: Roux-en-Y in biliary atresia, with timely diagnosis, is favorable as an initial procedure, followed by liver transplantation for failures, while it is the treatment of choice in cases of choledochal cysts.
109
DIAGNOSIS AND TREATMENT OF CHOLEDOCHAL CYSTS
Uribarrena AR, Fuentes J, Serrablo S, Garcia S, Raventos N, Uribarrena ER, Simon M, Elias J
Hospital Universitario Miguel Servet, Zaragoza, Spain
Aim: We report our experiece of 10 cases of choledochal cysts (CC) and the different therapeutic options depending on the type of cyst.
Methods: Since 1991, 10 cases of CC have been diagnosed in our hospital. 7 were type I cysts, 1 was type III, 1 type IVa and 1 type V. 8 patients were under 14 years old and 2 were adults, with an age range from 17 months to 45 years. The clinical manifestations were abdominal pain in all cases, jaundice in 6 and pancreatitis in 3.
Results: The diagnosis was established with abdominal ultrasonography or computed tomography followed by endoscopic retrograde cholangiopancreatography (ERCP). 7 patients with type I CC underwent total cyst excision with Roux-en-Y hepatojejunostomy. In type III CC an endoscopic sphincterotomy (ES) was performed and in type IVa CC a transductal sphincterotomy and cholecystectomy was carried out. The patient with type V CC had left hepatectomy initially and later underwent liver transplantation. There were no surgical or endoscopic complications. There have no been degenerations to cholangiocarcinoma.
Conclusions: CC are more frequent in childhood, but it is not exceptional to find cases in adults. ERCP plays an important role in the diagnosis and, in type III cysts, also in the treatment. Due to the potential malignancy of this disease total cyst excision is recommended if possible in type I, II and IV CC. In type III cysts ES is the first choice for treatment, while in type V liver transplantation is sometimes necessary.
110
CHOLEDOCHAL CYST: LATE PRESENTATION IN ADULTS
Osman M, El-Sefi T, Sadek A, Shawki A, Ibrahim T, Boghdadi I, Marwan I, Sidkey F, Taher M-Y
National Liver Institute, Menoufeya University, Alexandria, Egypt
Aim: To describe the clinical presentation and management of choledochal cysts in 16 adult patients.
Methods: The medical records of 16 adult patients with choledochal cysts, during the period from 1992 to 2000, were analysed retrospectively. The age range was 17–56 years, with a mean of 33 +/− 6.4 and male:female ratio of 1:2. Diagnostic imaging modalities included US, CT and ERCP. Cysts were classified using the Todani modification of the Alonso-Lej classification. All patients except one underwent either surgical or endoscopic treatment of the cyst. Short- and long-term follow-up data were recorded for a period ranging from 6 months up to 4 years.
Results: All patients presented clinically with recent attacks of recurrent right upper quadrant pain, and with symptoms and signs of cholangitis. Six patients were diagnosed after being submitted for cholecystectomy. Type I Todani cyst was the most common (9 patients), type II (1 patient), type III (3 patients), type IVA (2 patients) and type V Caroli's disease in 1 patient. Total cystectomy and hepaticojejunostomy (HJ) were performed for 12 patients. Type III patients were submitted to endoscopic sphincterotomy (ES). The only patient with Caroli's disease died while on medical treatment. There was no operative mortality. 2 patients had late complications after cyst excision, in the form of recurrent attacks of cholangitis.
Conclusions: Choledochal cyst, in adults, is a not uncommon finding in this era of imaging, and therefore, clinicians should be aware of such a diagnosis in the adult patient. Choledochal cysts presenting for the first time in adulthood were not accompanied by neoplastic changes in the present study. Proper preoperative evaluation of the biliary tree with cholangiography is mandatory in patients with disturbed liver profile and recurrent attacks of cholangitis, before making the decision for cholecystectomy.
Friday 30 May 2003
09:00–10:30
Best Paper Prize Session
(DOI 10.1080/16515320310000922)
111
CELLULAR IMMUNE RESPONSE AND EXPRESSION OF HLA CLASS I AND II IN HUMAN NEUROENDOCRINE TUMORS OF THE PANCREAS
Schmidt J, Reidel M, Klar E, Buchler MW, Ryschich E
Department of Surgery, University of Heidelberg, Heidelberg, Germany
Aim: Peptide presentation by HLA class I and II regulates the specific antigen recognition by T-cells. The present study aimed to investigate the T-cell infiltration and its relation to HLA in human pancreatic neuroendocrine tumors.
Methods: Fresh tissue samples were collected from 5 insulinomas and 6 other neuroendocrine tumors (one gastrinoma, one glucagonoma, two carcinoids, two neuroendocrine carcinomas). 8 normal pancreatic and 2 splenic tissue samples were used as controls. The tissue samples were immediately frozen and stored in liquid nitrogen. Investigation of infiltrating lymphocyte populations (CD3, CD4, CD8), as well as staining of monomorphic epitope of HLA class I and II, were performed by standard immunohistochemistry.
Results: The majority of investigated tumors demonstrated an intratumoral infiltration by CD3+, CD4+ and CD8+ T-cells, which was significantly higher than in normal pancreatic islets (p < 0.01). Expression of HLA class I by tumor cells was 100% in all tumors except neuroendocrine carcinoma. Both euroendocrine carcinomas showed a total loss of HLA class I which was associated with a complete absence of infiltrating T-cells. HLA class II molecules were expressed by endothelial and lymphoid cells and not by tumor cells.
Conclusions: Most neuroendocrine tumors induce a T-cell-mediated immune response resulting in an intratumoral infiltration with CD3+, CD4+ and CD8+ T-cells. HLA class I expression was positive in all neuroendocrine tumors except neuroendocrine carcinoma. The total loss of HLA class I expression in neuroendocrine carcinoma completely abolished the cellular immune response. In contrast to malignant tumors of the exocrine pancreas, neuroendocrine tumor cells demonstrated no expression of HLA class II.
112
DEVELOPMENT OF A OLIGONUCLEOTIDE MICROARRAY FOR THE DIAGNOSIS OF PANCREATIC CANCER
Kim Y-T, Whang JH, Jung JB, Yoon YB, Kim CY
Seoul National University College of Medicine, Department of Internal Medicine, Seoul, South Korea
Aim: We have developed a oligonucleotide microarray (pancreas chip) for the diagnosis of pancreas cancer, which carries out minisequencing (APEX) reactions on the chip to analyse mutation and promoter methylation of multiple genes simultaneously. We have analysed diagnostic value of the oligochip.
Methods: Mutation of p53 and K-ras gene and aberrant promotor methylation of 15 tumor suppressor genes were analysed in 36 tissue specimens of pancreatic ductal adenocarcinoma and 13 of chronic pancreatitis. Mutation profile was comparatively analysed with automated sequencing and oligochip. Promotor methylation was comparatively analysed by methylation specific PCR (MSP), bisulfite genomic sequencing (BGS) and pancreas chip.
Results: On the analysis of pancreatic cancer, K-ras mutation was found in 24 cases by sequencing and 26 cases by pancreas chip. 15 cases of pancreatic cancer showed the same p53 mutation profile on sequencing and pancreas chip analysis. Pancreatic cancer commonly showed aberrant promotor methylation of multiple genes, including preproenkephalin, calcitonin, RASSF1A, H-cadherin, and retinoic acid receptor (RAR)-b2. The results of BGS and oligochip analysis were concordant in 35 cases (97.2%). MSP could not detect the degree of methylation and showed false-positive results in 3 cases. On the analysis of chronic pancreatitis, 3 showed mutation of K-RAS, no mutation of p53 and 7 methylation of RAR-b2. All the pancreatic cancer specimens showed mutation or aberrant methylation of at least 3 genes, whereas none of the chronic pancreatitis specimens showed changes of more than 2 genes.
Conclusions: The pancreas chip analysis used in this study can accurately analyse mutation and aberrant methylation of multiple critical genes and differentiate between pancreatic cancer and pancreatitis.
113
CONNECTIVE TISSUE GROWTH FACTOR INFLUENCES THE PROGNOSIS IN PATIENTS WITH PANCREATIC CANCER
Gardini A, Ercolani G, Di Mola FF, Di Sebastiano P, Grazi GL, Cavallari A, Buchler MW
Department of Surgery and Transplantation, S. Orsola Hospital, University of Bologna, Bologna, Italy
Aim: To analyse the expression and localization of connective tissue growth factor (CTGF) and to evaluate whether it influences the prognosis of pancreas cancer. Connective tissue growth factor (CTGF), which is regulated by transforming growth factor-β (TGF-β), has recently been implicated in the pathogenesis of fibrotic diseases and of tumor stroma. Inasmuch as generation of desmoplastic tissue is characteristic for pancreatic cancer, it is not known whether it gives pancreatic cancer cells a growth advantage, or is a reaction of the body to inhibit cancer cell progression.
Methods: Tissue samples were obtained from 27 individuals (8 female, 19 male) undergoing pancreatic resection for pancreatic cancer. Tissue samples from 13 previously healthy organ donors (5 female, 8 male) served as controls. The expression of CTGF was studied by Northern blot analysis. In situ hybridization and immunohistochemistry localized the respective mRNA moieties and proteins in the tissue samples.
Results: Northern blot analysis revealed that pancreatic cancer tissue samples exhibited a 46-fold increase in CTGF mRNA expression (p < 0.001) over normal controls. By in situ hybridization, CTGF mRNA signals were located principally in fibroblasts and also in degenerating acinar cells. Tumor cells showed only weak CTGF mRNA expression. High CTGF mRNA levels in the tissue samples correlated with better tumor differentiation (p<0.05). In addition, patients whose tumors exhibited high CTGF mRNA levels lived significantly longer than those whose tumors expressed low CTGF mRNA levels (p < 0.02).
Conclusion: Our present data indicate that CTGF, as a downstream mediator of TGF-β is overexpressed in connective tissue cells and to a lesser extent in pancreatic cancer cells. Because patients with high CTGF mRNA expression levels have a better prognosis, our findings indicate that the desmoplastic reaction provides a growth disadvantage for pancreatic cancer cells.
114
PROSPECTIVE OBSERVATIONAL STUDY OF INCIDENCE AND RISK FACTORS FOR POST-SPLENECTOMY PORTAL VEIN THROMBOSIS
Stamou KM, Kekis BP, Toutouzas K, Manouras A, Apostolidis N, Nakos S, Gafou S, Androulakis G
1st Department of Surgery, University of Athens, Hippokrateion Hospital, Athens, Greece
Aim: Portal vein thrombosis (PVT) has been reported as a potentially lethal complication of splenectomy. The exact frequency of the thrombosis is not known, nor has any risk factor been determined.
Methods: This prospective observational clinical study was carried out in the University Surgical Clinic, in a teaching hospital, between January 1999 and January 2003. The criterion for inclusion was splenectomy regardless of indication. Preoperative evaluation comprised ultrasound-Doppler examination of the large visceral vessels and evaluation of hemostasis (PLT, PT (INR), PTT, d-dimer, FDs, fibrinogen). Intra-operative data collected were technique and mean arterial pressure/time. Postoperative evaluation comprised ultrasound-Doppler examination on the 7th and 30th postoperative days. Patients identified with thrombosis were submitted to complete thrombophilic control. Statistics were analysed by chi-squared, Pearson's test, t-test and regression analysis.
Results: 107 patients were enrolled with a mean age of 45.3 years. Indication for surgery was hematologic disease in 62 patients, GI malignancy in 35 and other in 10. Postoperative mortality and morbidity were 4.1% and 34%, respectively. Portal system thrombosis was diagnosed in 7 (6.5%) patients. In two of these patients a congenital thrombophilic status was diagnosed (V-Leiden factor, protein S). No PVT was associated with mortality. The mean of the maximum postoperative platelet count was 525,333/mm3 (SD +/ − 268,217). The single identified independent risk factor for the occurrence of the complication was PLT count >650,000/ mm3 (99% CI). D-dimer test showed a sensitivity of 85%, specificity of 91% and a negative prognostic value of 98%.
Conclusion: Post-splenectomy PVT should be anticipated in a relatively important percentage of patients. Early diagnosis may reduce the consequences of the complication. Routine postoperative US/Doppler examination is advocated for any splenectomised patient.
115
PANCREATOGASTROSTOMY AFTER PANCREATICODUODENECTOMY. A COMPARATIVE STUDY OF TWO TECHNIQUES
Sabater L, Pla V, Calvete J, Pallas A, Arlandis P, Fernandez C, Camps B, Flors C, Roig JV, Lledo SH
Clínico Universitario and Sagunto Hospital, Valencia, Spain
Aim: Pancreatic anastomosis is the major source of severe complications after pancreatic resection. There are 2 techniques to restore the pancreatic drainage when the reconstruction is performed via pancreatogastrostomy (PG): implantation (I) of the pancreatic remnant into the stomach and duct-to-mucosa anastomosis (D-M). The aim is to compare the results of these techniques performed by two independent groups.
Methods: This was a prospective multicentric study comparing duct-to-mucosa PG with implantation PG. Both techniques were performed by two groups of surgeons with preferential dedication to pancreatic surgery. 47 patients were included in the study. D-M anastomosis was performed in 26 patients and the I type anastomosis in the remaining 21 patients. D-M anastomosis is carried out by suturing of the Wirsung duct to the gastric mucosa over a pancreatic duct tube, while I type is done by invagination of the pancreatic remnant inside the stomach, through a posterior gastrotomy. Morbidity and mortality were compared in these two techniques. Pancreatic fistula was defined as the presence of fluid with amylase in the surgical drain adjacent to the pancreatic anastomosis.
Results: The mean age for the whole series was 64.2±8.6 years (D-M = 64.15,1 = 64.38) and sex distribution was 32 male and 15 female (D-M = 16 and 10, I = 16 and 5). Etiologies leading to surgery were: pancreatic adenocarcinoma 27 (D-M = 12, I = 15), ampuloma 12 (D-M = 9, I = 3), chronic pancreatitis 2 (D-M = 1,1 = 1), cholangiocarcinoma 1 (D-M), benign tumor of the pancreas 2 (D-M), lymphoma 1 (I), duodenal neoplasia 2 (D-M = 1, I = 1). Overall morbidity for the series was 24/47 (51%): 12/26 (46%) in the D-M group and 12/21 (57%) in the I group (p = 0.561). Overall mortality for the series was 3/47 (6.4%): 2/26 (7.7%) in the D-M group and 1/21 (4.8%) in the I group (p = 0.581). Incidence of pancreatic leak was 2/47 (4.3%), 1 in each technique (3.8% vs 4.8%, p = 0.699); biliary leak in 5/47 (10.6%), 2 in D-M (7.7%) and 3 in I (14.3%), p = 0.644; small bowel leak in 1/47 (2.1%), 1 in D-M (3.8%) and 0 (0%) in I, p = 0.553; delayed gastric emptying in 5/47 (10.6%), 2 in D-M (7.7%) and 3 in I (14.3%), p = 0.644, postoperative bleeding in 3/47 (6.4%), 0 in D-M (0%) and 3 (14.3%) in I, p = 0.082, intra-abdominal abscess in 5/47 (10.6%), 4 in D-M (15.4%) and 1 (4.8%) in I, p = 0.362. The group with D-M anastomosis required 3 re-operations (11.5%) vs 3 in the I group (14.3%), p = 0.558.
Conclusion: PG is a safe technique associated with a low incidence of pancreatic leak. There were no differences in morbidity and mortality between the two PG techniques.
116
THE EFFECT OF N-ACETYLCYSTEINE ON NITRIC OXIDE ACTIVITY AND LIVER TISSUE OXYGENATION FOLLOWING WARM ISCHEMIA-REPERFUSION INJURY
Glantzounis GK, Yang W, Sheth H, Seifalian AM, Davidson BR
Academic Department of Surgery, Royal Free Hospital, London, UK
Aims: There is experimental evidence that N-acetylcysteine (NAC) reduces warm liver ischemia-reperfusion injury (I/R) but the mechanism of action is unclear. The present study has investigated tissue mitochondrial oxygenation and nitric oxide (NO) metabolism following NAC administration in the rabbit lobar I/R model.
Methods: Lobar liver ischemia was induced for 60 min, followed by 7 h of reperfusion. In the NAC group (n = 6) N-acetylcysteine (150 mg/kg/h), was administered i.v. over the 15 min before reperfusion and maintained by continuous infusion at a dose of 10 mg/kg/h during the reperfusion period. Control groups were I/R alone (I/R group, n = 6) and sham laparotomy (Sham group, n = 6). Liver cytochrome oxidase activity (Cyt Ox) was measured by near-infrared spectroscopy, plasma nitrite/nitrate levels by chemiluminescence and peroxynitrite formation by the oxidation of the fluorescent dihydrorhodamine (DHR) 123.
Results: Following liver I/R the tissue levels of Cyt Ox and plasma levels of nitrite and nitrate fall significantly during the reperfusion period compared with baseline (I/R group, p < 0.05). Oxidation of DHR 123 significantly increased 7 h after reperfusion (I/R vs Sham, p < 0.05). NAC administration reduced the fall in tissue Cyt Ox (NAC vs I/R, p < 0.05), increased nitrite and nitrate plasma levels and reduced oxidation of DHR 123 (NAC vs I/R, p < 0.05).
Conclusion: The protective effect of NAC in warm liver I/R may be via the inhibition of peroxynitrate formation and maintenance of mitochondrial Cyt Ox activity.
117
PRETREATMENT WITH ENDOSTATIN INHIBITS SEEDING OF COLON CANCER CELLS IN THE LIVER
Te Velde EA, Vogten JM, Smakman N, Brandsma D, Reijerkerk A, Kranenburg O, Voest EE, Gebbink MFBG, Borel Rinkes IHM
Department of Surgery, UMC Utrecht, Utrecht, The Netherlands
Aims: Endostatin (ES) inhibits angiogenesis and growth of liver metastases. However, its exact mechanism of action remains unknown. We investigated whether ES acts during initial-phase metastasis by inhibiting intrahepatic tumor cell seeding.
Methods: We investigated the effect of ES on the spatiotemporal fate of metastasizing C26 colon carcinoma cells in mice. Following ES pretreatment, quantitative analysis of tumor cell seeding was performed by use of intravital microscopy (IVM) and by counting radioactivity of radiolabeled C26 cells at t = 15 min and t = 1 h post tumor cell injection. In vitro, the effects of ES on tumor cell adhesion to isolated endothelial cells was assessed.
Results: Pretreatment with ES (t = − 2 h) was most effective in reducing hepatic tumor growth (15±3.5% tumor replacement vs 60±2.9% in controls, day 12) (p = 0.001). ES did not reduce tumor growth when administered later than 4 days after tumor cell injection. Using IVM, ES pretreatment reduced tumor cell seeding by 56.2% vscontrols (p < 0.001). Findings from radioactivity counts were similar (p = 0.001). In both IVM and radiolabeling experiments, results at t = 15 min and t = 1 h were comparable. Under flow conditions, the adherence of C26 cells to isolated endothelial cells was decreased by pretreatment with ES by 43% (p = 0.007). Tumor cell death and migration were unaffected by ES.
Conclusions: In conclusion, 2-h pretreatment with ES results in reduced tumor cell seeding in vitro and in vivo and therefore enhances its anti-tumor efficacy. These data can be helpful in the design of anti-angiogenic therapies to augment surgical treatment of liver metastases.
118
THE EFFECTS OF VASCULAR BED EXPANSION IN STEATOTIC RAT LIVER GRAFT VIABILITY
Astarcioglu H, Karademir S, Sagol O, Kocdor H, Atila K, Coker A, Astarcioglu I
Department of General Surgery, DEU Medical School, Izmir, Turkey
Background: Use of steatotic donor grafts in liver transplantation is limited due to increased risk of primary non-function. The present study was intended to improve microvascular reperfusion and subsequent graft function in fatty liver donors by the use of vascular bed expansion (VBE) during cold preservation.
Methods: Inbred male Wistar rats (240–280 g) were used as donors and recipients of orthotopic liver transplantation. Moderate liver steatosis was induced by feeding the animals with a choline-deficient diet for 4 weeks. Rats received either normal, steatotic or VBE-pretreated steatotic grafts after 1 h or 9 h of cold preservation. Tolerance of the transplanted liver to cold ischemia was determined by 7-day survival and serum liver enzymes. Plasma tumor necrosis factor (TNF)-α, interleukin (IL)–6 and malondialdehyde (MDA) levels were analysed by bioassays. Post-reperfusion bile flow and liver histology were examined.
Results: After 1-h preservation, recipient survival rates, serum liver enzymes and bile flow were not different among the groups. After 9-h preservation, however, survival rates with normal, steatotic and VBE-pretreated steatotic grafts were 100%, 0% and 75%, respectively. Compared with the untreated grafts, VBE-pretreated steatotic liver grafts revealed significantly reduced levels of serum liver enzymes, plasma TNF-α, IL-6 and MDA, as well as increased bile flow after long-term preservation. On histopathological examination, except for more prominent hepatocyte ballooning in the untreated group, no significant difference in necro-inflammatory changes could be observed between the untreated and VBE-pretreated groups after long-term preservation.
Conclusion: The current results show that VBE protects the fatty liver grafts from subsequent long-term cold preservation-reperfusion injury in a rat liver transplantation model. This positive effect may be contributory in the expansion of donor pool in clinical settings.
14:00–15:30
Session 16
Liver Transplantation – 3
(DOI 10.1080/16515320310000931)
119
HEMODYNAMIC PATTERNS IN RIGHT LIVER LIVING DONORS
Andriani OC, Alvarez D, Castellini D, D'Angelo P, Beltramino D, Fauda M, Villamil FG, Podesta LG
Liver Unit, Fundacion Favaloro, Buenos Aires, Argentina
Aim: Liver mass reduction after right hepatectomy causes changes of splachnic blood flow through the remaining liver during the early postoperative period, which could in turn be linked to parenchymal regeneration. The aim of this study was to analyse postoperative hemodynamic patterns in right liver living donors.
Methods: Doppler ultrasound was prospectively performed in 18 living donors undergoing a right hepatectomy on: preoperative day as a baseline, postoperative days 1 (PO1), 7 (PO7), 15 (PO15) and 30 (PO30). Portal flow (PF) and velocity (PFV), left hepatic vein flow (LHVF), hepatic artery resistive index (HARI) and left hemi-liver volumes (LLV) were assessed.
Results: Mean values showed increments in PF: 176% at PO1, 289% at PO7, reaching a peak of 306% at PO15, decreasing slightly at PO30 (215%). PFV increased 87% at PO1, with a peak of 104% at PO7, decreasing later to 72% at PO15, and 51% above the baseline at PO30. A transient reduction of HARI was observed at PO1 (0.67–0.62) returning to normal values after PO7. LHVF increased slowly from 20% at PO1 to 45% at PO30. As for LLV, a 138% of growth was detected at PO7, remaining steady at PO15 and reaching 159% of the initial volume at PO30. When individual changes were analysed, PF increase did not correlate significantly with degree of regeneration.
Conclusion: Hemodynamic inflow and LLV changes occur mostly between PO7 and PO15. Outflow changes are more evident at PO30, when 60% regeneration is completed.
120
LIVER TRANSPLANTATION FOR HEPATOCELLULAR CARCINOMA: PARTIAL NECROSIS ASSOCIATED WITH TUMOR VASCULAR INVASION AND LOW E-CADHERIN EXPRESSION FAVORS TUMOR RECURRENCE
Ravaioli M, Grazi GL, Ercolani G, Cescon M, Gardini A, Del Gaudio M, Vetrone G, Cavallari A
Department of Surgery and Liver Transplantation, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
Aims: As there is a long waiting time for orthotopic liver transplantation (OLT), many centers apply preoperative treatments (pre-Ts) for patients with hepatocellular carcinoma (HCC). We evaluated the role of the pre-Ts on tumor recurrence (TR) and their relation to partial necrosis and E-cadherin expression.
Methods: We retrospectively reviewed the outcome of 68 patients with a histological sample available, where the diagnosis was HCC and with a survival longer than 1 year. Correlation between clinicopathological variables and HCC recurrence was investigated; in particular, partial necrosis, tumor vascular invasion and E-cadherin expression were evaluated alone, in association and dividing patients according to the pre-Ts.
Results: There were 6 (8.8%) cases of HCC recurrence. In the univariate analysis the presence of partial necrosis and low expression of E-cadherin were significantly related to TR, p < 0.01 and p < 0.05, respectively. All patients with HCC recurrence had vascular invasion. In the multivariate analysis the simultaneous presence of tumor vascular invasion, partial necrosis and low E-cadherin expression was the only variable related to TR. Partial necrosis secondary to pre-Ts was related to TR and to low E-cadherin expression.
Conclusions: Tumor vascular invasion, partial necrosis and low expression of E-cadherin were related to TR, particularly when all were simultaneously present. Pre-Ts without a 100% of necrosis may cause a partial necrosis, which favors the development of low adhesion protein, tumor vascular invasion and consequently TR.
121
SEQUENTIAL AND SIMULTANEOUS REPERFUSION IN ADULT PIGGY-BACK ORTHOTOPIC LIVER TRANSPLANTATION
Polak WG, Miyamoto S, Peeters PMJG, de Jong KP, Porte RJ, Hendriks HG, Slooff MJH
Liver Transplant Group, University Hospital Groningen, Groningen, The Netherlands
Aim: The aim of this study was to analyse a single centre's experience with two reperfusion protocols in adult piggy-back orthotopic liver transplantation (PB-OLT) and compare outcome in terms of survival, morbidity, operative characteristics and liver function.
Methods: 71 adult patients who underwent a primary full-size PB-OLT between May 1995 and December 2001 were analysed. In the first protocol reperfusion of the graft was performed only via portal vein (sequential reperfusion – SeqR) and next arterial anastomosis was made. In the second protocol the graft was reperfused simultaneously via portal vein and artery (simultaneous reperfusion-SimR). The choice of protocol was decided by the surgeon. 48 (67.6%) patients had SeqR and 23 (32.3%) had SimR.
Results: The overall 1-, 3- and 5-year patient survival in the SeqR and SimR groups were 83%, 81% and 81%, and 87%, 81% and 81%, respectively (p = NS). Graft survival at 1, 3 and 5 years in the Seq and Sim groups was 74%, 63% and 63%, and 82%, 72% and 72%, respectively (p = NS). There were no differences in complications in the two groups. Except for the warm ischemic time (WIT) and revascularisation time (REVT) there were no differences in operative characteristics in the two groups. The WIT was significantly longer in the SimR group compared with the SeqR group (63 min vs 50 min, p < 0.05); however, REVT was significantly shorter in the SimR group (64 min vs 97 min, p < 0.05). Also, recuperation of liver function after the OLT did not differ between both groups.
Conclusions: The results of this study show that both techniques of reperfusion of the liver graft are comparable in survival, morbidity and postoperative liver function.
122
A COMPARISON OF CONVENTIONAL AND PIGGY-BACK TECHNIQUE IN ADULT ORTHOTOPIC LIVER TRANSPLANTATION
Miyamoto S, Polak WG, Geuken E, Peeters PMJG, de Jong KP, Porte RJ, Hendriks HG, Slooff MJH
Liver Transplant Group, University Hospital Groningen, Groningen, The Netherlands
Aim: The aim of this study was to analyse a single centre's experience with two techniques of orthotopic liver transplantation (OLT) – conventional (CON-OLT) and piggy-back (PB-OLT)-and to compare outcome in terms of survival morbidity, mortality and postoperative liver function as well as operative characteristics.
Methods: A consecutive series (1994–2001) of 167 adult primary OLT was analysed. 96 patients had CON-OLT and 71 patients had PB-OLT.
Results: 1-, 3- and 5-year patient survival in the CON-OLT and PB-OLT groups were 90%, 84% and 83%, and 85%, 78% and 78% respectively (p = NS). Graft survival at the same time points was 81%, 73% and 69%, and 79%, 66% and 66%, respectively (p = NS). Apart from the number of patients with sepsis, which was higher in the CON-OLT group, morbidity, retransplantation rate and postoperative kidney function were not different in the two groups. Liver function after OLT did not differ in the two groups. The total operation time was not different in the two groups (9.4 h in PB-OLT vs 10.0 h in CON-OLT), but in the PB-OLT group cold and warm ischemic time (CIT and WIT), revascularisation time (REVT), functional and anatomic anhepatic phases (FAHP and AAHP) were significantly shorter (8.9 vs 10.7 h, 54 vs 63 min, 118 vs 160 min, 87 vs 114 min and 82 vs 114 min, respectively, p < 0.05). RBC use in the PB-OLT group was lower compared with the CON-OLT group (4.0 vs 10.0 units, p < 0.05).
Conclusions: The results of this study show that both techniques are comparable in survival and morbidity; however, PB-OLT results in shorter AAHP, FAHP, REVT and WIT, as well as less RBC use.
123
LONG-TERM OUTCOME IN CHILDREN, 10 YEARS AFTER ORTHOTOPIC LIVER TRANSPLANTATION FOR BILIARY ATRESIA
Fouquet V, Alves A, Branchereau S, Grabar S, Debray D, Fabre M, Houssin D, Gauthier F, Bernard O, Soubrane O
Hospital le Kremlin Bicêtre, le Kremlin Bicêtre, France
Aims: The aim of this study was to evaluate the long-term follow-up of children who have undergone orthotopic liver transplantation (OLT) for biliary atresia (BA). We analysed the subgroup of children who had at least 10 years of follow-up after OLT.
Methods: Between April 1986 and December 2000, the Bicêtre-Cochin liver transplant group performed 332 OLT in 280 children with BA. 80 children are still alive 10 years after OLT. Medical records included growth, liver function, renal function and immunosuppressive drugs. Graft function was also documented by liver biopsy. Quality of rehabilitation evaluated school performance, employment and social situation.
Results: 10 years after OLT, 80 children were 1.35 and 0.47 alive with average height and weight standard deviations of 1.44 respectively. Chronic rejection and centrilobular fibrosis were 0.15 observed on liver biopsies in 62%. 63 children attended normal school, 5 children received part-time remedial teaching and 4 children attended a special school. Among the 80 children, 25 (31%) had a delayed school performance.
Conclusions: At 10 years after OLT for BA, the majority of pediatric liver recipients have good results without adverse influence of immunosuppression on somatic growth, renal function and schooling. However, despite encouraging results, most of those children have an abnormal liver biopsy.
124
SURGICAL MANAGEMENT OF CAROLI'S DISEASE – EXPERIENCE FROM A HEPATOBILIARY AND TRANSPLANT UNIT
Kotru A, Halazun KJ, Ghoz A, Toogood GJ, Pollard SG, Prasad KR, Lodge JPA
St. James University Hospital, Leeds, UK
Background: Diffuse Caroli's disease is complicated by recurrent episodes of cholangitis, variceal haemorrhage, or the development of cholangiocarci-noma. Therapeutic modalities include medical treatment, endoscopic decompression, biliary drainage procedures, liver resection and liver transplantation.
Methods: During a 7-year period (1995–2002), 10 patients underwent surgical treatment for Caroli's disease. 7 liver resections and 5 liver transplants were carried out. 2 patients who had liver resection initially, required liver transplantation at a later date. The details of these patients were analysed and presented.
Results: There were 6 female and 4 male patients with a median age of 34 years (range 26–45). The indications for liver resection in patients with localised Caroli's disease were recurrent cholangitis in 4, and development of cholangiocarcinoma in 1 patient. The procedures undertaken included: right hepatectomy in 2, right trisegmentectomy in 1, left lateral segmentectomy and cholecystectomy in 1 and left hepatectomy in 1 patient. The patient with cholangiocarcinoma had excision of extrahepatic bile ducts with hepaticojejunostomy in addition to right trisegmentectomy. No significant postoperative morbidity occurred in this patient. 2 patients who underwent liver resections (right posterior segementectomy in 1 patient and left hepatectomy in the other), initially, further underwent liver transplantation performed 2 and 9 years post resection. One patient who underwent liver resection was found to have incidental carcinoma of the gallbladder. Over a follow-up period of 38 months (range 24–60), 4 patients remain symptom-free, including 1 patient with cholangiocarcinoma. The patient with carcinoma of the gallbladder developed hepatic and extrahepatic recurrence 26 months after resection. The indication for liver transplantation was recurrent cholangitis in all 5 patients, with associated haemobilia and intractable abdominal pain in 1 patient each. No major immediate postoperative morbidity occurred in these patients. All patients received immunosuppression with Cyclosporin/Tacrolimus combined with prednisolone and azathioprine. Incidental cholangiocarcinoma was detected in 2 of the explanted livers. Both these patients succumbed to recurrent tumour at 3 and 16 months postoperatively, respectively. The remaining 3 patients were well on follow-up at 51, 60 and 80 months.
Conclusions: Liver resection and liver transplantation are valid treatment options for Caroli's disease and have the potential to alter its natural history. The risk of development of cholangiocarcinoma should be an indication for early surgical management. Liver resection remains an option in patients with segmental Caroli's disease and cholangiocarcinoma. However, once cholangiocarcinoma develops in diffuse Caroli's disease, transplantation is not an option due to the high risk of developing recurrent disease.
125
PREDICTING THE DONOR LIVER LOBE WEIGHT FROM BODY WEIGHT FOR SPLIT-LIVER TRANSPLANTATION
Chaib E, Saad WA, Gama-Rodrigues J
Department of Gastroenterology, Sao Paulo University, Sao Paulo Medical Faculty, Sao Paulo, Brazil
Aim: It is possible to obtain two good quality hepatic transplants from a single cadaveric liver by separation of the right and left lobes of the liver. We attempted to define a relationship based only on donor body weight for predicting donor total liver weight as well as donor right (segments V–VIII) and left (segments II–IV) hepatic lobe weight. Segment I (caudate lobe) is resected and thus lost in this procedure.
Methods: The study was performed on 60 human cadaveric livers. We correlated cadaveric body weight (mean±SD), 72.43±9.5 kg, with total liver weight, 1.54±0.36 kg, and right and left lobe weight, 0.88±0.23 kg and 0.65±0.17 kg, respectively, with total liver weight.
Results: A formula was obtained by linear regression which provided the following relationships: total liver weight (g)=[245.57 + 17.92×(body weight, kg)]; right lobe weight (g)=[67.58 + 0.52×(total liver weight, g)]; left lobe weight (g)=[−63.38 + 0.47×(total liver weight, g)].
Conclusion: The selection of the recipient on the liver transplant waiting list can be made on the basis of these relationships.
Session 17
Liver Resection – 4
(DOI 10.1080/16515320310000940)
126
OUTCOME OF RIGHT HEPATECTOMIES IN PATIENTS OLDER THAN 70 YEARS
Cescon M, Grazi GL, Ercolani G, Del Gaudio M, Gardini M, Ravaioli M, Vetrone G, Nardo B, Cavallari A
Department of Surgery and Transplantation, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
Aim: The increasing number of elderly patients undergoing hepatectomy mandates updating of outcomes of this population. We evaluated the results of right hepatectomies in patients older and younger than 70 years in a single center case-series.
Methods: 23 patients older (Group 1) and 99 younger (Group 2) than 70 years who underwent right hepatectomies between 1995 and 2001 were included. Preoperative, intraoperative and postoperative parameters were analysed and compared.
Results: The two groups were similar for indications for surgery and underlying liver diseases. Group 1 had a higher incidence of associated pulmonary diseases (p = 0.02) and ASA score III (p = 0.01). There were no differences in intraoperative blood transfusions and operation time. In-hospital mortality was 0% in Group 1 and 2% in Group 2. Postoperative complication rate was 39.1% in Group 1 and 32.3% in Group 2 (p = 0.53), with 21.7% and 17.2% of transient liver dysfunction (p = 0.56). Supplementary ICU stay was required in 17.4% of cases in Group 1 and 5.1% in Group 2 (p=0.06). Postoperative stay and peak values of aminotransferases, total serum bilirubin (TBIL), and prothrombin time were similar in the two groups, as well as the timing of peak value of TBIL (4.1 vs 2.5 days, p = 0.28) and its period of normalization (9.4 vs 6.7 days, p=0.67).
Conclusions: Age over 70 should not be a contraindication for major hepatectomies, provided that liver cirrhosis and severe associated medical conditions are ruled out during preoperative evaluation.
127
LIVER RESECTION FOR MULTIPLE COLORECTAL METASTASES: TOTAL TUMOR VOLUME, NOT NUMBER OR LOCATION, SIGNIFICANTLY AFFECTS LONG-TERM SURVIVAL
Ercolani G, Grazi GL, Ravaioli M, Cescon M, Gardini A, Varotti G, Del Gaudio M, Vetrone G, Cavallari A
Department of Surgery and Transplantation, Ospedale Sant'Orsola, University of Bologna, Bologna, Italy
Aim: Multiple and bilateral colorectal liver metastases are not absolute contraindications to surgical resection. Influence on survival of tumor volume has been not yet investigated.
Methods: A total of 245 curative liver resections for colorectal metastases were reviewed retrospectively. There were 144 (58.8%) males and 101 (41.2%) females. Mean age was 59.5±9.9 years. The 245 patients were divided into 3 groups: 146 (59.6%) with a single lesion (Group M1), 60 (24.4%) with multiple unilobar lesions (M2) and 39 (16%) with multiple bilobar lesions (M3). Considering the tumor as sphere-shaped, patients were arbitrarily divided into 3 groups: patients with total tumor volume <125 cm3 (Tl), patients with total tumor volume from 125 to 380 cm3 (T2) and patients with total tumor volume >380 cm3 (T3).
Results: Overall operative mortality was 0.8%. Overall 5-year survival was 34%. The 5-year survival was 41% in group Ml, 17% in M2 and 34% in M3 (group Ml vs M2, p = 0.05; group Ml vs M3 and M2 vs M3 = NS). The 5-year survival was 40.3% in group Tl, 22.8% in T2, and 15.4% in T3 (p < 0.01). Among several common prognostic factors evaluated, at the multivariate analysis only the total tumor volume significantly affected long-term outcome (p = 0.01).
Conclusions: A better outcome in patients with small single lesions was shown. In patients with multiple and/or bilateral metastases an acceptable 5-year survival superior to 20% was obtained by surgical approach. The total volume of metastases, not number and location, seems to be the strongest predictor of survival.
128
GROWTH PATTERN OF COLORECTAL LIVER METASTASES DOES NOT INFLUENCE PROGNOSIS AFTER PARTIAL LIVER RESECTION
De Jong KP, Vermeulen PB, Boot M, Slooff MJH, Gouw ASH
Department of HPB Surgery & Liver Transplantation, University Hospital Groningen, Groningen, The Netherlands
Aims: Three types of growth can be identified in liver tumors: pushing, desmoplastic and infiltrative. In hepatocellular carcinoma the presence of the fibrotic capsule of the desmoplastic type is associated with a better prognosis. The aim of the present study was to evaluate the growth pattern of resected colorectal liver metastases in relation to prognosis.
Methods: Histological slides of resected specimens of colorectal liver metastases from 102 consecutive patients were evaluated for the growth pattern using H&E and Masson trichrome staining. The interface of the tumor and surrounding liver tissue was scored as predominantly pushing, desmoplastic or infiltrative. Patient and tumor characteristics were retrieved from our database. Using non-parametic statistics and Kaplan-Meier survival analysis the growth type was evaluated in relation to these characteristics.
Results: The infiltrative growth type was rarely seen and never occurred as the predominant growth type. The pushing type was seen in tumors of 60 patients, and the desmoplastic type in 42. Patient (age, sex, primary tumor localization and differentiation) and tumor characteristics (number and size of metastases) were not different in the two groups. Pre-liver resection CEA levels in patients with the pushing type were higher as compared with patients with the desmoplastic type (median (IQR) 90 (387) and 36 (107), respectively). Survival was not different (p = 0.6) in the groups, with a median survival of 31 (pushing) and 35 (desmoplastic) months.
Conclusion: The growth pattern of colorectal liver metastases does not influence the prognosis after partial liver resection.
129
MULTIMODAL THERAPY FOR HEPATIC METASTASES OF COLORECTAL CARCINOMA
Pantoflicek J, Ryska M, Belina F, Langer D
Transplant Surgery Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
Background: The Czech Republic is leading world statistics of colorectal carcinoma with an incidence of 73.5/100,000. Only 25% of colorectal hepatic metastases are suitable for liver resection. A number of adjuvant and neoadjuvant methods changed the surgical strategy for treatment and improved the results in this disease.
Methods: 98 patients with liver metastases of colorectal origin were preoperatively indicated for multimodal therapy and were operated between 1998 and 2002 in our department. Peroperative assessment of metastatic extent allowed application of multimodal strategy to each patient. 20 explorative laparotomies and 121 multimodal procedures (40 implantation of port catheter, 11 metastasectomies, 20 hepatectomies, 19 segmentectomies and bisegmentectomies, 31 cytodestructive procedures) were performed in 78 patients.
Results: Postoperative complications were seen in 12% of patients and mean survival time was 19.8 months. There was a significant difference in survival between the group of receiving multimodal treatment and the group undergoing intra-arterial chemotherapy (p = 0.0363).
Conclusion: We propose a standard approach in the diagnosis and treatment of liver metastatic disease and orientation of patients to units offering all managements strategies and techniques so as to deliver optimal care.
130
ECHO-GUIDED LIVER RESECTION OF INVISIBLE AND NON-PALPABLE METASTATIC COLORECTAL CANCER
Chiappa A, Biffi R, Luca F, Bertani E, Zbar AP, Crotti C, Pace U, Venturino M, Andreoni B
European Institute of Oncology-University of Milan, Milan, Italy
Aims: Several experiences underline that in many cases a neoplastic lesion, especially hepatic metastases from colorectal cancer (CRC), may be missed by surgical inspection and palpation, even if correctly demonstrated by an ideal preoperative imaging assessment. The role of intraoperative ultra-sonography (IOUS) in detecting and localizing invisible and non-palpable CRC liver metastastic nodules was evaluated.
Methods: In a series of 83 histologically demonstrated CRC liver metastasis nodules in 67 patients, liver resection was carried out under ultrasonographic control. Hepatectomies, segmentectomies, systematic subsegmentectomies and hepatic wedge resections were performed.
Results: IOUS showed the presence and the location of 8 (10%) invisible and non-palpable lesions, which were resected in all cases. Of 22 lesions ≤1 cm in diameter, 5 (23%) were occult to surgical evaluation, so that 3/39 (8%) nodules 1–5 cm in diameter. All 22 tumours >5 cm in diameter were palpable. Among patients with single CRC liver metastases, 5/57 (9%) nodules were detected only by IOUS, compared with 2/10 (20%) in subjects with multicentric CRC liver metastases.
Conclusions: US intraoperative detection of invisible and non-palpable CRC liver metastasis nodules can be mandatory to avoid blind resections, allowing a selective surgical approach. The role of IOUS is especially demonstrated in detecting and localizing CRC liver malignancies.
131
ANATOMICAL BLOODLESS LIVER RESECTION BY RADIOFREQUENCY THERMAL ABLATION UNDER VASCULAR CONTROL
Lupo L, Gallerani A, Aquilino F, Di Palma G, Memeo V
University of Bari, Bari, Italy
Background: Surgical resection remains the treatment of choice for primary or secondary liver cancer and an anatomical resection should be preferred. Complications are mainly related to blood loss.
Methods: We tested the feasibility, efficacy and safety of radiofrequency (RF) thermal ablation to perform resection aiming to increase margin clearance, reduce cancer cell spread and perform a bloodless section of the parenchyma. Seven patients (age: 54, range 42–68 years) underwent open liver resection: 5 patients for HCC (1 right hemihepatectomy and 4 segmentectomy) and 3 for colorectal liver metastases (1 right hemiepatectomy, 1 left hemihepatectomy and 1 segmentectomy) using this technique, after control of main or segmental portal and arterial branches by section or embolization. Ablated was achieved by multiple insertion of a triple cooled needle (Radionics, Barlington, MA, USA). Parenchyma section was performed with knife and scissors through the burnt tissue. Few stiches were put on the main vessels.
Results: No death or hemoperitoneum occurred. In two cases abscess on margin resection occurred and patients needed percutaneous drainage. No technical difficulties were encountered. After resection, all small and medium size vessels on the section were thrombosed, but the main hepatic veins remained patent at US control.
Conclusions: A new technique for parenchymal section using thermal ablation by RF, was adopted, offering 'bloodless' surgery and oncologic adequacy.
132
MAJOR HEPATECTOMY: WHAT IS THE RATE OF FUTURE LIVER REMNANT FOR A SAFE RESECTION WITHOUT PORTAL VEIN EMBOLIZATION?
Ferrero A, Vigano L, Polastri R, Muratore A, Sgotto E, Capussotti L
Department of Surgery, Ospedale Mauriziano “Umberto I” Torino, Italy
Aims: Indications for preoperative portal vein embolization (PVE) remain controversial. The aim of this prospective study was to investigate early outcomes of major hepatectomies without PVE.
Methods: Between April 2000 and November 2002, 109 patients underwent major liver resection (>3 Couinaud's segments) for benign or malignant disease. Future liver remnant (FLR) was calculated by computed tomography-volumetry and liver function was investigated by the indocyanine green (ICG) retention test. Patients with FLR <25% underwent PVE. The remaining patients were divided in two groups according to the estimated FLR: 25–40% (30 patients) and >40% (53 patients). Pre- and postoperative blood test results, intraoperative data and early outcomes were compared in both groups.
Results: The two groups were comparable in terms of presence of chronic liver disease, ICG retention test and preoperative blood test results, excluding a higher bilirubin level in the first group. Mean number of resected segments was 4.5 in group 1 and 3.8 in group 2 (p=0.0001). Associated resections, intraoperative data and perioperative blood transfusion rate were similar. Mortality and morbidity rates were 0 and 40% in group 1 vs 3.7% and 34% in group 2 (p = NS). Mean hospital stay was similar (11.9 vs 14.4 days). On day 3, bilirubin level and prothrombin time were significantly altered in group 1. The same pattern was present on day 7.
Conclusions: Patients with a FLR between 25% and 40% have early clinical outcome similar to those with a FLR >40%, but they present a slower recovery to a normal liver function.
133
USE OF LEUKOCYTE DEPLETION FILTERS FOR TUMOR CELL FILTRATION DURING EXTENDED LIVER SURGERY
Fruhauf NR, Kaiser G, Lang H, Oldhafer KJ, Broelsch CE
Klinik fur Allgemein und Transplantations Chirurgie, University of Essen, Essen, Germany
Aim: During oncologic surgery intraoperative manipulation of tumor tissue is almost unpreventable and causes a high risk of tumor cell dissemination into venous blood. Under in vitro conditions a tumor cell reducing effect of some leukocyte adhesion filter systems had been shown.
Methods: In a first clinical attempt leukocyte adhesion filters were integrated into veno-venous bypass systems in 4 patients undergoing extended liver surgery for secondary hepatic malignancies. Practicability, handling and safety aspects as well as potency of cell removal and clinical side effects of the filter system were analysed.
Results: All patients tolerated the application of the system without problems during the operative and the postoperative follow-up. Cytoker-atin-positive cells, suspected as tumor cells, were detected in 3 cases during the mobilization of the liver in perioperative blood samples.
Conclusions: Effectiveness of the tumor cell depletion and safety of the procedure was shown. Clinical significance has to be examined in a larger amount of patients; therefore the presented technique represents a safe and innovative tool.
Session 18
Acute Pancreatitis – 2
(DOI 10.1080/16515320310000959)
134
HEMOSTATIC ABNORMALITIES AND THE SEVERITY OF ILLNESS IN PATIENTS WITH SEVERE NECROTIZING PANCREATITIS
Radenkovic DV, Bajec DJD, Ivancevic NDJ, Karamarkovic AR
Emergency Center, Medical Faculty of Belgrade, Belgrade, Yugoslavia
Aims: Disturbances of coagulation and fibrinolysis are well-known systemic effects of severe necrotizing pancreatitis (SNP). The purpose of this study was to find out whether changes within the hemostatic system are related to severity of illness.
Methods: This prospective study included 41 patients surgically managed by repeated operative necrosectomy for SNP. The coagulation, anticoagulation and fibrinolysis variables: prothrombin ratio, activated partial thromboplastin time, fibrinogen, antithrombin III (AT III), protein C, plasminogen activator inhibitor-1 (PAI-1), d-dimer, alfa-2 antiplasmin and plasminogen were obtained on day of first operation (day 1) and on days 3, 5, 7, 10 and 14. At the end of the study, two groups were compared: 26 surviving (group S) and 15 non-surviving patients (group D).
Results: Protein C levels were low on days 1, 3, 5, 7 and 14. in non-survivors and on day 1 in survivors. On day 3 the difference between both groups was statistically significant. AT III levels were decreased on days 1 and 3 in survivors and on days 1,3,5,7,10 and 14 in non-survivors. On day 5 levels in survivors and non-survivors became significantly different. The PAI-1 levels were high in both groups on days 1, 3 and 5. On day 7 the difference between survivors and non-survivors reached statistical significance. The d-dimer levels were high in group D on days 1,3,5,7,10 and 14 and on days 1, 3 and 5 in survivors. Values on day 7 were significantly different between groups.
Conclusion: Changes in protein C, AT III, d-dimer and PAI-1 levels indicate exhaustion of fibrinolysis and coagulation inhibitors in patients with poor outcome during the course of severe acute necrotizing pancreatitis.
135
PREDICTORS OF SEVERITY IN ACUTE PANCREATITIS: COMPARATIVE ANALYSIS OF RANSON SCORE, GLASGOW IMRIE SCORE AND CT
User Y, Bilsel Y, Poyraz A, Tilki M, Kacmaz A, Talu M
Haydarpasa Numune Training and Research Hospital, 3rd General Surgery Clinic, Istanbul, Turkey
Aims: The assessment of the severity of acute pancreatitis is a critical early step in its management, as severity of pancreatitis predicts prognosis. We sought to determine whether the Ranson score was still an acute marker for the severity of illness, and to compare the Ranson and Glasgow Imrie scores with computed tomography grade and severity index to see which system would prove to be superior for the prediction of severity in patients with acute pancreatitis.
Methods: Over a 4-year period, a total of 73 consecutive patients admitted with acute pancreatitis were prospectively studied. The Ranson and Glasgow scores were calculated, and a contrast-enhanced computed tomography (CECT) of the abdomen was performed within 48 h of admission with determination of CECT grade and severity index. Several clinical endpoints were also recorded: local or systemic complications, surgical or radiological interventions and duration of hospitalization. The correlation between each of the Ranson and Glasgow score, and the CT criteria (grade and severity index) was determined. Each predictor was also tested for any relationship to the occurrence of complications and necrosis using a logistic regression analysis.
Results: Ranson and Glasgow Imrie scores were quite similar to each other (r = 0.80, p < 0.001). Statistically significant strong correlations also existed between the Ranson and CECT grade (r = 0.610, p < 0.01) and CT severity index (r = 0.619, p < 0.01). The CECT grade and severity index also strongly correlated with the occurrence of complications (r = 0.629, p < 0.001; r = 0.622, p < 0.001 respectively). None of these systems was found superior to any other as a predictor of complications (p>0.05).
Conclusions: The mathematical integration of CECT criteria and the Ranson and Glasgow scores fails to yield a predictor of outcome superior to the use of any one measure alone. Therefore, the simple Ranson score still remains valid for predicting the outcome in patients with acute pancreatitis. CECT and CT severity index are also very helpful tools in the assessment of severity. However, CECT should be used selectively. It should be avoided in those with mild cases, and should be reserved for those with a more complicated clinical course.
136
THE ROLE OF ENDOSCOPIC RETROGRADE CHOLANGIO- PANCREATICOGRAPHY IN PATIENTS WITH SEVERE ACUTE BILIARY PANCREATITIS
Yanar HT, Ertekin C, Guloglu R, Taviloglu K, Ayalp I
Department of Trauma and Emergency Surgery, School of Medicine, University of Istanbul, Turkey
Aim: The timing of endoscopic retrograde cholangiopancreatography (ERCP) in patients with severe acute biliary pancreatitis is an issue that has been discussed for a long time. On the other hand, it is known that the presence of gallstones in the biliary tract increases risk of biliary leakage after cholecystectomy.
Method: 27 patients with acute severe biliary pancreatitis who underwent ERCP among 132 patients treated in the Emergency Unit of Istanbul University Faculty of Medicine for acute pancreatitis during a 2-year period (January 2000-December 2002) were studied: 18 (66.6%) females and 9 (33.4%) males, with an average age of 52.2 (27–81 years). Patients with three or more positive values from Ranson scores are considered to have severe pancreatitis. The indication criteria for ERCP are determined as total bilirubin level >3, blood levels of alkaline phospotase twice normal, and ultrasound evidence of stone or dilatation in the biliary tract.
Results: Cannulation of the papilla could not be achieved in the first trial one of the patients (3.4%) and ERCP was repeated 24 h later with successful cannulation. Gallstones were found in 6 (22.2%) patients and sludge was found in the common bile duct in 3 (11.1%) patients. Edema of the papilla was seen in 12 (44.4%) patients and obliteration due to edema of the common bile duct was seen in 6 (22.2%) patients. Sphincterotomy was performed in all the patients, whereas gallstone extraction was performed in 6 (22.2%) patients. There was no mortality related to ERCP. Among these patients, 11 (40.7%) underwent surgery due to infection of necrosis and 6 patients died. Nine (33.3%) of the patients underwent laparoscopic cholecystectomy after the relapse of disease without any complications.
Conclusion: ERCP may be used as an efficent method for bile drainage and also lower septic complications in the treatment of severe biliary pancreatitis.
137
THE ROLE OF OCTREOTID VERSUS PLACEBO IN THE PREVENTION OF POST-ERCP PANCREATITIS
Aydin M, Kisli E, Baser M, Guler O, Soylemez O
Department of General Surgery, School of Medicine, Yuzuncuyil University, Van, Turkey
Aims: Acute pancreatitis is the most common major complication of ERCP. Octreotide may reduce the frequency of post-ERCP pancreatitis because it is a potent inhibitor of pancreatic secretion. The aim of this study was to evaluate the effectiveness in preventing post-ERCP pancreatitis and progressing hyperamylasemia.
Methods: 120 of 130 patients (71 female, 59 male) who had been diagnosed with pancreaticobiliary pathology were included in this study. Intravenous administration of 100 mg octreotide was begun 30 min before the procedure and continued during the procedure until 10 min after the procedure. Placebo was given in 87 patients. Serum amylase level was assessed before and during the procedure. These results were compared with placebo groups.
Results: Papilla of Vater was catheterized in 33 patients who were administered octreotide and pancreatic duct could be visualised by radioopac solution. Hyperamylasemia was assessed in 14 of 33 (42.4%). Clinical findings of pancreatitis were observed in 5 of these 14 (11.5%) patients but they were free from these findings on the 5th day after the procedure. Hyperamylasemia was also assessed in 41 of 87 (47.1%) patients who received placebo. Clinical findings of pancreatitis were observed in 10 of these 41 (11.5%) patients but their amylase levels were in the normal range on the 5th day after the procedure and they were free from these findings. There were no statistically significant differences between the groups.
Conclusion: The results of this trial indicate that octreotide does not prevent ERCP-induced pancreatitis and effects on serum amylase levels.
138
BILIARY PARASITE-INDUCED ACUTE PANCREATITIS: DIAGNOSTIC AND THERAPEUTIC MODALITIES
El-Sefi T, Osman M, Salman T, Boghdadi I, Shawki A, Sadek A, Taher M-Y
National Liver Institute, Menoufeya University, Alexandria, Egypt
Aim: To describe the presentation, diagnosis and therapeutic modalities of acute biliary pancreatitis caused by parasites not uncommon in Egypt.
Methods: 13 patients with a mean age of 44.6 years were included. All patients fulfilled the criteria for clinical diagnosis of acute biliary pancreatitis. 6 patients (46%) were cholecystectomised 8–15 months before presentation. According to the Atlanta classification, all patients were diagnosed as mild pancreatitis. All patients were subjected to ultrasound and computed tomography examination followed by ERCP and endoscopic sphincterotomy (ES).
Results: There were no specific clinical signs of biliary parasites. Eosinophilia (>7%) was found in 7 patients. US examination was suggestive of parasitic infection in 9 patients, revealing mobile echogenic structures (with no posterior shadow) and duct dilatation in 4, non-shadowing linear echogenic structures in 3, and liver cysts in 2. In the remaining 4 patients, US revealed only mild ductal dilatation. ERCP examination demonstrated cholangiographic patterns characteristic for fasciola flukes in 7, and ascaris worms in 4. In the other 2 patients, hydatid cyst-biliary communication was found. ES was performed in all patients with successful retrieval of the parasite (s). Prompt relief of pain and return to normal levels of serum enzymes and bilirubin followed the procedure. Antihelminthics and antibiotics were given for all patients who were discharged 3–5 days after ERCP/ES.
Conclusions: In Egypt, biliary parasites may be considered an etiological factor of acute biliary pancreatitis, especially if cholecystectomy has been performed in the past. ERCP/ES are very helpful in denning changes in the bile ducts as well as retrieval of biliary parasites. Endoscopic management followed by antihelminthics results in a rapid resolution of symptoms and prevents development of complications.
139
ACUTE PANCREATITIS: A CONSTANT CHALLENGE FOR THE SURGEON
Papavramidis Th, Zandes N, Hatzimisios K, Koutsimani Th, Kehagia F, Agorastou P, Doulgerakis M, Patoulidis I (Thessaloniki, Greece)
General Peripheral Prefecture Hospital of Kozani, Thessaloniki, Greece
Aim: Acute pancreatitis is an inflammation of the pancreas caused by autodigestion of the gland by its enzymes. It includes a broad spectrum of pancreatic disease, which varies from parenchymal edema to necrosis. The present study aimed to reinforce the opinion that operation in patients with gallstone-associated pancreatitis, within the first 72 h after the onset of the disease, has many advantages and has to be considered as a treatment option.
Methods: The retrospective study included all patients who were hospitalized in Mamatsio Hospital of Kozani during the period January 1997 to January 2002 with a diagnosis of gallstone-associated acute pancreatitis. 108 cases were identified (43 males and 65 females). The mean age was 62.93 years (SD 15.85, range 17–91). 24 patients (22.22%) fulfilled >3 Ranson's criteria. 20 patients (18.52%) presented necrotizing pancreatitis. All patients underwent open cholecystectomy and common bile duct exploration. Necrosectomy concomitantly with cholecystectomy was performed in 7 patients (6.48%).
Results: The mean hospitalization was 10.53 days (SD 6.38, range 2–36). The associated mortality reached 5.55% (6 patients) and no patient died in the operating theater. During the 12-month follow-up period, 2 patients (1.85%) developed pancreatic pseudocysts.
Conclusions: Immediate removal of the gallstone in gallstone-associated acute pancreatitis is of vital importance for the patient. In a peripheral hospital, where ERCP with endoscopic sphincterotomy is unavailable, immediate operative procedures have to be performed. The surgeon has to be aggressive before further deterioration of the patient's health and without the fear that surgery may be of greater difficulty or may aggravate the patient's condition.
140
CLINICAL VALUE OF PROCALCITONIN TEST IN SEVERE ACUTE PANCREATITIS
Issekutz Á, Belagyi T, Olah A
Petz Aladar County Teaching Hospital, Gyor, Hungary
Aims: The clinical value of a procalcitonin semiquantitative test (PCT-Q; BRAHMS Diagnostica GmbH, Berlin) was evaluated in a prospective study of acute necrotizing pancreatitis controlled by fine needle aspiration (FNA) biopsy.
Methods: A total of 24 consecutive patients was admitted to the Surgical Department and enrolled to the study between 1 January and 31 December 2001. Imrie score (>3), CRP level (>150) and extension of necrosis (>30%) were criteria of severity form. The PCT test was evaluated within the first 48 h in all cases, and was repeated between the 7th and 10th days. In case of positive PCT test or suspected septic complications (abscess or infected necrosis) CT/US-guided FNA biopsy was performed, with Gram's staining and culture. FNA positivity was an indication for surgical intervention in all cases. Bacterial culture of surgical specimens was also performed.
Results: Infected necrosis or abscess was detected in 12 cases. Infection was monobacterial only in 4 cases. PCT level was moderately high (>0.5 ng/ml) in 5, high (>2 ng/ml) in 4, and very high (>10 ng/ml) in 2 patients. FNA biopsy was positive in 11 cases. 12 patients required surgical intervention, four patients were lost. Sensitivity and specificity of FNA biopsy were 92% and 100%, respectively. Both of these parameters of the PCT test were lower (75% and 83%). However, sensitivity and specificity were both 100% in cases of infected necrosis (6 patients), 4 of them had multiorgan failure.
Conclusions: Based on these results the PCT semiquantitative test seems to be a simple, non-invasive method, but it could not replace FNA biopsy. PCT concentration > 2 ng/ml – besides septic signs or MOF – detects bacterial infection. A lower concentration does not exclude localised infection, which requires repeated CT scan to search for the focus.
Session 19
Liver Resection – 5/Video
(DOI 10.1080/16515320310000968)
141
RESULTS OF A CONSECUTIVE SERIES OF 64 RADIOFREQUENCY-ASSISTED LIVER RESECTIONS
Navarra G, Jiao L, Tysome JR, Habib NA
Imperial College of Medicine, Hammersmith Hospital Campus, London, UK
Aims: Despite an improved mortality, intraoperative blood loss, post-operative biliary leak and liver failure remain a major concern in liver resection. The authors present the results of major and segmental liver resections using a new technique assisted by the use of radiofrequency energy.
Methods: From January 2001 to November 2002, 64 consecutive resections were performed using the radiofrequency energy-assisted technique. Radiofrequency energy was applied along the resection edge to create a 'zone of desiccation' prior to resection with a surgical scalpel.
Results: The median resection time was 60 min (range 30–210). The median blood loss during resection was 50 ml (15–1500) with a mean preoperative and postoperative haemoglobin of 13.4 + 1.5 g/dl and 11.5 + 1.5 g/dl, respectively. One patient died on the 7th postoperative day due to a rupture of the thoracic portion of a large dissecting thoracoabdominal aortic aneurysm. 3 patients were transfused either intra- or postoperatively. There were 8 major postoperative complications: 3 biliary leaks including 1 from a hepatico-jejunostomy, 1 subphrenic abscess, 1 pleural empyema necessitating thoracotomy, 1 chest infection, 1 skin burn and 1 prolonged ileus. The median postoperative stay was 8 days (range 5–86). 3 of the 64 patients were admitted to the Intensive Care Unit.
Conclusion: Major and segmental liver resections assisted by radio-frequency energy are feasible and safe. This technique offers a new method for resection without the need for sutures, ties, staples, tissue glue or hypotensive anaesthesia and is associated with minimal intraoperative blood loss, and few biliary leaks or liver failures.
142
RIGHT ANTERIOR SEGMENTECTOMY WITH BILE DUCT RESECTION FOR ICTERIC-TYPE HEPATOCELLULAR CARCINOMA
Kubota K, Shimoda M, Kita J, Nemoto T, Rokkaku K, Sakuma A
Second Department of Surgery, Dokkyo University School of Medicine, Tochigi, Japan
In this report we present a radical resection of icteric-type hepatocellular carcinoma (HCC) by right anterior segmentectomy with bile duct resection. A 72-year-old male with HCV antibody was referred to our department due to liver dysfunction and icterus. CT showed a tumor in segment 8. ERCP demonstrated a tumor thrombus in the bile duct. The left hepatic duct and the bile duct of the posterior segment were drained by ENBD. As the patient had liver cirrhosis, we decided to perform anterior segmentectomy with bile duct resection. First, abdomino-thoracotomy was accomplished by J-shaped incision. After cholecystectomy, the right hepatic artery, the anterior and posterior branches were exposed. Then, the portal vein, the anterior and posterior branches were exposed. The respective anterior branches were divided. Hemihepatic clamping was employed for liver dissection. The liver dissection between the anterior segment and medial segment was performed and subsequently the left hepatic duct was divided. The common bile duct was divided at the entrance to the pancreas. Finally, the liver dissection between the anterior segment and posterior segment was performed and the bile duct to the posterior segment was divided. Thus the operation was accomplished without exposing the main tumor and the tumor thrombus in the bile duct. The bile ducts to segments 2 and 3 and the posterior segment were reconstructed by bilio-jejunostomy. The bleeding amount was 1106 ml and the operation time was 11 h and 23 min. His postoperative course was uneventful.
143
ANATOMICAL RESECTION OF SEGMENT 8 WITH SECTION OF RIGHT HEPATIC VEIN FOR HEPATOCELLULAR CARCINOMA ON CIRRHOSIS
Grazi GL, Ercolani G, Gardini A, Cescon M, Ravaioli M, Cavallari A
Department of Surgery and Transplantation, University of Bologna, Ospedale Sant'Orsola, Bologna, Italy
Liver resection of segment 8 remains one of the most challenging procedures for hepato-biliary surgeons. The video shows an anatomical resection of segment 8 for hepatocellular carcinoma on cirrhosis with previous ligation of a right superior hepatic vein. The laparotomy was performed by J right subcostal incision. Intraoperative ultrasonography (IUS) first shows the limit of the tumor between the middle hepatic vein and the right hepatic vein and secondary between the pedicle of segment 5 and the pedicle of segment 8. Then the portal branch for segment 6 and 7 and the portal branch for segment 5 and 8 are identified and taped. Next the right anterior branch of hepatic artery is encircled. In the case of bleeding, the right hemiliver could be clamped. The right side of inferior vena cava is dissected. Right superior, right middle and right inferior hepatic veins are identified and encircled. The medial limit of segment 8 is landmarked by the middle hepatic vein which is identified by IUS. Liver resection starts from the limit between segment 8 and segment 4, under US guidance. The anterior and posterior glissonian pedicles of segment 8 are identified, ligated and tied. An ischemic demarcation of the segment 8 is visualized. The right superior hepatic vein is sutured with prolene and tied. Anatomical resection of segment 8 is accomplished without any vascular clamping. After resection, anatomical limits of segment 8 are shown, the middle hepatic vein, the right hepatic vein and the glissonian pedicles for anterior segments. The resection is performed without need for blood transfusion
144
HEPATIC RESECTION OF A LIVER METASTASIS USING A TISSUELINK MONOPOLAR FLOATING BALL® DEVICE
Di Carlo I, Russello D, Puleo S, Latteri F
Department of Surgical Sciences, Organs Transplantation and Advanced Technologies, University of Catania, Catania, Italy
Aim: Hepatic resections are more and more safe due to the development of new techniques and devices such as CUSA® preventing bleeding and avoiding blood transfusions. The aim of this study is to describe a case report concerning a young patient affected by liver metastases from adrenal carcinoma and operated using a tissuelink monopolar floating ball device. Case report: A 29-year-old woman was admitted to the First Surgical Clinic of University of Catania presenting liver metastases located at segment VI. The patient was operated 3 years before for adrenal gland carcinom. The surgery was performed in 90 min, without any clamping of the hepatic inflow or outflow. The hepatic section was performed with a tissuelink monopolar floating ball® device without ligature of the parenchimal vessels. The tumor located in the segment VI was resected in 15 min. No bleeding was recorded during or after resection, and post-resection biliary leakage control with methylene blue, of the resected surface was negative. The patient was discharged 4 days after the procedure and any complications occurred after 6 months of follow-up.
Conclusion: The tissuelink monopolar floating ball could represent a valid option in relation to the more expensive devices for hepatic resections.
145
LAPAROSCOPIC HEPATIC SURGERY
Filauro M, Cappato S, Bagarolo C, Franceschi A, Marini P
HBP Surgery Galliera Hospital, Genoa, Italy
Aims: To confirm the possibility of performing safe liver surgery by videolaparoscopic technique.
Methods and results: The first case concerns a patient presenting a segment 3 haemangioma causing epigastric pain with increasing size. The lesion originating from the inferior face of the left lobe was removed with a portion of surrounding parenchyma. The second patient had a huge hepatic cyst of segment 5 close to the gallbladder. Cystic wall was excised by ultracision after evacuation of serosal fluid. The cyst was then removed with the attached gallbladder. The third case concerned a small nodule of segment 3 of unclear origin in a patient who was HCV-positive. The lesion was detected by ultrasonography and liver surface was marked before resection. Subsegmental pedicles were isolated and divided between clips and segmentectomy was then completed. Finally ultrasound checked the clearance of the resection. Pathological examination demonstrated a nodule of focal hyperplasia.
Conclusion: Videolaparoscopic applications in liver surgery are gradually increasing, mainly in focal diseases of left lateral segments. Use of ultracision helps parenchymal resection, minimizing blood loss.
146
NEW EXPERIENCES WITH BENGMARK'S TUBE IN SURGICAL NUTRITION
Mangiante G, Colucci G, Ciola M, Bassi C
University Verona, Department of Surgery, Verona, Italy
Background: Enteral nutrition (EN) is the gold standard for nutrition in surgical and critically ill patients. The most important problem is the EN delivery beyond the ligament of Treitz to avoid aspiration pneumonia.
Methods: Data and results of SPT insertions during the last 3 years have been reviewed.
Results: Between 2000 and 2002 we inserted 153 SPT for EN: 110 for uninterrupted EN (UEN) (68 liver resections, 42 colonic resections) and 43 in other patients (28 acute pancreatitis (AP) 8 acute peritonitis, 6 g astro-enteric fistulas). In all 110 UEN patients the right position was reached within 4 h. In 33 conventional patients, 17 (52%) SPT were at Treitz at the 4-h check, 10/39 (26%) at 24 h, 4/33 (12%) at 48-h check. In 10 patients (6 AP cases, 2 fistulas and 2 paediatric) SPT were placed by fluoroscopy to short the delivery of EN. They reach Treitz during X-ray procedures in a mean time of 15 min (4–25). Mean time of SPT stay was 4 days (3–8) in UEN patients and 15 days in the others (5–38). We recorded 4 dislocations (3 due to nurses' errors, 1 to poor patient compliance).
Conclusions: SPT is a reliable tool for aggressive EN in surgical and critically ill patients. X-ray procedures can be useful in critically ill patients to obtain a correct and fast insertion after Treitz ligament to start EN immediately.
Session 20
Biliary Tumour
(DOI 10.1080/16515320310000977)
147
CHOLANGIOCARCINOMA: WHEN SURGERY REACHES ITS LIMITS
Hatzimisios K, Zandes N, Kehagia F, Koutsimani Th, Papavramidis Th, Agorastou P, Doulgerakis M, Patoulidis I
General Peripheral Prefecture Hospital of Kozani, Thessaloniki, Greece
Aim: Cholangiocarcinoma (CCC) is an uncommon malignant tumor that is difficult to diagnose and treat. It tends to grow slowly and infiltrate surrounding structures. The aim of the present study was to clarify the clinical findings, analyse the methods of diagnosis and evaluate the treatment of patients with CCC.
Methods: In this retrospective study 21 cases of CCC, admitted from January 1997 to December 2002, were reviewed. 15 patients (71.42%) were males and 6 (28.58%) females. The mean age at diagnosis was 68.86 years (SD 5.79, range 57–77).
Results: A higher incidence of CCC appeared in males (2.5:1). The main clinical manifestations were abdominal pain in 52.38% (n = ll) and obstructive jaundice in 85.70% (n = 18) of the cases. The first-line investigation included ultrasonography and CT scanning. In 4 patients (19.04%) cholangiography was performed and in 1 case (4.76%) MRI. Localization of the CCC was extrahepatic in 18 (85.7%) and intrahepatic in 3 (14.3%) patients. In 12 cases (57.14%) metastatic lesion was found at the time of diagnosis. Chololithiasis coexisted in 38.09% (n = 8) of the patients. 12 patients (57.14%) underwent surgery: 2 (9.5%) had tumor resection, 7 (33.3%) palliative surgery and 3 (14.2%) diagnostic laparotomy.
Conclusions: CCC remains a dismal disease with only a 9.5% chance of a curative surgical resection. There is a predominance of extrahepatic CCC. At the time of diagnosis metastatic lesions were already present. The algorithm that has to be followed includes thorough laboratory and imaging study. The predominant symptoms are obstructive jaundice and abdominal pain. The patient presenting CCC has a short life expectancy but surgical treatment improves the quality of life.
148
POSSIBLE STEM CELL ORIGIN OF CHOLANGIOCARCINOMA
Liu C, Frilling A, Broelsch EC
Klinik fur Allgemein und Transplantations Chirurgie, University Hospital Essen, Germany
Aims: Recently human liver stem cells have been identified in normal liver tissue. They take part in the renewal of liver tissue in some patholgogical situations, such as chronic hepatitis and fulminant hepatic failure. It has been suggested that maturation arrest of liver stem cells is one of the mechanisms of hepatocarcinogenesis. Liver stem-like cells have been reported in human hepatoblastoma, hepatic adenoma and focal nodular hyperplasia, but not in cholangiocarcinoma. CD34 and c-kit (receptor of stem cell factor) are two markers of stem cells. In this study, the expression of CD34 and c-kit by cholangiocarcinoma was investigated.
Methods: 15 cases of intrahepatic cholangiocarcinoma and 17 cases of extrahepatic cholangiocarcinoma were studied in this experiment. They included 18 male and 14 female patiens, with an average age of 64 years. Using the Envision detection system, paraffin-embedded sections of the resected cholangiocarcinoma tissue were stained with antibodies against CD34 and c-kit, respectively. The sections were counterstained with hematoxylin, and the results were examined under light microscope. Normal tonsil and mammary tissue were used as positive controls for CD34 and c-kit, respectively.
Results: CD34 were positive in all sections, but only in capillary endothelial cells of tumor tissue. No cholangiocarcinoma cells were positive for CD34. c-kit positive cells were not detected in intrahepatic cholangiocarcinoma; however, tumor cells in 1 case of extrahepatic cholangiocarcinoma were positive for c-kit to a medium degree.
Conclusions: CD34 or c-kit positive cells in liver tissue may represent biliary stem cells, as they can differentiate into mature biliary cells in vitro. The expression of c-kit by some cholangiocarcinoma cells suggests that cholangiocarcinoma might originate from biliary stem cells. However, other mechanism of hepatocarcinogenesis, such as de-differentiation of mature bilary cells, may also exist.
149
SURGERY PLUS INTRAOPERATIVE RADIATION THERAPY FOR HILAR CHOLANGIOCARCINOMA
Lang H, Oldhafer KJ, Kaiser G, Fruhauf NR, Sauerwein W, Stavrou G, Paul A, Malago M, Broelsch CE
Klinik fur Allgemein und Transplantations Chirurgie, University of Essen, Germany
Aim: Despite advances in surgical therapy the prognosis of patients with hilar cholangiocarcinoma (Klatskin tumor) is still poor. Due to the often very small safety margins locoregional tumor recurrence is frequent. Intraoperative radiation therapy (IORT) is an attractive method for local application of a high energy dose in order to improve local tumor control. However, so far there is only little experience with IORT in the treatment of hilar cholangiocarcinoma. It is the purpose of this report to present our initial results with radical surgery in combination with IORT in this tumor entity.
Methods: The charts of 71 patients undergoing surgical exploration for stage IV hilar cholangiocarcinoma between April 1998 and July 2002 were reviewed. Tumor resection including hilar resection plus hemihepatectomy or extended hemihepatectomy was possible in 36 cases. In 35 patients only an explorative or palliative approach was possible. IORT was added in 15 patients after tumor resection and in 10 patients after palliative surgery with a maximum dosage of 20 Gy.
Results: Postoperative complications were comparable after liver resections plus IORT vs liver resection. In 5 patients reoperation was necessary for bile duct complications. Mean follow-up after liver resection is 19 months. Overall survival after tumor resection is 78% at 1 and 41% at 3 years. So far, there is no significant difference between radical surgery plus IORT vs surgery alone.
Conclusions: These results suggest that application of intraoperative radition therapy is not associated with an increased risk of postoperative complications. However, it remains undetermined whether IORT has a beneficial effect after potentially curative resection. In future, prospective randomized trials are required to clarify whether IORT leads to an improvement of the prognosis after radical surgery for hilar cholangiocarcinoma.
150
EFFECTS OF COMBINED HEPATIC RESECTION FOR HILAR CHOLANGIOCARCINOMA
Choi DW, Kim SB, Lee BH, Park SH
Department of Surgery, Korea Cancer Center Hospital, Seoul, South Korea
Aims: This study was conducted to evaluate the clinicopathologic outcome following combined hepatic resection for hilar cholangiocarcinoma (HC), and to identify the significant factors affecting the prognosis.
Methods: 55 HC cases underwent surgery for curative resection from February 1994 to March 2002 in KCCH. Among them, 5 cases were excluded because only bile duct resections were performed. 50 cases consisted of 28 male and 22 female patients. Median age was 60 years (39– 75) and median follow-up period was 18.9 months (10–100). Survival rates and its difference were estimated by Kaplan-Meier methods and log-rank test using SPSS 10.0 for Windows.
Results: Various types of combined hepatic resection were carried out in 42 patients; resectability was 84% (42/50). The remaining 8 patients had unresectable HC due to extensive hepaticoduodenal ligament invasion or peritoneal seeding. In-hospital death occurred in 3 patients, so the mortality rate was 7.1% (3/42). The causes of death were ARDS, thrombotic thrombocytopenic purpura and liver failure resulting from hepatic artery thrombosis. With regard to curability, pathologic curative resection could be achieved in 73.8% (30/42) of the resected cases. Postoperative morbidity rate was 59.5%, mainly pulmonary origin. 5-year survival rate (5-YSR) was 29.3% for the whole surgery group including unresectable cases and 39.5% for the pathologically curative group. Actual 5-YSR was 42.8% (6/14). Resectability, polypoid growth, T1 and low stage were good prognostic factors following combined resection.
Conclusion: Combined hepatic resection for HC should be attempted to achieve long-term survival and better quality of life in the absence of evident contraindications for surgery.
151
GALLBLADDER CARCINOMA: RESULTS OF TERTIARY REFERRAL CENTER
Tekin K, Shrestha P, Imber C, Atli M, Buckels JAC, Mayer AD, Bramhall SR, Mirza DF
Birmingham University, Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
Aims: In view of its rarity in the UK, problems with making a diagnosis and poor prognosis if left untreated, reported series of the surgical management of gallbladder carcinoma are uncommon and debate remains as to whether curative resection of locally advanced disease (>stage II) is appropriate. As a tertiary referral hepato-biliary unit we report a 10-year series with the aim of demonstrating the benefits of attempted surgical resection.
Methods: All 47 patients seen at the QE liver unit Birmingham between 1991 and 2002 with a presumptive diagnosis of gallbladder carcinoma were identified and the data for these patients were extracted from our prospectively collected database. Parameters examined included demographics, clinical history including previous operations, pathology, perioperative course including complications, and outcome. Kaplan–Meier survival curves were established for stage II, III and IV disease.
Results: 15 patients referred were suitable for curative resection, of whom 10 had undergone previous cholecystectomy elsewhere. Procedures performed included completion cholecystectomies, extrahepatic biliary resection + reconstruction (4), wedge resection of gallbladder bed (7) and one right hemihepatectomy with biliary resection. Mean overall survival, including curative and non-curative procedures, was 35 +/ − 14.28 months for stage II disease, 26 +/ − 7.2 months for stage III and 8 +/ − 1.68 months for stage IV (AJCC staging system).
Conclusion: Survival according to the stage of disease for all patients demonstrated significant differences (p < 0.0089). Attempted curative surgical resection for stage II and III disease is worthwhile, as suggested by our results.
152
RESULTS OF RE-RESECTION AFTER PRIOR SIMPLE CHOLECYSTECTOMY FOR GALLBLADDER CANCER INVADING THE PERIMUSCULAR CONNECTIVE TISSUE
Muratore A, Vigano L, Sgotto E, Ferrero A, Capussotti L
Istitudo Per La Ricerca e La Cura Del Cancro, Candiolo, Torino, Italy
Aims: Gallbladder carcinoma is an aggressive tumour; most of the patients are treated at advanced stages with a dismal prognosis. Long-term outcome of surgery is significantly better for early stage tumors. Most T2 gallbladder cancers are diagnosed at final pathology after prior cholecystectomy. Reoperations including liver resection and regional lymph node dissection seem to achieve a better survival. The aim of this study is to evaluate long-term results of reresections after prior non-curative surgery for T2 carcinomas.
Methods: This was a retrospective study from January 1985 to July 2001. 12 of 14 pT2 cancers were found postoperatively. All but one underwent re-resection: these 11 patients are the basis of our paper.
Results: The in-hospital mortality rate was 0%. Overall 5-year survival of these 11 cases was 63.5% with a median survival of 25 months. Median and 5-year survival of the 8 patients without preoperative signs of disease (Group A) were 46.7 months and 100%; these results were significantly better than those obtained in Group B (3 cases) with preoperative signs of recurrence (p = 0.01): all these patients died of disease within 25 months from the reoperation. Of the 8 Group A patients, 2 had lymph node metastases in the hepatic pedicle (N1) and 1 had microscopic disease in the liver parenchyma with a positive retroportal node. The presence or absence of microscopic residual disease at final pathology in Group A did not modify long-term survival (p = 0.1): 100% at 5 years in both subsets of patients (residual vs no residual microscopic disease) with a median survival of 47 months.
Conclusions: Simple cholecystectomy is not an adequate treatment for T2 patients because of the high risk of residual disease. T2 cancers incidentally discovered after simple cholecystectomy should be reoperated as soon as possible, as the appearance of a recurrence is significantly related to a dismal prognosis.
153
INCIDENTALLY DETECTED VS PREOPERATIVELY DIAGNOSED CANCERS OF THE GALLBLADDER – A COMPARATIVE STUDY
Agarwal A
Department of GI Surgery, G.B.Pant Hospital & Maulana Azad Medical College, Delhi, India
Aim: Unsuspected gallbladder cancer (GBC) is reported in 1–3% of cholecystectomies. Radical second resection is advocated in these incidentally detected GBC, with lesions beyond pTlb. This study was undertaken to analyse the patients with incidental gallbladder cancers (IGBC), managed over the last 2 years and to compare them with patients who underwent surgery for diagnosed or suspected gallbladder cancer (DGBC).
Methods: The study included 50 patients with GBC, operated betwen Oct. 2000 and Nov. 2002. Group A included 13 patients with IGBC, detected on histology (4 in-house, 9 referred) and Group B had 37 patients operated for DGBC.
Results: In Group A there were 10 females and 3 males with an average age of 43.9 years (range 32–65, median 44), while in Group B there were 28 females and 9 males with an average age of 51.8 years (range 28–74, median 55). Of the 13 patients, a completion radical cholecystectomy was possible in 8 patients (61.5%). All 4 patients with GBC, detected following in-house cholecystectomy, were found to be resectable, compared with 4 of 9 referred patients. The median time interval between cholecystectomy and second surgery was 41.5 days in the resectable group, while in the unresectable group the median interval was higher, 83 days. In addition to the standard radical resection, performed in all these 8 cases, a bile duct and duodenal sleeve resection was performed in 1 case each. In 5 patients, advanced, unresectable disease was found and a palliative bypass was done in 2 patients. In Group B, 13 of 37 patients (35.1%) were found to have resectable disease, including 2 patients presenting with obstructive jaundice. Hepatopancreatoduodenectomy with segmental colectomy was performed in 1 patient. A palliative bypass was performed in 8 of 37 patients.
Conclusion: The patients with incidentally detected GBC were on an average younger than patients with DGBC. Overall resectability rate was significantly higher in incidentally detected GBC at 61.5% compared with 31.5% in DGBC. The time interval since the primary cholecystectomy is of crucial importance in IGBC, delay can lead to recurrence and inoperability. Development of jaundice in a patient with IGBC was a sign of inoperability, while in patients with DGBC resection was possible in a minority of patients with jaundice.
154
PREOPERATIVE ERCP DRAINAGE OF MALIGNANT OBSTRUCTIVE JAUNDICE: THE EFFECT ON BILE BACTERIOLOGY
Jethwa P, Breuning E, Lala A, Wong T, Bramhall SR, Mayer AD, Mirza DF, Buckels J
Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
Aims: It is unclear whether there is an improvement in surgical outcome for patients that undergo preoperative ERCP. We therefore sought to establish if the use of preoperative ERCP for biliary decompression is associated with an alteration in bile bacteriology and highlight the potential morbidity.
Methods: A retrospective analysis was performed of 206 patients that had undergone HPB resection in our unit. The use of preoperative ERCP was established and a microbiological comparison made between those cases that underwent surgery alone and those that underwent preoperative ERCP with or without stent placement.
Results: Of the 206 patients, 89 had ERCP before surgery and 117 had surgery only. Bacterobilia and fungal colonisation: surgery alone 58 (50%), 9 (7.7%) (n = 117); ERCP + surgery 30 (86%), 0 (n = 35); ERCP + stent + surgery (n = 54) 53 (98%), 37 (68.5%). The incidence of bacterobilia and fungaemia was significantly higher in the ERCP with stent group in comparison to those who had only surgery (p < 0.001). The most common organisms cultured for the all groups were coliforms and enterococci, with an equal incidence of Candida in those undergoing ERCP.
Conclusion: ERCP for preoperative drainage of obstructed biliary systems is associated with a high incidence of bacterobilia and fungal colonisation. ERCP should be reserved for those patients with cholangitis preoperatively and should not be used routinely until thorough staging has been completed.
16:00–16:30
Session 21
Liver Resection – 6
(DOI 10.1080/16515320310000986)
155
PORTAL (ARTERIOPORTAL) OCCLUSION AND NEOADJUVANT CHEMOTHERAPY IN EXTENDED LIVER RESECTION
Kupcsulik PK, Kokas P, Lukovich P, Szijarto A
1st Department of Surgery, Semmelweis University, Budapest, Hungary
Aim: Advanced liver tumors require extended resection. Size and functional reserve of the remnant liver are critical for postoperative outcome and survival. Ligation of the portal branch may enhance regeneration of healthy liver segments. Progression of the tumor will not be inhibited however. Might liver artery ligation promote regeneration and simultaneous tumor necrosis?
Methods: 13 patients with advanced tumors involving right lobe and segment IV were selected for ligation of right portal branch because of critical volume of segments II–III (<20% of estimated liver volume). All interventions were performed by laparotomy for correct assessment of operability. In 4 patients right liver artery was ligated simultaneously. In 2 cases an arterial port was inserted into the right arterial branch for neoadjuvant chemotherapy with oxaliplatin. A second intervention was performed 6–8 weeks later. Portal clamping not exceeding 30 min, resection with CUSA and complete hepatoduodenal lymph node dissection was employed.
Results: In 3 patients progression of the disease excluded resection at the second intervention. All patients had previous portal ligation only. 4 further patients from this group underwent a successful extended right lobectomy. Regeneration of segment II–III was 22–34%. All patients with arterial ligation showed excellent regeneration of the left lateral lobe (35– 44%) and significant regression of right lobe tumor mass. Extended right lobectomy was completed in all cases. After portal/and arterial ligation in 6 patients with transient subfebrility, fever occurred in only 1 case. Liver function remained stable in all cases. Elevation of transaminases was not accompanied by high bilirubin or low prothrombin levels.
Conclusion: There was no difference in liver function between the arterioportal and portal groups.
156
ASSESSMENT OF α-GLUTATHIONE-S-TRANSFERASE (α-GST), π-GST AND HYALURONIC ACID AS LIVER DAMAGE MARKERS IN PATIENTS WITH LIVER TUMORS
Erdogan D, Heijnen BHM, Pelt van G, Kok M, Dinant S, Straatsburg IH, Gouma DJ, Gulik van TM
Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
Aims: Conventional liver function tests (LFTs) are widely used for determination of hepatocellular damage and liver function in the work-up of patients with primary or secondary liver tumors. The aim of this study was to assess the correlation of recently developed liver damage markers α-glutathione-S-transferase (α-GST), π-GST and hyaluronic acid (HA) with conventional LFTs. π-GST is a cytosolic enzyme localized in hepatocytes with a half-life shorter than AST. ti-GST is localized in bile duct epithelium and is a marker of acute bile duct injury. HA is selectively metabolized by the liver sinusoidal endothelial cells (SEC) and reflects disturbed SEC function.
Methods: 53 patients with hepatocellular carcinoma (HCC) (n = 9), Klatskin tumors (n = 20), colorectal metastasis (n = 14) or miscellaneous tumors (n = 10), underwent work-up for resection between March 2000 and November 2002. One day prior to surgery, blood samples were collected for assessment of LFTs and quantitation of serum α-GST, π-GST and HA using commercial ELISA-kits.
Results: Significant positive correlation was obtained between HA and almost every conventional LFT. α-GST had only significant positive correlation with ALT (r = 0.56, p < 0.05), AST (r = 0.48) and conjugated bilirubin(r = 0.32). π-GST was not significantly different in patients with Klatskin tumors and no correlation was obtained with the conventional LFTs. Positive significant correlation was obtained between HA and α-GST (r = 0.36).
Conclusions: Our results show that α-GST has no additional value above conventional LFTs. π-GST as marker of bile duct injury provided no additional information, not even in patients with cholestasis. Serum HA levels were significantly greater in patients with HCC and in patients with Klatskin tumors and reflect decreased overall liver function.
157
PREOPERATIVE ASSESSMENT OF LIVER FUNCTION: A COMPARISON OF 99mTc-MEBROFENIN SCINTIGRAPHY WITH INDOCYANINE GREEN CLEARANCE TEST
Erdogan D1, Heijnen BHM1, Bennink RJ2, Kok M1, Dinant S1, Straatsburg IH1, Gouma DJ1, Gulik van TM1
Departments of 1Surgery and 2Nuclear Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
Aims: Preoperative assessment of liver function is used to estimate the outcome of major liver surgery. The indocyanine green (ICG) clearance test is the most frequently used test but has its limitations. The aim of our study was to examine the uptake of 99mTc-mebrofenin as measured by hepatobiliary scintigraphy and to compare this with the ICG clearance test.
Methods: 54 patients with a liver tumor underwent work-up for resection between March 2000 and September 2002. Patients were diagnosed as having hepatocellular carcinoma (n = 9), hilar (Klatskin) tumors (n = 20), colorectal metastasis (n = 15) or miscellaneous tumors (n = 10). 99mTc-mebrofenin scintigraphy was obtained after intravenous injection of 85 MBq 99mTc-mebrofenin. Subsequently, the ICG clearance test was performed after a bolus injection of 25 mg ICG.
Results: The mean ICG-C15 was 86.86±1.19% (SEM). The mean 99mTc-mebrofenin uptake rate was 12.87±0.52%/min. A significant correlation was obtained between 99mTc-mebrofenin uptake rate by scintigraphy and ICG-C15 (r = 0.73, p < 0.0001). The mean 99mTc-mebrofenin clearance capacity of the right liver segments (mean 79.83%±1.63, range 47.75–95.97%) was larger than that of the left segments (20.24%±1.55, range 6.51–52.51%). Patients with the non-parenchymal disease showed better uptake compared with other categories (p<0.05).
Conclusions: These data show that 99mTc-mebrofenin uptake rate as assessed by scintigraphy is an efficient method for determining liver function and correlates well with ICG clearance. At the same time, 99mTc-mebrofenin scintigraphy provides segmental information about functional liver tissue which is of additional use when planning liver resection.
158
PREDICTING THE POSTOPERATIVE COURSE TO ESTABLISH THE SAFETY OF HEPATECTOMY
Osada S, Amaoka N
Second Department of Surgery, Gifu University School of Medicine, Gifu City, Japan
Aim: The clinical significance of monitoring alkaline phosphatase (ALP) and γ-glutamyl transpeptidese (γ-GTP) was studied to estimate postoperative liver failure after hepatectomy.
Patients: 163 patients have undergone hepatectomy in this department in the past 12 years.
Results: (1) In the postoperative course after hepatectomy, ALP and γ-GTP were found to decrease in the early stage (mostly 1 postoperative day) and recover the preoperative levels or more. Regression analysis showed significant correlation between the preoperative values of the indocyanine green retention test at 15 min and the postoperative changes in ALP or γ-GTP. (2) ALP levels in trisegmentectomy cases were decreased significantly, compared with the other operative methods, and the lowest value in subsegmentectomy or partial resection was lower than bi- or mono-segmentectomy. In bi-segmentectomy cases, the time for recovery was shorter and recovered level was higher. Regression analysis with regard to the distinction of the operative method indicated that it reflected the postoperative changes in ALP and γ-GTP more strictly. (3) The good correlation between postoperative levels of ALP and γ-GTP was noted. Furthermore, after showing under 80% decreased level of ALP and γ-GTP, most cases resulted in high bilirubinemia or liver failure, and under 55% levels, the early postoperative prognosis was more critical. By contrast, in high bilirubinemia cases, recovered levels of ALP and γ-GTP were important to distinguish the liver failure cases.
Conclusion: The monitoring of ALP and γ-GTP levels were shown to be useful for predicting postoperative liver failure.
159
ASSESSMENT OF HEPATOCYTE RECOVERY BY DUPLEX DOPPLER ULTRASOUND AFTER BILIARY DRAINAGE
Marwan I, Ibrahim T, Shawky A, Osman M, Youssef A, El Sefi T
Department of Surgery, National Liver Institute, Menoufeya University, Cairo, Egypt
Aim: To evaluate hepatocyte recovery patterns after biliary drainage in cases of obstructive jaundice using Doppler ultrasound in adults.
Methods: Using duplex Doppler ultrasonography, we prospectively studied the changes in portal blood flow (PBF) in 30 patients with obstructive jaundice pre- and post-surgical drainage days 1, 3, 7, 10 and 14. We also evaluated the correlation between PBF and serum total bilirubin levels as a hepatocyte recovery index.
Results: The patients' ages ranged between 21 and 76 years (mean 50.1±13.2) and there were 16 males and 14 females. There were 18 malignant cases were and 12 benign cases, excluding cases with advanced hepatic cirrhosis, hepatic malignancy, hepatic or portal vein thrombosis and severe portal hypertension with porto-systemic collateral. The mean value of PBF increased progressively following biliary drainage due to significant increases in the maximum velocity of the portal flow (Vmax.) (p < 0.01) regardless of the cause of obstruction. The maximum velocity was significantly higher in the benign group of patients than those with malignant tumors only on the 1st day after drainage. The PBF in patients without cholangitis was only significantly higher than those with cholangitis on the 14th day after drainage (p < 0.05).
Conclusion: Measurement of Vmax. in assessment of PBF can be considered a useful parameter for evaluating hepatocyte recovery after biliary drainage in patients with obstructive jaundice.
160
IPSILATERAL PREOPERATIVE SELECTIVE PORTAL VEIN EMBOLIZATION FOR INCREASING LIVER VOLUME
Guven K1, Poyanli A1, Rozanes I1, Acunas B1, Ozden I2, Bilge O2, Emre A2
Departments of 1Radiology and 2General Surgery, Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey
Aim: Preoperative occlusion of the portal vein branches feeding the hepatic segments to be resected reduces the risk of postoperative liver failure after major liver resection and increases resectability. The aim of this study was to review our preliminary experiences of ipsilateral preoperative selective portal vein embolization for increasing liver volume.
Methods: Between 1998 and January 2003, ipsilateral preoperative portal vein embolization was performed in 9 patients with different histopathologic diagnoses (3 hepatocellular carcinomas, 1 proximal cholangiocellular carcinoma involving the hilus, 2 Klatskin tumors, 3 colorectal adenocarcinoma metastases). In all patients selective right portal vein embolization was performed via percutaneous route under fluoroscopic control with gelfoam particles. Atrophy of the right lobe and compensatory hypertrophy of the left lobe were achieved in all patients. Preprocedure computed tomography volumetric analysis of liver was done and after 3 weeks was re-evaluated by the same method. No complications occurred.
Conclusion: Portal vein embolization with gelfoam particles is a feasible, safe and inexpensive method of increasing the remnant functional liver volume for safe major hepatectomy.
161
EFFECT OF INFRA-HEPATIC INFERIOR VENA CAVA CLAMPING ON BLEEDING AMOUNT DURING HEPATIC DISSECTION: RANDOMIZED CONTROLLED STUDY
Kubota K, Kato M, Kita J, Shimoda M, Nemoto T, Rokkaku K, Sakuma A
Second Department of Surgery, Dokkyo University School of Medicine, Tochigi, Japan
Aim: We hypothesized that decrease in the central venous pressure (CVP) is associated with the bleeding amount during hepatectomy. The aim of this study was to evaluate the effect of infra-hepatic inferior vena cava (IVC) clamping on the bleeding amount during hepatectomy.
Methods: 20 patients who were scheduled to undergo hepatectomy were assigned to either IVC clamping or IVC non-clamping group according to age (60 ÅU or <60), indocyanine green retention rate at 15 min (20% ÅU or <20%), operative procedure (resection <1 or >1 Couinaud's segment) and tumor number (single or multiple) by a prospective, randomized method. Pringle's maneuver was employed for 15 min and was released for 5 min. The infra-hepatic IVC was clamped for 15 min simultaneously.
Results: 10 patients were assigned to respective groups. There were no differences in the 4 factors. Bleeding amount: IVC clamping 282 ml vs IVC non-clamping 216 ml (p = 0.325). Dissection area: 63.25 cm2 vs 52.25 cm2(p = 0.21). Bleeding amount/cm2: 5.12 ml vs 5.74 ml (p = 0.596). CVP: 2.5 cmH2O vs 1 cmH2O (p < 0.05).
Conclusion: Although infra-hepatic IVC clamping decreased the CVP significantly, it did not contribute to reducing the bleeding amount during hepatectomy.
Session 22
Liver – Miscellaneous – I
(DOI 10.1080/16515320310000995)
162
LIVER ABSCESS: ANALYSIS OF 205 PATIENTS
Abbasoglu O, Oren D, Emre A, Karademir S, Tokat Y, Kotan C, Polat C, Deniz S, Bulbuller N
Turkish Liver Abscess Study Group
Aim: Liver abscess is a life-threatening infection. The aim of this study was to determine the clinical manifestations of liver abscess in Turkey.
Methods: The records of 205 patients with pyogenic and amebic liver abscesses that were treated in 10 university hospitals of Turkey between 1990 and 2002 were reviewed.
Results: The majority of patients were male (62%) and the most common presenting symptoms were abdominal pain (80%) and fever (67%). Diabetes mellitus was seen 7% of the patients. 154 patients (75%) had pyogenic and 51 patients (25%) had amebic abscesses. The majority of patients with amebic abscess were from eastern parts of Turkey. Of the patients with pyogenic abscess, 41% had either treated or active hydatid cyst disease as an etiologic factor. Of the patients with available pus culture, gram-negative bacteria were isolated in 50%. The mean hospital stay was 20 days. The majority of patients were treated by open surgical drainage (47%). The morbidity and mortality rates were 23% and 4%, respectively.
Conclusion: Hydatid cyst is the leading etiologic factor in the development of liver abscess in Turkey. With appropriate and tailored treatment of liver abscess, the mortality and morbidity rates are reasonably low.
163
ALVEOLAR ECHINOCOCCOSIS IN TURKEY: A MULTI-CENTRE SURVEY
Polat KY1, Emre A2, Yagmur O3, Balik AA1, Oren D1, Alper A2, Ozden I2, Atamanalp SS1, Akinoglu A3, Tekant Y2, Demiryurek H3, Kotan C4
Departments of General Surgery, School of Medicine, 1Ataturk University, 2Istanbul University, 3Cukurova University and 4Yuzuncu Yil University, Turkey
Aim: To review the results of different surgical and medical treatment modalities in patients with alveolar echinococcosis (AE).
Methods: A multicentre, retrospective study.
Results: Between 1990 and 2002, 141 patients were treated for AE. Most patients were from Eastern Anatolia. 68 (48%) were male and 73 female with ages ranging between 14 and 66 years. Main clinical symptoms were epigastric pain in 53 (37%) patients, cholestatic jaundice in 47 (33%) and hepatomegaly in 44 (31%). Diagnosis was made incidentally during checkup in 15 patients (11%). Hematologic examination, liver function tests, serologic tests (ELISA, Em2 antigen), ultrasound, computed tomography and magnetic resonance imaging were used for diagnosis and follow-up. Fine needle aspiration or true cut biopsy was used for histopathologic diagnosis. There were distant metastases in 14 patients; 5 had regional lymph nodes, 3 pulmonary, 4 brain, 1 left adrenal gland and 1 peritoneal metastasis. Curative surgical resection was performed in 54 (38%) patients (29 right hepatectomies, 5 left hepatectomies, 6 left lateral segmentec-tomies, 5 extended right hepatectomies, 3 segmental resections, 6 non-anatomic resections). Four patients died (7%) following curative resection. Complications were: biliary fistula in 2 (4%), wound infection 3 (6%) and biliary stricture 1 (2%) patient. There were 5 recurrences (9%) in the follow-up period ranging between 6 months and 11 years. 87 patiens had non-resectable AE and 31 of them (36%) underwent a palliative procedure. The other patients with non-resectable AE received albendazole or mebandazole. Chemotherapy was successful in 2 patients who received mebendazole, partially successful in 9 patients who received albendazole. In the follow-up, 24 patients (27.6%) died because of liver failure and its complications. Three patients were listed for liver transplantation because of advanced AE with chronic liver failure.
Conclusion: In endemic regions, screening programs are important for early detection. Such programs may increase the rate of curative resection. More research is needed on new chemotherapeutic agents in an effort to obtain better results in non-resectable cases.
164
THE LOCAL USE OF TACHOCOMB AND CEFEPIME COMBINATION FOR POSTOPERATIVE SEPTIC COMPLICATION PREVENTION (LIVER RESECTIONS)
Severtsev A, Mischerjakova T, Volodin D, Pfaf V, Alexandrov V, Melnikov G
Central Clinical Hospital; Department of HPB Surgery, Moscow, Russia.
Aim: According to available data, liver resection for large secondary tumors (colorectal cancer metastases, MTS) is a risk factor for postoperative septic complications. Some studies claim certain benefits from the use of systemic cefepime (first generation of cefalosporins) in the prevention and treatment of such complications. At the end of each liver resection the raw liver surface is covered with fibrin glue or collagen for final haemostasis to prevent additional postoperative complications. The aim of this study was to assess the effectiveness of local TachoComb (Nycomed) impregnated with cefepime solution in preventing postoperative septic complications.
Methods: There were 2 groups of patients. The main group (MG, 10 patients) had liver resection with the local use of TachoComb fleeces impregnated with cefepime solution (1 g of the drug dissolved in 10 ml of physiologic solution). The control group (CG, 22 patients) had liver resection with the local use of TachoComb and conventional i.v. cefepime use. Postoperative regimes of cefepime use were the same in both groups (2 gper day, i.v., 5 days after surgery). Patients in both groups were selected on the basis of the presence of huge MTS with central necrosis (potential infection in the field of operation).
Results: The number of patients with postoperative complications was the same in both groups (40% in the MG vs 45.45% in the CG; NS). The number of local (in the field of operation) septic complications (abscesses, fistula formation) was less in the main group (20% vs 36.36%; p < 0.01). The impregnation of TachoComb fleece with cefepime solution did not diminish the adhesive properties of TachoComb.
Conclusion: Despite general rules on TachoComb use, it is possible to use it locally in combination with antibiotics (cefepime). That combination could contribute to reducing the local septic complications in cases of possible infection in the zone of surgery.
165
MORPHINE PLUS BUPIVACAINE VS MORPHINE PERIDURAL ANALGESIA: OUTCOME AFTER MAJOR HEPATOBILIARY SURGERY
Mangiante G, Barzoi G*, Carluccio S*, Bianchi B*, Colucci G, Bassi C
Department of Surgery, University of Verona, Pie LA Scuro, Verona, Italy
Aim: Anaesthesia and surgical procedures lead to postoperative ileus. Poor pain control leads to delayed hospital stay with an higher risk of developing infections. A randomised prospective study has been performed to determine if different kinds of epidural analgesia can reduce hospital stay by avoiding complications.
Methods: 60 patients who were candidates for major surgery due to hepato-biliary neoplasm (28 males and 32 females, mean age of 61.2 years, ASA score 2 or 3) were included. We compared two different pharmacological approaches by means of a thoracic epidural catheter. Group A, 30 patients: morphine 0.0017 mg/kg/h, plus bupivacaine 0.125% 0.058 mg/kg/h. Group B, 30 patients, morphine alone at 0.035 mg/kg/12h. In the postoperative course we recorded peristaltic activity every 6 h.
Results: Effective peristalsis was present in all patients in Group A within the first 6 postoperative hours, and in Group B after 30 h. 6 patients in Group A had bowel motions on the 1st day, 11 on the 2nd, 10 on the 3rd and 3 on the 4th day, while in Group B there were none on the 1st day, 2 on the 2nd, 7 on the 3rd, 15 on the 4th and 6 on the 5th. The difference was significant (p < 0.05 on the 1st, 2nd, 4th and 5th days). Pneumonia occurred in 2 patients in Group A, and in 10 in Group B (p < 0.05).
Conclusion: These results suggest that epidural analgesia with morphine plus bupivacaine allowed a more rapid return to normal gut activity and early enteral nutrition compared with epidural analgesia with morphine alone.
166
HILAR HEMI-HEPATIC BLOCK IN PERCUTANEOUS RADIOFREQUENCY ABLATION
Kume A, Nimura Y, Ikeyama T
Nagoya University, Japan
Aim: To evaluate the feasibility and efficacy of hilar hemi-hepatic block (HHHB) in reducing the pain during percutaneous RFA.
Methods: From November 2001 to January 2003, 5 RFA treatments were performed for colorectal liver metastases under HHHB in 3 patients. A single lesion was treated in every RFA treatment. After administration of 15 mg of intramuscular pentazocine, the patients were placed in the supine position and the skin of the puncture site was locally anesthetized with 5 ml of 1% lidocaine. The connective tissue just ventral to the right portal vein (when the tumor was located in the right hepatic lobe) or the connective tissue just ventral to the left portal vein (when the tumor was located in the left hepatic lobe) was punctured using a 21-gauge needle under ultrasound guidance. Subsequently, 6–10 ml of 1% lidocaine were injected. Then, percutaneous RFA was performed. The pain during the procedure was scored as compared to the pain with the local anesthesia of the skin (pain score: 10). Vital signs were monitored during the procedure.
Results: The pain scores during HHHB and during percutaneous RFA were 1–10 (mean 4) and 1–20 (mean 9.4), respectively. During the procedure, no significant change in vital signs was recorded.
Conclusion: During the RFA under HHHB, the patients were fully conscious, could communicate ordinarily, and could cooperate with us in the treatment (such as holding of breath), which helped us perform the RFA treatment safely. HHHB is feasible and seems to be effective in controlling the pain during percutaneous RFA.
167
RELATIONSHIP OF CHOLESTATIC ENZYMES AND T-TUBE
Vatansev C, Kartal A, Kucukkartallar T, Aksoy F, Pamukcu A, Yurtcu M, Belviranli M
Department of General Surgery, Selcuk University Meram Medical Faculty, Konya, Turkey
Aim: We investigated the effect of T-tube on cholestatic enzymes, alkaline phosphatase (AP) and gamma-glutamyltranspeptidase (GGT) of patients with T-tube choledochostomy in the last 18 years.
Methods: Of 257 cases, 107 were men and 150 were women. We detected AP and GGT in 110 cases preoperatively twice and postoperatively 5 times (on the 3rd, 5th and 7th days of surgery and 3rd, 7th days of tube extraction). The diagnoses of the cases in which T-tube choledochostomies (n = 257) were performed were as follows: choledocholithiasis 58, cholecystocholedocholithiasis 51, cholelithiasis 32, biliary injury 26, hepatic hydatid cyst 20, acalculous cholecystitis 20, Mirizzi syndrome 7, duodenal perforation 7, others 36. The operations were performed by open surgery. None of the cases had primary choledochus closure. Partial cystectomy and open drainage were added to tube choledochostomy in cases with hepatic hydatid cysts. As a rule after the exploration and on the postoperative day 10, tube cholangiography was done and the T-tube was removed on day 11. In biliary injury tube extraction was delayed until 6 or 8 weeks after surgery. Other extrahepatic reasons for elevated AP were excluded from the study.
Results: The preoperative enzyme values were 2–6 times higher than the upper limit of normal. The enzymes decreased by up to 2–3 time normal in cases of choledocholithotomy and hepatic cyst. After removal of the tube, the enzymes decreased to normal in 7 days except for 9 cases in which the enzymes remained high for some reason (retained stone, infection, etc.). The ratio of T-tube application was low compared with those obtained in the pre-laparoscopic cholecystectomy and pre-ERCP era.
Conclusion: A T-tube in the choledochus may act as a stone or hydatid cyst particle that does not prevent bile flow and the enzymes would not return to normal until extraction of the T-tube in the majority of cases. Generally, on day 7 of tube extraction the enzymes returned to normal levels. In spite of T-tube extraction, a decrease of the enzymes to normal levels may depend on the sensitivity of the enzymes. T-tube application was decreased in the second half of the study compared with the first 9 years.
168
CLINICAL PREDICTORS OF LIVER DAMAGE IN SEVERELY OBESE PATIENTS
Papadia FS, Murelli F, Carlini F, Marini P, Stabilini C, Zambrini E, Ramberti G
University of Genoa School of Medicine, Genoa, Italy
Aims: This study analysed the preoperative clinical data of 455 severely obese patients undergoing surgery for morbid obesity with intraoperative wedge liver biopsy, and investigated correlations with their liver histology.
Methods: Clinical data included age, body weight (BW), waist-to-hip ratio (W/H), blood pressure, body mass index (BMI), serum glucose (SG), triglycerides (try), cholesterol (chol), total protein (tp), albumin (A), γ-globulin (G), A/G ratio, total (tb) and indirect bilirubin (ib), γ-GT (GGT), POA, AST, ALT and prothrombin time (PT). The degree of steatosis (S), inflammation (INF) and fibrosis (FIB) was determined on liver biopsy and scored. Liver damage (LD) was defined when bridging FIB was present.
Results: Mean BMI was 47.2 kg/m2. 333 patients had S >10%. 37 patients had LD. Regression analysis showed association between S and AST (p< 0.0001), ALT (p< 0.0001), BW (p < 0.0001), W/H (p < 0.0001), SG (p < 0.0001), tri (p < 0.0001), BMI (p=0.0001), tb (p<0.05), tp (p < 0.05), AST/ALT (p < 0.05). INF was associated with BMI (p < 0.05), age (p < 0.05), BW (p < 0.05), G (p < 0.05). FIB was associated with W/H (p < 0.01), G (p< 0.05), SG (p < 0.05), POA (p < 0.05). Patients with LD had a significantly higher degree of S (p<0.01), G (p<0.05), AST (p < 0.05), W/H (p < 0.05) and SG (p < 0.01) and were significantly older (p <0.05). LD was associated with diabetes (p < 0.0001) and W/H >1 (p < 0.05). Positive predictive value (pp) of diabetes for liver damage was 25%; negative predictive value (np) was 95%. When combined with age >50, pp of diabetes increased to 40%.
Conclusion: Progressive liver damage seems to be associated with the features of the metabolic syndrome.
169
ROLE OF SURGICAL RESECTION IN MANAGEMENT OF GASTROINTESTINAL STROMAL TUMOURS
Lala A, Jethwa P, Bramhall SR, Mirza DF, Mayer AD, Buckets JAC Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
Aim: Gastrointestinal stromal tumours (GIST) are rare tumours often presenting with advanced disease requiring extensive surgical resection. The benefits of surgery in improving survival remain unknown and alternative drug therapy has shown promising results. We present the outcome of patients from a tertiary centre.
Methods: 31 patients (15M, 16 F: ages 16–82 years, mean 59.7) with GIST were referred between January 1992 and November 2002 for surgery. Patients treated were those with advanced primaries (considered inoperable by referring surgeons) or those with metastases following primary resection elsewhere.
Results: 18 patients were referred with primary lesions. 13 patients underwent complete resection including partial gastrectomy (4), partial gastrectomy and distalpancreatectomy (2), pylorus-preservingpancreatico-duodenectomy (2), duodenal resection (3) and retroperitoneal mass excision (2). 3 patients had palliative resection and 2 were deemed unsuitable for any form of resection. Median follow-up of these patients was 23 months. 3- and 5-year survival following complete resection were 86% and 57%, respectively. Longest survival following palliative resection was 15 months. 13 patients were referred for management of metastases, 2 of which were inoperable. 9 of the 10 patients with hepatic metastases underwent hepatic resection. One of these underwent liver transplantation (LT) for a massive central metastasis. Median follow-up for those with metastatic lesions was 19 months. Only one patient survived more than 4 years (post LT) and is receiving Glivec for skeletal metastasis.
Conclusions: Complete resection of primary GIST leads to prolonged survival in the majority of patients, whereas resection of metastatic disease has limited application. The use of Glivec as neoadjuvant or adjuvant therapy warrants further study.
Session 23
Pancreas Tumour – 3
(DOI 10.1080/16515320310001002)
170
ANALYSIS OF CLINICAL FEATURES AND FACTORS PREDICTIVE OF MALIGNANCY IN INTRADUCTAL PAPILLARY MUCINOUS TUMOR OF THE PANCREAS: MULTI-CENTER ANALYSIS IN KOREA
Jang JY, Kim SW, Ahn YJ, Yoon YS, Lee KU, Park YH
Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
Aims: Despite increasing numbers of reports on intraductal papillary mucinous tumor (IPMT), there is still difficulty in its diagnosis, treatment and prediction of prognosis. The purpose of this multicenter study was to evaluate the clinico-pathological features of IPMT in Korea and suggest the prediction criteria of malignancy in IPMT.
Methods: We retrospectively reviewed the clinico-pathological data of 208 patients who underwent operations with IPMT between 1993 and 2002 at 28 institutes in Korea.
Results: Of the 208 patients with a mean age of 60.5±9.7 years, 147 were men and 61 were women. 124 patients underwent pancreatoduodenectomy, 42 distal pancreatectomy, 17 total pancreatectomy, 25 limited pancreas resection. There were 128 benign cases (adenoma (n = 62), borderline (n = 66)) and 80 malignant cases (non-invasive 29, invasive 51). A significant difference in 5-year survival was observed between the benign and malignant groups (92.6% vs 65.3%; p = 0.006). Of the 6 factors (age, location, duct dilatation, tumor appearance, main duct type and tumor size) that showed the statistical difference in univariate analysis between benign and malignant groups, we found 3 significant factors: tumor appearance (p = 0.013), tumor size (p = 0.001) and dilated duct size (p = 0.001), by multivariate analysis.
Conclusion: Although overall prognosis of IPMT is superior to ordinary pancreatic cancer, more curative surgery is recommended in malignant IPMT. Tumor appearance (polypoid), tumor size (>30mm) and dilated duct size (>12 mm) can be used as preoperative indicators of malignancy in IPMT.
171
FINE NEEDLE ASPIRATION IN THE DIAGNOSIS OF CYSTIC TUMOURS OF THE PANCREAS
Badia JM, Hidalgo LA, Franch G, Sunyol X, Sala Pedros J
Hospital de Granollers, Barcelona, Spain
Aim: To investigate the value of cystic fluid analysis for tumour markers, amylase content and cytology as preoperative diagnosis criteria in cystic tumours of the pancreas; and to compare it with the combination of clinical and radiological data.
Methods: 22 cases of cystic tumours of the pancreas were analysed. Clinical data, plasma tumour markers and radiological, intraoperative and pathological diagnosis were evaluated. The amylase contents, tumour markers CEA, CA 19.9 and CA 125, and cytology reports were studied for cystic fluid. Results are shown as mean±standard error (interval). The Student-Fischer t test was used for statistical analysis.
Results: 2 serous cystadenomas, 4 mucinous cystic neoplasms, 2 mucinous cystadenocarcinomas, 3 ductal carcinomas with cystic degeneration and 11 pseudocysts were analysed. The main clinical sign was epigastric pain, followed by weight loss > 10% of body mass and dorsal pain. Mean age was 41±6 years (17–71). Most cystic lesions were localized in the tail of the pancreas, with a mean diameter of 80±24 mm (30–200). Radiological tests achieved a high index of correct diagnosis. Plasma biochemistry and tumour markers were normal. Cystic amylase content was useful to diagnose pseudocysts, but followed an erratic pattern in neoplastic tumours, not useful for diagnosis. The finding of epithelial cells at cytology classified the lesions in the neoplastic group. Cystic CEA levels were normal in serous cystadenomas and most pseudocysts, but were elevated in benign or malignant mucinous cystic neoplasms and in the ductal carcinomas, with a mean value of 1194 ±513 ng/ml (p = 0.05). CA 19.9 followed a variable pattern, being elevated in the 3 mucinous neoplasms and in the ductal carcinomas, but negative in mucinous cystadenocarcinomas and pseudo-cysts. CA 125 was positive in malignant or borderline tumours, but did not achieve significant differences when compared to benign lesions.
Conclusions: The preoperative analysis of the cystic fluid, obtained by FNA, can provide useful data in certain cases of pancreatic cystic tumours, but adds little information to clinical and radiological diagnosis. Cystic CEA, and probably CA 125, can be useful to differentiate mucous and malignant tumours from pseudocysts and serous tumours. When an operation is performed, frozen section study of the cyst wall is fundamental to confirm the diagnosis and to make a decision as to whether resection or drainage is the treatment of choice.
172
DRAINAGE AFTER PANCREATICODUODENECTOMY: OUTPUT AND AMYLASE ACTIVITY RELATED WITH COMPLICATIONS
Filauro M, Franceschi A, Marini P, Angelini G, Papadia F
HBP Surgery, Galliera Hospital, Genoa, Italy
Aim: To evaluate characteristics of fluid collected by drains as possible predictive factors of complications.
Methods: From January 1997 to December 2002, 63 pancreaticoduode-nectomies were performed for neoplasms (57) or inflammatory pancreatic diseases (6). A Jackson-Pratt and a tubular drain by pancreaticojejunostomy and bilioenteric anastomosis were routinely inserted. Daily output was recorded and amylase levels from fluid collected by peripancreatic drain were analysed. Octreotide (0.3 mg/day) was administered after surgery in all patients.
Results: Overall operative mortality and morbidity were 1.6% and 11.1%, with 3 pancreatic fistulas (4.8%). Total and mean daily output from peripancreatic drainage were less (Student's t test) in patients affected by chronic pancreatitis (p=0.0004; p=0.00009). No different output was found in patients who did or did not develop a pancreatic fistula. Regarding amylase content of fluid collected by peripancreatic drainage, the highest value for every patient was compared in the 2 groups. Higher values were found in patients who developed a fistula, with an increase in amylase content starting at postoperative day 5. Patients affected by chronic pancreatitis present a decreased exocrine function correlated to lower levels of amylase activity in the fluid collected. They could be considered at low risk of a pancreatic fistula.
Conclusion: The use of perianastomotic drains is a successful method for 20000 U/l in early diagnosis of pancreatic fistula. Only high amylase values (fluid collected after day 5 seem to be significantly related. We recommend a systematic amylase activity analysis of fluid collected on day 5 and before drainage removal.
173
CORRELATION BETWEEN L-MYC GENE POLYMORPHISM AND PANCREATIC ADENOCARCINOMA
Tekant Y1, Demirel T1, Ergen HA2, Bozkurt N2, Yaylim Y2, Bilge O1, Ozturk O2, Ariogul O1, Ysbir T2
1Istanbul University, Istanbul Faculty of Medicine, Department of General Surgery, HPB Unit and 2Istanbul University Institute of Experimental Medical Research, Department of Molecular Medicine, Istanbul, Turkey
Aim: L-myc is a nuclear proto-oncogene which is sometimes activated late in tumorigenesis. Digestion of DNA with EcoR I reveals a simple restriction fragment length polymorphism (RFLP) located in the second intron of L-myc, with allele sizes 10 kb (L-allele) and 6.6 kb (S-allele). Some studies have suggested that the presence of the S-allele is associated with a higher risk of metastasis in some carcinomas. The aim of this study was to determine the association between pancreatic adenocarcinoma and L-myc S genotype.
Methods: We studied 18 pancreatic cancer patients and 16 healthy controls. Polymerase chain reaction (PCR), RFLP and agarose gel electrophoresis techniques were used to determine the L-myc genotypes (Table).
Table Distribution of L-myc genotypes
| Group | LL | LS |
| Patients (n = 18) | 11.1% (2) | 88.9% (16) |
| Controls (n = 16) | 50% (8) | 50% (8) |
L-myc S-allele was found to be higher in the pancreatic cancer group than the healthy controls χ2, 6.17; p, 0.023; OR, 1.778).
Conclusion: These results suggest that L-myc S-allele may play an important role in patients with pancreatic adenocarcinoma.
174
INVESTIGATION OF SERUM MALONDIALDEHYDE, DIEN CONJUGATE, PARAOXANASE LEVELS AND PARAOXANASE GENE POLYMORPHISM IN PANCREATIC CARCINOMA
Tekant Y1, Demirel T1, Ergen HA2, Bozkurt N2, Agachan B2, Yilmaz H2, Bilge O1, Zeybek U2, Ariogul O1, Ysbir T2
1Istanbul University, Istanbul Faculty of Medicine, Department of General Surgery, HPB Unit and 2Istanbul University Institute of Experimental Medical Research, Department of Molecular Medicine, Istanbul, Turkey
Aim: Paraoxanase (PON1) is a serum enzyme with an anti-oxidant function, protecting the low density lipoproteins (LDL) from oxidative modifications. Because cancer patients are suggested to be at greater risk of oxidative stress, we investigated the effect of PON1 192 glutamine (A)/ arginine (B) polymorphisms on the oxidant-antioxidant system in 18 pancreatic cancer patients and 15 healthy controls in Turkish subjects.
Methods: Polymerase chain reaction (PCR), restriction fragment length polymorphism (RFLP) and agarose gel electrophoresis techniques were used to determine PON1 genotypes. Serum PON1 activity, malondialde-hyde (MDA), dien conjugates were measured spectrophotometrically. Mean serum paraoxanase activities were significantly lower (109±64 U/ml vs control 347±205 U/ml) and malondialdehyde levels were significantly higher (20.6±6.4 nmol/dl vs control 5.6±1.2nmol/dl) in pancreatic cancer patients than in healthy controls (p < 0.05). There was no significant difference in serum dien conjugate levels in pancreatic cancer patients (13.27±6.53 nmol/ml) compared with the controls (14.15±2.91 nmol/ml) (p > 0.05).
Conclusion: Oxidative stress, which is an important factor in carcinogenesis, causes a decrease in antioxidant levels.
Table Distribution of PON 192 gene frequency
| Group |
AA |
AB |
BB |
| Patients (n = 18) | 11.1% (2) | 77.8% (14) | 11.1% (2) |
| Controls (n = 15) | 60% (9) | 33.3% (5) | 6.7% (1) |
175
THE ENDOTHELIN SYSTEM IN THE HAP-T1 SYRIAN HAMSTER PANCREATIC CANCER MODEL
Abraham AT, Shah SR, Satyadas T, Tsui J, Anand R, Dashwood M, Davidson BR
Royal Free & University College London School of Medicine, London, UK
Aim: To study the expression of ET-1, ETA-R and ETB-R in the Hap-T1 Syrian hamster pancreatic cancer model, and correlation of (PPET-1) and VEGF in hamster pancreatic cancer.
Methods: Tumours induced in 32 Syrian hamsters by intrapancreatic injection of (0.1 ml) 2×106/ml HaP-Tl cells. Groups of animals (n=4) were sacrificed at weekly intervals. Local invasion and distant spread were assessed at necropsy. Semi-quantitative RT-PCR for PPET-1 and VEGF mRNA was performed on frozen tumour tissue. Immunohistochemistry for ET-1, ETA-R and ETB-R were done on paraffin-embedded tumours.
Results: ET-1, ETA-R and ETB-R were present on immunohistochemistry in the hamster pancreatic cancers. Extrapancreatic tumour spread and metastases were noted from week 2 onwards. The incidence of metastasis increased with increasing tumour weight and size. 2/20 hamsters (10%) with tumour weight <2g developed liver metastases, as opposed to 6/11 (54%) with tumour weight ≥2 g (p = 0.012). PPET-1 and VEGF expression was raised in tumours ≥2 g in size (p = 0.0008 and 0.02, respectively). There was linear correlation between levels of expression of PPET-1 and VEGF mRNA (r = 0.80).
Conclusion: ET-1, ETA-R and ETB-R have been demonstrated for the first time in the Hap-T1 Syrian hamster pancreatic cancer. Tumour growth is associated with an increase in levels of expression of PPET-1 and VEGF mRNA. PPET-1 and VEGF correlation supports a link in expression of these factors. This experimental model may help to establish the role of the endothelin system in pancreatic cancer progression, and the possible therapeutic benefits of endothelin blockade.
Session 24
Biliary–Pancreas/Video
(DOI 10.1080/16515320310001011)
176
HEPATOPANCREATODUODENECTOMY FOR ADVANCED GALLBLADDER CARCINOMA
Uesaka K, Kanemoto H, Maeda A, Ebata T
Shizuoka Cancer Center Hospital, Shizuoka, Japan
Although diagnostic modalities for hepatobiliary diseases have advanced recently, gallbladder cancer is still encountered at the advanced stage. We present surgical techniques of hepatopancreatoduodenectomy with combined resection and reconstruction of the portal vein and transverse colon for locally advanced gallbladder carcinoma by video. The patient is a 61-year-old gentleman with the chief complaint of fever. Preoperative images revealed a huge gallbladder tumor, 9.3 cm in diameter, involving the liver, extrahepatic bile duct and duodenum. After amelioration of the serum total bilirubin level by percutaneous transhepatic biliary drainage, percutaneous transhepatic portal embolization (PTPE) of the right portal vein was performed. The calculated ratio of the right lobe volume to the total liver by CT volumetry decreased from 62% before PTPE to 55% 10 days after PTPE. The operation was performed 13 days after PTPE. First, right hemicolectomy was performed because of firm attachment of the gallbladder tumor to the transverse colon. Then, the stomach was cut 2 cm proximal to the pyloric ring. After skeletonization resection of the hepatoduodenal ligament, the right hepatic artery and gastroduodenal artery were ligated and divided. The portal bifurcation was found to be involved by the huge mass. Pancreas was divided at the level of the portal vein and the head of the pancreas was detached from the portal system and superior mesenteric artery. Following extended right hepatic lobectomy, the left medial, left lateral superior and left lateral inferior segmental bile ducts were individually divided. Finally, the portal bifurcation was resected and end-to-end anastomosis between the portal trunk and left portal vein was made. Modified Child method reconstruction and ileocolostomy were performed. The operating time was 12 h and 23 min and blood loss was 2525 ml. The patient was discharged 33 days after operation without any complications.
177
LEFT HEPATECTOMY AND CAUDATE LOBE RESECTION FOR KLATSKIN TUMOR
Bracco R, Grondona J
Clinica Pueyrredon, Mar Del Plata and Centro Medico Martin Y. Omar, San Isidro, Argentina
Aim: The prognosis of patients with Klatskin tumors (KT) remains poor. Radical resection offers the only chance of cure. In this video a 61-year-old male patient with a type III b KT, according to Bismuth-Corlette classification, is presented.
Methods: The patient suffered from dyspepsia and mild jaundice 3 weeks before admission. Ultrasonography and magnetic resonance cholangiography showed the tumor at the confluence and a slight dilatation of the intrahepatic bile ducts. Intraoperative ultrasonography confirmed the presence of the tumor and its relationship with vascular structures. The surgical treatment consisted of: (1) complete removal of regional limph nodes, (2) left hepatectomy, (3) resection of the caudate lobe to exclude the bile duct drainage from the confluence, (4) resection of the whole extrahepatic bile duct. A Roux-en-Y hepaticojejunostomy was performed with magnification and fine sutures.
Results: A localized biliary collection was percutaneously drained on the 9th postoperative day and the patient was discharged on the 11th day. One year later the patient is symptom-free and 99Tc scintigraphy confirmed the normal bile fluid through the anastomosis.
Conclusions: The main issue that must be considered during the operation are: (1) confirmation of the diagnosis, (2) identification of the intra-hepatic tumoral spread, (3) evaluation of the vascular structures involvement.
178
PORTAL VEIN LYMPHADENECTOMY
Djukic VR, Karamarkovic A, Culafic DJ, Micev M, Stepic D
University Surg. Clinic, Belgrade, Yugoslavia
Aim: The aim of the study is to present the original operative technique of hepatoduodenal dissection as well as the results of systematic lymph node dissection in a group of patients operated for hepatobiliary malignancies. Positive periportal node has been regarded as a poor prognostic sign but still not a clear contraindication for extensive surgery.
Methods and Results: 20 patients were operated for HBP malignances in the period January 2000 to December 2002 at this clinic. 12 patients were operated for pancreatic head carcinoma, 4 for common bile duct carcinoma and 4 for gallbladder carcinoma.
Conclusion: Histopathology and immunohistochemistry data from lymph node dissection proved that extensive radical surgery of pancreas has to be completed with high hilar dissection not only with low periportal cleaning of cystic duct level.
179
EXTENDED RIGHT HEPATECTOMY WITH EXTRAHEPATIC BILE DUCT RESECTION AFTER TRANSILIAC PORTAL EMBOLIZATION FOR RHABDOMYOSARCOMA OF THE GALLBLADDER
Shimoda M, Kubota K, Kita J
Second Department of Surgery, Dokkyo University School of Medicine, Tochigi, Japan
Aim: Liver resection for advanced gallbladder malignancy still presents a clinical difficulty. In these cases, extended hepatectomies are often required. We present an extended right hepatectomy combined with resection of the extrahepatic bile duct after transiliac portal embolization (TIPE).
Methods and Results: A 69-year-old female was diagnosed as having an advanced gallbladder carcinoma by preoperative imaging. The tumor revealed an invasion to the liver parenchyma on preoperative abdominal CT scan. The patient received complete embolization of the right branch of the portal vein 2 weeks before surgery. After the procedure, the left lobe volume was increased from 30.9 to 39.9% 14 days after TIPE. First, the lymph nodes in the retropancreatic regions and those along the hepatoduodenal ligament were thoroughly dissected. We carefully dissected the right and left hepatic artery and portal vein, then ligated and cut the right hepatic artery and the right portal vein at their origins. The liver was mobilized from IVC with the dissection of some small short hepatic veins. Then the right hepatic vein was extrahepatically encircled and divided. Along the demarcation line, the liver was transected under Pringle's maneuver. At the end of dissection of the liver parenchyma, the left hepatic bile duct was divided. Frozen section of the distal and proximal bile ducts did not reveal any malignancy. Reconstruction including hepatico-jejunostomy was carried out with Roux-en-Y manuver and a lost stent was fixed at the left hepatic bile duct using a 7.5 Fr canula. The tumor was diagnosed as rhabdomyosarcoma of the gallbladder histologically and there were no lymph node metastases. The postoperative course was uneventful and no evidence of recurrence has been observed even 6 months after operation.
180
A MODIFIED APPROACH TO GALL BLADDER DISSECTION PRODUCED LESS COMPLICATIONS AND GREATER ECONOMY FOR ROUTINE BENIGN GALLBLADDER DISEASES
Ganguly NN
Gauhati Medical College, Guwahati, Assam, India
Aim: Cholecystectomy is almost a routine procedure throughout the world. Although the progress of surgery so far as solid viscera are concerned has been tremendous, this simple and regular procedure has not seen much change in the recent past. As a result, whereas the mortality and morbidity in pancreaticoduodenectomy, hepatic resection, etc. have almost reached zero in a short period of time, gallbladder surgery is still producing a low but steady amount of complications including death. We have been trying a different approach to gallbladder dissection and found that it significantly reduced the complication rate over the last 7 years. While performing the procedure as an open procedure it reduced the cost burden significantly too.
Methods: We have performed this slightly different approach to >1000 patients, who underwent routine cholecystectomies for benign gallbladder disease. All of these patients were given a choice of the procedures between open and laparoscopy; most of them opted for open surgery, the reason primarily being economic. These pateints were admitted following a strict protocol and fully prepared on the morning of operation. The procedure was kept uniformly standard. After gaining controle of the duct and the cystic artery the gallbladder was dissected from the fundus towards the porta. The cystic duct and the cystic artery were dismembered only after being sure. In this way, to date we have never faced any complications. In addition, as the procedure was performed through a small incision (3.5–4.5 cm), these patients were discharged within 24 h of heir surgery. To date no additional morbidity or mortality has been reported.
Results: Of almost 1000 procedures, most patients were discharged within 24 h of surgery. In the initial cases there were some increased seroma, which later could be controlled to a very low level. There were no deaths, strictures, retained stones or hernias. The longest observation was well over 7 years. If done as open surgery the proceduere costs approximately Rs 800,000–900,000 ($125–$150) less than when done laparoscopically.
Conclusion: This slightly different approach to gallbladder dissection definitely reduced the complication rate and lowered the economic burden to the patients.
181
OPEN CHOLECYSTECTOMY: A DISSECTION TECHNIQUE MAKES THE PROCEDURE SAFER AND COMPLICATION-FREE
Ganguly NN
Gauhati Medical College & Hospital, Guwahati, Assam, India
Aim: Laparoscopic cholecystectomy (LC) has become the gold standard treatment for gallbladder diseases. The situation has become so intense that every rural township and place in this part of India boast facilities for LC. Many surgeons strongly claim that the superiority of LC is unmatched and unachievable by open technique. There are many reasons for such claims. We tried to improve the open procedure to match the advantages of LC point by point and when we analysed our data we found that not only we could produce results comparable to LC but could even supercede the benefits of LC.
Methods: Over the last 7 years around 1000 patients were operated through a modified small incision open procedure. The patients were not randomized and were done serially. The patients were prepared for surgery as outpatients and taken for surgery when found to be fit for surgery. All underwent a minilap procedure through a subcostal oblique incision. A pattern of dissection of the gallbladder was maintained in the procedure for evaluation purposes.
Results: There were no deaths, no retained calculi, no strictures and no hernia in the series. All patients were discharged within 3 days of operations. The commonest problem was wound seroma, which could be managed by paramedics.
Conclusion: This variant of dissection in open cholecystectomy can be compared with the claimed superiority of LC point by point, in addition to generating less complications. The only significant differences were requirement of postoperative analgesia. In the open series the patients needed 2–3 extra doses of intramuscular analgesia.
182
SECURED PANCREATOJEJUNAL ANASTOMOSIS
Manabe T, Sawai H, Okada Y, Tanaka M
Department of Surgery, Nagoya City University Medical School, Nagoya, Japan
Failure of a pancreatojejunal anastomosis leads to leakage problems and/or stenosis after pancreatoduodenectomy. A new and reliable technique that avoids the leakage and stenosis problems associated with pancreatojejunal anastomosis is presented in this video. After the parenchyma of the pancreas is resected, the main pancreatic duct is isolated and a small incision is made in the duct. A pancreatic duct tube with a circumferential knot is inserted into the pancreatic duct and tied tightly with absorbable sutures. The head of the pancreas is resected free. A small hole is made in the jejunal wall and the 6–8 stitches are put along the inner wall of the hole. The pancreatic duct tube is inserted into the jejunal lumen through the hole and brought out from the distant jejunal wall. Pancreatojejunal anastomosis is performed by meticulously approximating the seromuscular layer of the jejunum to the parenchyma of the pancreas with interrupted sutures. Pancreatic juice is completely drained through the pancreatic duct tube. The knot on the tube is properly secured by tieing the absorbable suture around the pancreatic duct, preventing the tube from dislodging for 4 weeks. This tube is safely removed about 4 weeks after operation. In a follow-up study of 201 patients leakage problems and stenosis of the anastomosis were found in only 2.2%.
Session 25
Biliary – Miscellaneous – 2
(DOI 10.1080/16515320310001020)
183
THE ROLE OF OPEN CHOLECYSTECTOMY IN THE LAPAROSCOPIC ERA
Jethwa P, Lala A, Bramhall SR, Mirza DF, Buckets JAC, Mayer AD
Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
Background: Laparoscopic cholecystectomy remains the operation of choice in the management of uncomplicated gallstone disease, but there is still a role for open cholecystectomy in selected cases with particular indications and advantages. We present our experience of open cholecystectomy from a tertiary referral centre that specialises in the management of complex hepatobilary and pancreatic disease.
Methods: Data were obtained from our hepatobilary database (1997–2002). Cases that underwent a cholecystectomy as primary procedure were included (i.e. not at liver transplant or Whipple's procedure). A senior SpR or hepatobiliary consultant performed all operations.
Results: 131 open cholecystectomies were performed during the study period. Indications for cholecystectomy were: gallbladder stones 34 (26%), bile duct stones 33 (25%), gallstone pancreatitis 26 (19.8%), acute cholecystitis/empyema 18 (13.7%), suspected cancer 13 (10%). 21 were converted from laparoscopic (overall unit converson rate of 4.5%), 9 had previous pancreatitis, 4 had acute cholecystitis, 7 had previous surgery and 3 for complications during the laparoscopic procedure (equipment failure/ bleeding/CD leak). 110 were planned open procedures for a variety of reasons including bile duct stones not amenable to endoscopic extraction, previous major surgery, suspected cancer, bile duct strictures needing biliary reconstruction and in combination with other surgical procedures.
Conclusion: Laparoscopic cholecystectomy is appropriate for the great majority of patients with gallbladder disease. However, there is a role for open cholecystectomy in selected cases with complicated gallstone disease and particularly those with pathology that may render a laparoscopic approach more hazardous.
184
ULTRASOUND-GUIDED PERCUTANEOUS CHOLECYSTOSTOMY: EFFECTIVE TREATMENT OF ACUTE CHOLECYSTITIS IN CRITICALLY ILL PATIENTS
Guloglu R, Yanar H, Kurtoglu M, Taviloglu K, Ertekin C, Karabulut K
Department of Trauma and Emergency Surgery, School of Medicine, University of Istanbul, Turkey
Aim: To assess the efficiency and complications of ultrasound-guided percutaneous drainage using Seldinger technique in the treatment of acute cholecystitis in patients who had contraindications for general anesthesia.
Methods: 13 patients underwent ultrasound-guided percutaneous transhe-patic cholecystostomy (USGPC) in this unit for the management of acute cholecystitis between January 1999 and December 2002. The study included patients aged 29–82 years (mean 64), 10 women and 3 men with clinical and sonographic signs of acute cholecystitis. All patients had severe problems such as coronary heart disease, chronic obstructive pulmonary disease, chronic myeloid leukemia, thrombotic thrombocytopenic purpura, mitral valve replacement with heart failure, 50% I-II° burn injury.
Results: Ultrasound revealed gallbladder stones in 5 patients, acalculous cholecystitis in 4 patients and both gallbladder and common bile duct stones in 4 patients. Once the condition of each patient showed signs of improvement and stability, a cholangiogram was performed via percutaneous catheter. Cholecystostomy catheters were removed 15–45 days (mean 26.2) after the procedure and all the patients remained free of biliary symptoms. Sphincterotomy and stone extraction were performed successfully with endoscopic retrograde cholangiopancreatography in 4 patients who had both gallbladder and common bile duct stones. After cholecystostomy, 5 patients underwent elective cholecystectomy without any complications.
Conclusion: We believe that USGPC is a rapid, safe and effective treatment method for high risk elderly patients with acute cholecystitis and USGPC has low complications and a high success rate.
185
COMPARISON OF CEFUROXIME AND AMPICILLIN/SULBACTAM WITH REGARD TO CHEMOPROPHYLAXIS IN ELECTIVE OPEN CHOLECYSTECTOMY OPERATIONS
Dervishoglou Ath, Pinis S, Galanakis N, Liveranou S, Dasiou P, Kanellakopoulou K
2nd Department of Surgery, General State Hospital of Pireus, Pireus, Greece
Aim: In this precursor and prospective study, we present our experience of administering cefiiroxime in comparison with ampicillin/sulbactam with regard to chemoprophylaxis in elective open cholecystectomy to treat cholelithiasis.
Methods: In the semester extending from July 2002 to December 2002, 48 patients (14 male and 34 female, mean ages 58.43 and 53.41 years, respectively) underwent elective open cholecystectomy. 23 (47.92%) were deemed high-risk patients due to coexisting ailments as follows: arterial hypertension (18), obesity (13), diabetes mellitus (11), respiratory insufficiency (5), cardiac insufficiency (3), renal insufficiency (1) and corticoid administration (1). Biliary culture from the gallbladder was performed on all patients, while 1.5 g of cefuroxime or 3 g of ampicillin/ sulbactam were administered intra-operatively at random. The patients were under clinical and laboratory monitoring postoperatively to prevent postoperative infection.
Results: The results from 48 biliary cultures were as follows: Enterococcus spp. were found in 4 patients (3 in the cefuroxime-treated group and 1 in the ampicillin/sulbactam-treated group), Streptococcus spp. in 1 patient, Citrobacter sp. in 1 and Klebsiella sp. in 1. 2 patients ran a high temperature postoperatively while the number of leucocytes increased without any apparent source of infection, 1 patient suffered from sterile collection of the wound and 1 suffered from suppuration of the surgical wound. The patients that had a microbe isolated preoperatively did not suffer from an infection of the operating field, except for one who had Enterococcus sp. isolated in the biliary culture and suffered from postoperative suppuration of the wound and SNS isolation in the pus culture. No antibiotics were administered postoperatively in any of the patients. Their postoperative recovery was smooth without any postoperative deaths, the mean hospitalization duration being 8.79 days.
Conclusions: Chemoprophylaxis had the same results in both groups. The patients studied were, nonetheless, too few to come to any conclusions as far as enterococci are concerned.
186
SERUM AMIKACIN CONCENTRATION AND THE EFFICACY OF THE TREATMENT OF BILIARY TREE INFECTIONS
Radenkovic DV, Bajec DJD, Ivancevic NDJ, Karamarkovic AR, Mihailovic VK
Emergency Center, Medical Faculty of Belgrade, Belgrade, Yugoslavia
Aim: The aim of the study was to assess the influence of amikacin concentration on the efficacy of the treatment of biliary tree infections.
Methods: The study was prospective in design, and the number of postoperative complications and hospitalization time quantified the therapeutic efficacy. 60 patients were included, and they were operated on for biliary tree infection. The infection was proved by bacteriologic analysis of the gallbladder and biliary duct content, and also by clinical, visualization and laboratory studies (WBC, body temperature, ultrasound). The single daily bolus dose of 1 g amikacin was given intravenously. For the serum amikacin determination, blood was sampled 30 min after the injection, then 12 h later and 30 min before the next dose.
Results: High peak concentrations were found 30 min after the injection. At the other sampling times amikacin concentration was within the therapeutic range (12 h after the end of infusion, 2.8 g/l, and 30 min before next dose, 0.83 g/l). The minimal inhibitory concentration (MIC) was determined for all causative organisms. The ‘killing ratio’ (KR) was calculated as the ratio of the peak serum amikacin concentration to the MIC. The KR for the gram-negative bacteria (78.5% of all isolated organisms) was 16 to 64. In the gram-positive group the largest KR was found for staphylococci (4).
Conclusion: A high KR was prognostic of the good therapeutic effect of amikacin.
187
ANTIMICROBIAL EFFECTS OF AMIKACIN AND GENTAMICIN IN THE TREATMENT OF BILIARY INFECTIONS
Randekovic DV, Bajec DJD, Mihailovic VK
Emergency Center, Medical Faculty of Belgrade, Belgrade, Yugoslavia
Aim: The efficacy of different antimicrobial agents in the postoperative course of acute biliary diseases was evaluated.
Methods: We studied two groups of surgically treated patients (30 pts each group) for acute biliary diseases, with a prospective study design. Each group of pts was administered'bolus' doses of amikacin (1 g daily) or gentamicin (160 mg daily), during the postoperative course.
Results: The incidence of positive microbial findings was 60% in both groups. Among those pts we identified 10 different bacterial species, with predominance of gram-negative bacteria (70.2%), also a significant proportion of anaerobes (8.7%). The overall sensitivity of aerobic bacterias to amikacin was 77.7%, and gentamicin 63%, while gram-negative bacterial sensitivity was found to be as high as 95% for amikacin, and 72.4% for gentamicin. Based on minimal inhibitory concentrations (MIC), the'killing ratio' (KR) was calculated for each bacterial species, so among amikacin-treated pts the KR for gram-negative bacteria was 16–64, Streptococcus spp. 4 and an extremely low ratio for Enterococcus spp. Patients who were treated with gentamicin had the following KRs: 3–11 for gram-negative bacteria (with the exception of Psendomonas aeruginosa, with low KR), 5 for Enterococcus spp. and low KR for Staphylococcus aurens, too.
Conclusion: Our results confirmed the higher sensitivity of gram-negative bacteria to amikacin than to gentamicin.
188
SURGICAL TREATMENT OF INTERNAL BILIARY FISTULAS
Sekulic S, Lazic B, Kosanovic R, Dobricanin V
Surgical Clinic, Clinical and Hospital Centre, Medical Faculty, Pristina, Yugoslavia
Background: Spontaneous biliodigestive fistulas are pathologic communications of the biliary stem and tract, which are the results of different diseases. Most biliodige stive fistulas are the consequence of penetration of gull calculosis (90%) duodenum, stomach, colon, or very rarely in the small intestine, but complications of duodenal ulcer, cancer of stomach and gallbladder are very rare.
Methods: During the period 1990–1994 there were 2642 operations on the biliary stem at this clinic; 16.4% males and 83.6% females. Calculosis of gallbladder without complications was found in 59.5%. Material obtained during operations on the biliary system at our clinic was used in the diagnosis of biliodige stive fistulas.
Results: In a total of 2642 operations on the biliary stem, there were 61 (2.3%) spontaneous biliodige stive fistulas. There was gallbladder calculosis in 88.5% of cases, choledocho calculosis in 3.3%, duodenal ulcer in 3.3%, stomach cancer in 1.6% and gallbladder cancer in 3.3%. Spontaneous biliodige stive fistulas were: between choledochus and duodenum 2 (3.3%), cholecysto-duodenal 30 (49.1%), cholecysto-gastric 12 (19.7%), cholecysto-colic 8 (13.1%) and bilio-billiary 9 (147%). All fistulas were treated operatively: cholecystectomy in all cases, suture of duodenum, sutuire or resection of stomach and colon, plastic of choledochus and reconstruction of choledochus. There were postoperative complications in 7 (11.4%) cases. A lethal result occurred in 4 (6.6%) cases.
Conclusion: The postoperative results for spontaneous internal biliodigestive fistulas are best when diagnosis is made preoperatively.
189
DOES PNEUMOPERITONEUM INCREASE THE INTESTINAL AND RENAL INJURY IN OBSTRUCTIVE JAUNDICED RATS?
Bostanci B, Yol S, Kayaalp C, Ozogul Y, Bilgihan A, Ozel U, Akoglu M
Department of Gastrointestinal Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
Aim: The aim of this study was to investigate the influence of pneumoperitoneum (P) on intestinal and renal injury in obstructive jaundiced rats.
Methods: 20 male Sprague-Dawley rats aged 12 weeks and weighing 250–280 g were used. Using aseptic technique, the common bile duct of all animals was doubly ligated and divided in order to cause obstructive jaundice (OJ). Animals were assigned to two groups: group 1 (OJ +P − ), n = 10, only obstructive jaundice; group 2 (OJ + P+), n.=10, obstructive jaundice, and CO2 pneumoperitoneum after 6 days. In the CO2 pneumoperitoneum group, a 12mmHg pneumoperitoneum was induced at a flow rate of 0.2 L/min, maintained for 60 min, and released completely for 120 min. The abdomen was opened and small intestine and kidney were excised and immediately frozen in liquid nitrogen and stored at −80°C until used. The tissue levels of malondialdahyde (MDA, nmol/g tissue) and myeloperoxidase (MPO, U/g tissue) were determined.
Results: The differences in the intestinal and renal MDA and MPO levels after the application of pneumoperitoneum in obstructive jaundiced rats were not statistically significant (Table).
| Small intestine |
Kidney |
|||
|---|---|---|---|---|
| MDA | MPO | MDA | MPO | |
| Group 1 (OJ + P − ) | 14.0 | 0.47 | 49.0 | 0.80 |
| Group 2 (OJ + P+) | 10.3 | 0.40 | 49.4 | 0.76 |
Conclusion: CO2 pneumoperitoneum of 12 mmrig for 60 min did not cause oxidative injury in the intestine and kidney of the obstructive jaundiced rats and laparoscopy can be applied safely.
190
HEPATICOJEJUNAL ANASTOMOSIS: ANALYSIS OF 130 CASES
Vasiloglou-Gkanis M, Margaris E, Tsipras H, Gogas G, Papastratis G
3rd Department of Surgery, General Hospital of Athens, Athens, Greece
Aim: To analyse the results of the Roux-en-Y technique in hepaticojejunal anastomosis (HJA).
Method: Between June 1996 and September 2002, 130 patients underwent a Roux-en-Y hepaticojejunostomy in this department. 70 HJAs were performed as part of a Whipple's procedure (N1: 46 males, 24 females; age range 34–82 years). 51 HJAs were performed for biliary bypass for non-resectable pancreatic or periampullary cancers (N2: 27 males, 24 females; age range 40–90 years). 7 HJAs were performed for iatrogenic biliary injuries (N3: 3 males, 4 females; age range 40–80 years). As isolated cases, 1 HJA was performed for common bile duct stenosis in a 68-year-old man with previous pyloroplasty, and 1 anastomosis of the jejunum with a large duct of segment III in a 48-year-old woman suffering from a voluminous neoplasm that was occupying the entire hepatic hilum. In all the patients, the anastomoses were performed end-to-side with interrupted 4.0 PDS sutures.
Results: In the early postoperative period (30 days); 6 patients died in group N1 (9%) and none in groups N2 and N3. Two patients in group N1 required a reoperation (3%); 1 for intra-abdominal bleeding and 1 for abscess formation. In the late postoperative period, 1 patient in group N3 required anastomotic revision twice in 2 years due to recurrent stenosis, while none of the patients in groups N1 and N2 developed any complications related to the HJAs.
Conclusion: The Roux-en-Y technique with end-to-side HJA appears to have very good results in all the groups, and should be considered the technique of choice.
Saturday 31 May 2003
11:00–12:30
Session 26
Liver – Hydatid Disease
(DOI 10.1080/16515320310001039)
191
RADICAL VERSUS CONSERVATIVE SURGICAL TREATMENT OF LIVER HYDATID DISEASE
Tasev V, Gaydarski R, Dimitrova V, Popov V, Boulanov D
Department of General and Liver Pancreatic Surgery, Medical University of Sofia, Sofia, Bulgaria
Aim: The aim of this study was to check the correctness of the following hypothesis:'Radical surgical procedures on hydatid liver disease have lower rates of morbidity and mortality compared to conservative ones'.
Methods: To achieve the above-mentioned aim we analysed the results of 361 patients with hydatid liver disease, 267 (74%) of whom were treated retrospectively and 94 (26%) prospectively, at this clinic during the period 1 January 1985 to 1 January 2001. The patients were divided into 2 main groups: 102 (28.25%) underwent radical surgical procedures and 250 (69.25%) underwent conservative procedures. 9 of the patients (2.50%) had multiple echinococcal cysts and received surgical procedures of both types. Thus, the results for those patients did not correspond with the aim of the study and they were excluded. The analysis consisted of a comparison between the 2 main groups according to several criteria: sex, age, location and average size of the cysts, postoperative complications, reoperations, mean postoperative stay in hospital and mortality rate.
Results: There was a prevalence of female in the male/female ratio in the group of patients who received a radical procedure. The location of echinococcal cysts in the left hepatic lobe was found to be more frequent. In the group with radical surgical operations the postoperative morbidity and mortality rates were lower and the postoperative stay in hospital was shorter, compared with the group who underwent conservative procedures.
Conclusion: Radical surgical procedures showed better postoperative results. However, those procedures had to be performed only on patients who had certain indications and according to criteria described in surgical literature. The proper surgical equipment and a well-experienced surgical team were the other important conditions for good outcome.
192
SURGICAL TREATMENT OF HYDATID DISEASE
Stratopoulos Ch, Moustafellos P, Gourgiotis S, Papakonstantinou A, Drakopoulos S, Vougas V, Baratsis S, Alfaras P, Stokkos M, Hadjiyannakis EJ
1st Surgical Department & Transplant Unit, Athens Medical Center, Evangelismos Hospital, Athens, Greece
Aims: Despite its decreased incidence in recent years in Greece, hydatid disease is not uncommon. We present our experience in the surgical treatment of echinococcosis.
Methods: Our study included 191 patients (86 men and 105 women), treated in the last 30 years. Patients' ages ranged from 17 to 84 years. In 141 patients hydatid cysts were located in the liver. In 20 patients cysts were found in other organs.
Results: Treatment was always surgical. For liver cysts the following procedures were performed: (a) resection and omentoplasty in 64 patients (33.05%), (b) resection and drainage in 56 patients (29.31%), (c) pericystectomy in 25 patients (13.08%), (d) resection and marsupialization in 22 patients (11.51%), (e) hepatectomy or segmentectomy in 14 patients (7.32%). For cysts located in other organs, 5 patients underwent splenectomy, 2 nephrectomy, 1 hysterectomy and in 13 patients resection of the cysts was performed (lung, peritoneal, epiploic). Complications were minimal: abscess formation (3 patients), wound infection (9), postoperative haemorrhage from the cystic wall (3) and 14 postoperative fistulae that were treated conservatively. Cure of the disease was successful in 188 patients (98.6%), while only 2 patients died (1.04%). In 3 patients disease recurred (1.57%).
Conclusion: Treatment of echinococcosis sometimes demands radical surgical therapy (hepatectomy, segmentectomy). Older methods (omentoplasty, marsupialization) are still performed, when indicated, with excellent results.
193
TOTAL PERICYSTECTOMY FOR TREATMENT OF HYDATID LIVER DISEASE
Bracco R, Grondona J
Cilinica Pueyrredon, Mar del Plata, Argentina
Aim: Hydatid liver disease is a major health-care problem in Argentina. Several treatments have been designed to solve the presence of the cyst inside the liver. This study aimed to assess the advantages and drawbacks of total pericystectomy (TP).
Methods: Between 1988 and 2002 we operated on 113 patients with symptomatic hydatid liver cyst. Since 1994, the last 18 patients (16%) were treated by detaching the whole cyst from the normal liver parenchyma, in most cases, or leaving a small piece of the pericystum in the area where the vessels were in contact with the capsule. Operative ultrasonography was routinely employed and the ultrasound dissector was extremely useful for separating the normal liver parenchyma from the pericystum.
Results: No transfusions were required and the postoperative complications were related to two biliary collections, one bile leak and one subphrenic abscess that were treated conservatively. No mortality was observed and the mean length of hospital stay was 5 days. At 1 year after surgery no evidence of recurrence has been observed.
Conclusions: The TP is a radical procedure that avoids the problem of leaving the pericystum, which usually leads to neocavity formation and/or recurrence.
194
HYTADID CYST OF THE LIVER, SURGICAL APROACH IN A PERPHERAL HOSPITAL. OUR EXPERIENCE IN THE LAST 5 YEARS
Zandes N, Chatzimisios K, Koutsimani TH, Kechagia T, Papavramidis TH, Doulgerakis M, Agourastou P, Patoulidis I
General Hospital of Kozani Mamatsio, Greece and Department of General Surgery, Thessaloniki, Greece
Aim: To present our experience in approaches to hytadid cysts.
Methods: This retrospective study, covering the last 5 years (1997–2002), includes 23 patients with hydatid cyst. Diagnosis was made by ultrasonography or CT. 11 patients were women and 12 were men. The mean age was 58.83 years (SD 16.5).
Results: The cysts were located in the liver in 20 patients, in the biliary tract in 1 patient, 1 in the pericardium, 1 in lung. Of the 20 patients, 18 were operated in our clinic. Surgical approaches were removal of the cyst. In 4 cases marsupialization was inevitable because of the size of the cyst. In one case there was rupture into the biliary tree. Complications were liver colic in 2 patients, postoperative fistula in 1, wet pleuritis in 1. There was 1 death with comcomitant rupture of abdominal aorta. The 2 patients with cyst of the pericardium and cyst of the lung were treated in a central hospital.
Conclusions: (1) Hytadid cyst is characterized by frequent hepatic involvment; (2) in uncomplicated cases the results of treatment are excellent
195
SURGICAL TREATMENT OF HYDATID LIVER DISEASE: REVIEW OF 131 CASES
Yilmaz G, Akgun Y, Bac B, Tacyildiz I, Keles C
Dicle University Medical School, Department of Surgery, Diyarbakir, Turkey
Aims: Hydatid disease of the liver is endemic in Turkey. Although surgery remains the main treatment modality for the disease, there is controversy about the best surgical approach.
Methods: The records of patients treated surgically in our department between 1992 and 2002 were reviewed. They were analysed with respect to their mode of surgical treatment – either radical or conservative.
Results: Cysts were found in the right lobe in 87 cases, in the left lobe in 25 cases, and in both lobes in 19. Mean diameter of the cysts was 9.5×4.3 cm. There was concomitant extrahepatic disease in 10 cases and biliary communication in 14. 6 of them had recurrent disease. Conservative surgery was performed in 115 patients, while 16 patients underwent radical surgery. Conservative surgery was capitonage and intracavitary drainage in 63 cases, intraflexion and intracavitary drainage in 35 cases. Omentoplasty of residual cavity was performed in 14 of the cases. External drainage alone was performed in 3 cases. Choledochotomy and T-tube drainage was added in 16 cases. The rates of postoperative morbity and mortality were 12.5% and 6.2% in patients who underwent radical procedures, 9.5% and 2.6% in cases who underwent conservative procedures. There were no differences in the recurrence rates and duration of hospital stay.
Conclusions: Most cases can safely be treated by conservative surgical modalities with low morbidity and mortality rates, and without recurrence. So it is unnecesseray to perform a radical intervention which needs more experience for the hydatid disease of the liver.
196
SURGICAL AND PUNCTURE TREATMENT OF LIVER ECHINOCOCCUS
Damyanov D, Grigorov N, Lozanov R, Golemanov B, Zaharieva TAG
“Queen Joanna" University Hospital, Clinic of Surgery, Clinic of Gastroenterology, Sofia, Bulgaria
Background: The echinococcus has become more frequent in the last 10 years in Bulgaria, reaching illness levels of 8,470/0000 against 2,360/0000 in 1956.
Methods and Results: 721 sick people were operated on in the Surgery Clinic in the period 1971–2001, 347 women (48.2%) and 374 men (51.8%): ≤20 years, 3.6%; 20–45 years, 44.1%; 46–65 years, 46.1%; >65 years, 9.8%. There was a prevalence of liver localization (78.85%) vs combined forms with an independent find outside these organs. Single cysts were found for the first time in 384 patients and for the second time in 101 cases, and multiple cysts in 178 cases, with primary and secondary (relapse of illness) in 58 cases. 280 patients had preoperative complications. The most frequent types of surgical treatment were closed methods without reduction of the volume of the cavity (64 patients) or with reduction of the cavity (244 patients) (through invagination, tamponade with volume, seam). A semi-closed method was used in 194 patients, resection of the liver in 31 cases. Intra-operative complications developed in 14 patients and postoperative (general and local) in 198 cases, and the mortality rate reached 3.8% (22 patients). An analysis of surgical methods and results is presented. The application of the PAIR method – puncture of the cyst under echographic control, aspiration and processing of the cavity with alcohol is presented. Clinical results are defined precisely. The method was applied successfully in 150 patients.
197
LAPAROSCOPIC MANAGEMENT OF ABDOMINAL HYDATIDS OF LIVER ECHINOCOCCOSIS
Sinha R
MLB Medical College, Jhansi, India
Aims: The conventional surgical procedures for managing abdominal hydatids, including hepatic, carry a very high morbidity in terms of hospital stay and wound complications. Less invasive procedures may thus be logical alternatives.
Methods: The study included 58 patients. 16 patients were managed as day case patients, by ultrasound-guided aspiration followed by instillation of 15% saline. In the remaining 42 patients, saline instillation was combined with laparoscopic-aided percutaneous evacuation combined with partial pericystectomy. Omental packing was added in 4 patients. A pericystic tube drain was left in every patient managed laparoscopically.
Results: In the aspiration group, 2 sittings were required in 12 patients and more than 2 sittings (3×) in 2 patients. Laparoscopic parameters showed an average i.v. infusion time of 12.3 h, drain removal time 3.2 days and discharge time of 3.2 days. Short-term complications included prolonged tube drainage for 6 days in 1 patient, intracystic bile collection in 2 and intracystic pus in 4 patients. The aspiration group did not show any complications. Conversion to open evacuation was done in 1 patient. 54 months follow-up has been recurrence-free.
Conclusion: Minimal invasive management including aspiration, and laparoscopic intervention appear to be viable alternatives to open surgery because of the associated reduced morbidity.
198
METHYLEN BLUE: A SIMPLE METHOD TO DETERMINE BILE DUCT COMMUNICATION WITH HYDATID CYST CAVITY DURING OPERATION
Yol S, Erikoglu M, Boz S, Kartal A
Selcuk University Meram Medical School General Surgery Akyokus-Konya, Turkey
Background: During surgery, the determination of bile duct communications with the hydatid liver cyst cavity is very important, to prevent the bile leakage postoperatively. These communications cannot be determined before the operation because of the increased pressure in the cyst unless the cyst has perforated into the bile duct.
Methods: Following the evacuation of the cyst cavity during the operation, when we suspect a bile duct communication with the cyst cavity, we insert a Foley catheter into the biliary system through the choledochotomy. Foley's balloon is inflated, and diluted methylene blue is delivered through the catheter into the biliary system. The stained bile communications are sutured with PDS material. Then a T-tube is placed into the choledochus. Herein, we present 3 cases in which we have performed this procedure so far, with no complications. Case 1: A 52-year-old female patient had a huge hydatid cyst (15×16 cm) in the right lobe of the liver. Using the method described above, 11 bile communications were detected and sutured. The cyst cavity was left open into the abdomen. The T-tube was removed on the 10th postoperative day without any bile fistula. Case 2: A 32-year-old male patient was admitted with hydatid cyst (12×10 cm) in the right lobe of the liver. Biliary dilatation was reported before the operation. 6 bile communications were detected during the operation by methylene blue staining. Those communications were sutured. No additional intervention was carried out on the cyst cavity. The T-tube was removed on the 12th postoperative day. No complication occurred. Case 3: A 34-year-old female patient was admitted with hydatid cyst (7×5 cm) in the right liver, and the serum bilirubin level had increased. Bile communication was suspected before the operation. Methylene blue staining showed 4 bile duct openings into the cyst cavity. All of them were sutured and a T-tube was placed into the choledochus. 10 days after the operation, the T-tube was withdrawn without any complication.
Conclusion: We consider that staining of the bile ducts with methylene blue exposes biliary communications with the cyst cavity. Besides its feasibility and inexpensiveness, this method avoids the need for a biliary diversion procedure or at least a papillotomy.
Session 27
Liver – Miscellaneous – 2
(DOI 10.1080/16515320310001048)
199
SURGICAL MANAGEMENT OF HEPATIC INJURIES
Karamarkovic A, Djukic V, Stefanovic B, Mihailovic V, Mitrovic M
University Clinical Center for Emergency Surgery, Belgrade, Yugoslavia
Aim: This study was designed to analyse the results of the surgical management of 214 cases of hepatic injuries during the period 1996–2002.
Methods: In addition to the liver trauma, 41.6% of patients had one or more associated abdominal injuries. The mean ISS was 35.9. According to the OIS surgically treated patients presented lesions of grade I, II, III, IV and V in 11%, 25%, 41%, 19%, 4% of patients, respectively. The most common surgical procedure was hepatorrhaphy. Resectional debridement with selective vascular ligation we performed in 14% of patients. Anatomical resection (segmentectomy, hepatectomy) was done in 17 patients (7.9%), while atypical resection was performed in 5.1% cases. In 12 cases (5.6%), it was necessary to perform perihepatic packing and staged injury repair (STIR), with multiple re-explorations and delayed definitive repair, utilizing an ETIZIP device for TAC. Operative treatment also included Pringle manoeuvre or TVE, vascular sutures of the inflow hepatic circulation, hepatic veins and VCI, and also bile duct reconstruction.
Results: The observed mortality in our series was 16% (34 patients). In the group of the most severe hepatic injuries (grade III, IV and V) the overall mortality rates were 10%, 49% and 67%. The main causes of death were sepsis syndromes. The most common specific complications in patients after surgical treatment were intra-abdominal abscess (6.5%), late haemorrhage (4.2%) and biliary fistula (8.8%).
Conclusion: Hepatic trauma results in serious complications. These include general and specific complications directly related to the severity of the liver trauma and its treatment. There is a significant correlation between injury grade and mortality rate.
200
VASCULAR ISOLATION TECHNIQUES IN EXTENSIVE LIVER TRAUMA
Djukic V, Karamarkovic A
University Clinical Center for Emergency Surgery, Belgrade, Yugoslavia
Aim: Bleeding after applying the Pringle maneuver indicates the presence of dominant backflow from injured hepatic veins or vena cava confluence (arterial variations have to excluded). The aim of the study was to reduce the time surgeons usually lose before they decide to perform vascular isolation techniques.
Methods: From January 1999 to May 2002, 16 patients underwent different extensive surgical life-saving procedures because of severe liver trauma (grade IV and V). TVE total vascular exclusion 3 pts, atriocaval shunt 1, top hepatic IVC reconstruction t-t 1, caval repair 5, hepatic vein repair 2, liver resection with hepatic vein confluence repair and left hepatic vein ligation in 4 patients.
Results: Blood loss was 2340–7800 ml. The mortality rate was 75%. The authors were not able to use venovenous bypass and blood cell saver; the operations were performed with very basic surgical equipement.
Conclusion: To optimize the outcome in patients with serious hepatic injuries grade IV and V surgeons should never mobilize liver and try to stitch vessels before they obtain superior and inferior caval control complete with portal triad clamping.
201
SURGICAL TREATMENT OF RUPTURED CAVERNOUS HEMANGIOMAS OF THE LIVER
Alfaras P, Moustafellos P, Gourgiotis S, Germanos S, Baratsis S, Hadjiyannakis E
1st Surgical Department & Transplant Unit, Athens Medical Center, Evangelismos Hospital, Athens, Greece
Aim: To present our experience concerning diagnosis, localization and surgical management of 5 ruptured cavernous hemangiomas of the liver.
Methods: Between 1975 and 2001 we treated 46 hepatic hemangiomas. 15 of them were considered the critical point for surgical intervention. In 5 of these patients (33.33%) the hemangiomas were ruptured automatically (4 patients) or because of trauma (1 patient). The patients, 1 male and 4 female, were aged of 26–58 years. All of them presented acute abdominal pain, shock and hemorrhage. Methods for diagnosis included ultrasonography (U/S), computed tomographic (CT) scan, magnetic resonance imaging (MRI) and arteriography or combinations of more than one technique.
Results: We performed 2 right extended hepatectomies, 2 right hepatectomies and 1 left hepatectomy and right segmental resection. The perioperative mortality in our patients was 0, liver function tests were normal in all patients, the average hospital stay was 12.7 days and the follow-up at 48 months was normal. The postoperative morbidity was minimal and was related mainly to 2 subdiaphragmatic collections, 1 intra-abdominal collection, 1 wood infection and 1 case with Kasabach-Merritt syndrome.
Conclusions: The resection of giant hemangioma of the liver is safe. The indication for resection, however, should be carefully analysed before embarking on such a major operation. This should be done in a specialized hepatobiliary unit, where experience with liver resection is available.
202
THE ROLE OF SURGICAL PORTOSYSTEMIC SHUNTS IN THE ERA OF INTERVENTIONAL RADIOLOGY AND LIVER TRANSPLANTATION
Orug T, Tekin K, Soonawalla ZF, Jarufe N, Olliff SJ, Mirza DF, Buckels JAC, Mayer AD
Birmingham University, Liver Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
Aims: In the present era of liver transplantation and transjugular intrahepatic portosystemic shunts, the role and choice of shunt surgery for portal hypertension needs to be reviewed.
Methods: This retrospective study analysed the management of patients with portal hypertension from June 1993 to May 2002 in a tertiary liver transplant unit. During this 9-year period, patients underwent endoscopic control of their varices, 235 transjugular intrahepatic portosystemic shunts were inserted in 214 patients, 1142 liver transplants were performed, while only 29 patients needed a surgical portosystemic shunt.
Results: 29 shunt operations were performed in 8 cirrhotic and 21 non-cirrhotic patients: 12 side-to-side lienorenal, 9 mesocaval, 3 proximal lienorenal, 2 distal lienorenal, 2 portocaval and 1 mesoportal shunt. Encephalopathy was seen in 5 of 11 patients after non-selective shunts, and did not occur with the side-to-side or selective lienorenal shunts. At a mean follow-up of 42.5 months, 1 mesocaval shunt has thrombosed and 1 portocaval shunt has stenosed; both were successfully managed by percutaneous intervention. To date, 6 patients have died, 2 of who succumbed to postoperative complications, 1 being related to the shunt.
Conclusion: Patients with Budd-Chiari syndrome and cirrhosis can nearly always be managed by a combination of endoscopy, interventional radiology and liver transplantation. In the rare instances when these therapies fail in cirrhotic patients, a side-to-side lienorenal shunt can be a better alternative than other shunt procedures.
203
PROGNOSTIC ROLE OF BILIARY CEA IN COLORECTAL CANCER
Ipekci F, Ergun A, Sengezer S, Yener O, Iskender S, Aksoy F
SSK Goztepe Training Hospital, Istanbul, Turkey
Aims: The objective of this study was to determine the prognostic value of serum CEA and intra-operative biliary CEA level in colorectal cancer.
Methods: From November 1997 to November 1999, 31 patients were operated for colorectal cancer in this clinic. Biliary CEA levels (taken by fine needle intraoperatively) and serum CEA levels were determined in these patients. These patients were followed-up for a 2-year period postoperatively by physical examination and laboratory values. Cases of liver and distant metastases and synchronous tumor were not included in the study.
Results: 21 of the 31 patients had colorectal cancer; there were 10 patients in the control group. In 10 of the 21 patients serum CEA level was normal and biliary CEA level was high in 16 patients. CEA level was high in 2 patients in the control group. Liver metastases were found in 8 patients, in 5 of them serum CEA level was normal but biliary CEA level was high.
Conclusions: Serum CEA level may be used as a peroperative prognostic factor. We believe that biliary CEA level taken postoperatively via nasogastric route or intraoperatively via fine needle aspiration is a good prognostic factor.
204
LAPAROSCOPIC FENESTRATION FOR THE TREATMENT OF PATIENTS WITH SEVERE ADULT POLYCYSTIC LIVER DISEASE. CORRELATION WITH LONG-TERM CLINICAL OUTCOME
Leandros E, Paizis B, Konstadoulakis MM, Gomatos IP, Alexakis N, Androulakis G
Laparoendoscopic Unit, First Department of Propaedeutic Surgery, Hippocration Hospital, Athens University, Athens, Greece
Aims: We present our experience in laparoscopic fenestration for patients with symptomatic adult polycystic liver disease (APLD), analyse its feasibility and evaluate its immediate and long-term outcome.
Methods: Between January 2000 and January 2002, 9 patients underwent laparoscopic fenestration for symptomatic APLD in our laparoendoscopic unit. All patients had both liver lobes affected, while type II disease was not a contraindication for the procedure. The results were prospectively evaluated.
Results: Conversion to laparotomy was required in 1 patient who was submitted to a repeat laparoscopic procedure (2 years postoperatively) after being admitted to our department with sepsis. There was no surgical morbidity and complete regression of symptoms was achieved in all our patients. One death occurred due to acute renal failure established 3 weeks after the patient was discharged from the hospital. During a mean follow-up of 13.28 months only 1 patient presented a mild recurrence of his symptoms, but did not need to be reoperated.
Conclusions: Laparoscopic fenestration appears to be the treatment of choice for symptomatic APLD. It is associated with shorter hospital stay, lower morbidity, and a significant symptom-free period. Furthermore, aggressive and meticulous deroofmg of as many cysts as possible can be successfully applied for patients with type II disease.
205
TREATMENT OF NON-PARASITIC CYSTS OF THE LIVER
Pantoflicek J, Ryska M, Rudis J, Fronek J
Transplant Surgery Department, IKEM, Prague, Czech Republic
Aim: Diagnosis of liver cysts became very common with the developing of imaging methods, but they are rarely symptomatic and need surgical intervention.
Method: During the years 1998–2001, 20 patients were presented for surgical treatment, with liver cysts that were not suitable for conservative treatment. The main sign was upper abdominal mass and abdominal pain.
Results: 7 patients had simple solitary liver cyst and were treated laparoscopically, 2 patients had a large solitary cyst, which was indicated for laparoscopic procedure, but conversion was necessary, because of the large diameter of the cyst. 4 hepatectomies and 6 laparotomies with pericystectomies and marsupialisation of multiple cysts of liver parenchyma were performed. 1 patient with polycystic disease was indicated for orthotopic liver transplantation.
Conclusions: Various treatments were proposed for non-parasitic liver cysts. Every symptomatic liver cyst should be examined, and preoperative diagnosis should evaluate the origin and localisation of the cyst, to establish a rational and adequate method of treatment. Laparoscopic surgery is suitable for cases of certain origin, for complicated cysts with uncertain origin laparotomy and resection of cystic lesions is the method of choice.
206
NEUROLOGIC COMPLICATIONS OF PEDIATRIC MALIGNANT LIVER TUMORS
Tasdemiroglu E, Sengoz A
Istanbul Social Security Hospital, Neurosurgery Service, Istanbul, Turkey
Aim: Neurological complications of pediatric malignant liver tumors were evaluated.
Methods: Among 154 pediatric solid malignant tumors, 6 cases had malignant liver tumors (3.89%). Ages ranged between 0 and 6 years old (median 24.8 months). 2 cases were encountered with neurological complications: 1 case had brain metastasis and VIII nerve neuropathy due to cis-platinum chemotherapy, the 2nd case had varicella zoster infection due to chemotherapy. Only 2 cases were alive during the follow-up period.
Results: see Table below.
| Case no., age, sex |
Type of tumor |
Type of neurological complication |
Treatment of disease |
Treatment of neurological complication |
Outcome of complication |
Final outcome |
Notes |
| No. 6, 6 yo, M | Hepatocellular carcinoma | Brain metastasis and bilateral VIII nerve neuropathy | Chemotherapy | Craniotomy, chemotherapy and radiotherapy | Died, 22 days after craniotomy | Died, 9 months after diagnosis | |
| No. 13, 1 y0, f | Hepatoblastoma | Neurologic infection (varicella zoster) | Chemotherapy and surgery | Acyclovir Treatmment i.v. | Improvement | Alive 52 months | |
| No. 115. 0 yo, M | Hepatoblastoma (L. Iobe) and hemangioblastoma (R. Iobe) | – | – | – | – | Died 2 months | |
| No. 102, 3/12 yo, F | Hepatoblastoma | – | Chemotherapy and surgery | – | – | Lost to follow-up (5 months) | Hemihypertrophy R > L side |
| No. 66, 7/12 yo. M | Hepatoblastoma | Chemotherapy and surgery | – | – | Alive, 14 months | ||
| No. 127, 4 yo, M. | Hepatocellular | Chemotherapy and surgery | – | – | Died, 7 months after diagnosis | Bilateral lung metastases |
Conclusion: The incidence of pediatric malignant liver tumors was 3.89%. Neurological complications occurred in pediatric malignant liver tumors. Regardless of the presence of neurological complications pediatric malignant liver tumors had dismal prognosis.
Session 28
Pancreas/Miscellaneous
(DOI 10.1080/16515320310001057)
207
SURGERY OF NECROTIZING PANCREATITIS AND PANCREATIC WOUNDS
Rakhimov BM1, Shatokhin VD2, Romanov SA2, Simatov AM1, Volkov PP1, Krivov AA1, Izmalkov SN3
1Municipal Hospital No. 5 “MedVaz”, Togliatti, 2Centre of the Labour Medical Treatment of Aa AvtoV AZ and 3Department of Traumatology and Orthopedics of the Samara Medical University, Russia
Aim: Acute diseaes and injuries of pancreas account for a considerable place in the urgent surgery of the organs of abdominal cavity. The purpose of this research was the development of adequate surgical methods and optimization of surgical treatment of necrotizing pancreatitis and pancreatic wounds and injuries.
Methods: The results of treatment of 174 patients subjected to surgery for pancreatic necrosis and pancreatic injuries were studied. Of the 174 patients, 110 were men aged 17–68 and 64 were women aged 32–74 years. Results: The patients can be divided in two basic groups. The first group comprised 144 patients with acute necrotizing pancreatitis of alcoholic and biliary etiology. All these patients were operated and the surgery consisted of subtotal resection of pancreas – 14/9, varying degrees of sequestrectomy – 130/32. 41 patients died during the postoperative period. Of 121 patients operated at the stage of toxemia and infiltrate 40 patients died, whereas of 23 patients operated at the stage of purulent complications only 1 patient died. The second group included 30 patients with traumatic lesions of pancreas: 7 knife slash wounds, 3 gunshot wounds and 20 internal abdominal pancreatic injuries. 6 patients had isolated lesions while 24 patients suffered concomitant and multiple injuries. The following operations were performed: pancreatoduodenal resection-i/i, pancreatic resection – 6, suture of pancreas – 20/6 and drainage of wound-affected region – 3. Of these 30 patients, 11 patients developed various complications and 7 patients died.
Conclusion: Optimization of results of therapy of pancreatic wounds and diseases requires a differentiated approach with regard to the selection of adequate amount and time factors, as well as methods of operative intervention.
208
THE DUODENUM-PRESERVING PANCREATIC HEAD RESECTION (FREY) IN CHRONIC PANCREATITIS
Belagyi T, Pardavi G, Issekutz A, Olah A
Petz Aladár Teaching County Hospital, Gyor, Hungary
Background: Local resection of the head of the pancreas with longitudinal pancreatico-jejunostomy was developed by Charles Frey.
Methods: 34 patients suffering from chronic pancreatitis underwent this operation at this hospital, between 2000 and 2002.
Results: There was no postoperative mortality. Overall postoperative morbidity was 8.8% (3/34) and the rate of relaparotomy was 2.9% (1/34). Leakage of the hepatico-jejunostomy, pancreatic fistula and wound infection each occurred in 2.9% of cases. After a mean follow-up of 15 months, 2 cases (8%) developed acute exacerbation of chronic pancreatitis, both resolved with conservative treatment. 3 patients needed relaparotomy: 1 patient for pseudocyst breaking into the spleen (distal resection with splenectomy was performed) and 2 patients for jaundice (hepatico-jejunostomy was performed). We observed a significant 88% improvement in the patients' pain relief and in the overall quality-of-life index.
Conclusion: Duodenum-pre serving resection of the head of the pancreas is an organ-preserving procedure in patients with chronic pancreatitis, which combines the benefits of resection and drainage procedures. Besides resection we can treat other complications of chronic pancreatitis, like pseudocyst or jaundice and we can rule out malignancy as well. With low perioperative morbidity and mortality it significantly improves pain relief and quality of life.
209
PYLORIC EXCLUSION IN PANCREATICODUODENAL INJURY
You Y, Lee D, Kim J, Ahn C
Department of Surgery, College of Medicine, Catholic University of Korea, Seoul, Korea
Background: Pyloric exclusion has been recommended in patients with severe injuries to the pancreas and duodenum.
Methods: A retrospective case review of 8 patients treated with pyloric exclusion following pancreaticoduodenal injury from March 1994 to May 2002 in this department.
Results: The age range of the patients was 8–31 years. The most common etiology (n = 7) was blunt abdominal trauma and 1 case was due to iatrogenic injury from therapeutic endoscopic retrograde cholangiopan-creatography. The time interval between the injury and the operation varied from 3 to 48 h. The most common postoperative complication was wound infection (n = 8). We found other complications such as intra-abdominal abscess (n = 3), pneumonia (n = 3), but the complications were treated successfully with conservative measures. There was no mortality in these patients. The duration of admission was delayed in the cases of concomitant injury (64 vs 46 days). All patients >16 years old (n = 7) were supported with parenteral nutritional fluid via the central intravenous route (mean 32 days). We could not find the spontaneous opening of the pyloric closure in at least 4 patients in the postoperative 3 months but there was no major complication according to the sustained gastrojejunostomy.
Conclusion: Pyloric exclusion appears to offer a satisfactory option for the treatment of the severe pancreaticoduodenal injury with minor complications.
210
CURRENT SURGICAL APPROACH TO PANCREATIC PSEUDOCYSTS
Kapan M, Kapan S, Durgun A, Goksoy E, Perek S
Istanbul University, Cerrahpasa Medical Faculty, Department of Surgery, Istanbul, Turkey
Background: Pancreatic pseudocysts are complications of acute pancreatitis, chronic pancreatitis, pancreatic trauma or tumoral obstruction of the pancreatic duct compromising 75% of all cystic lesions of pancreas.
Therapeutic modalities include observation, percutaneous techniques, endoscopic techniques and surgical techniques.
Methods: Between 1992 and 2002, 39 cases who underwent surgical intervention for pancreatic pseudocyst in our clinic were evaluated retrospectively. There were 21 male and 18 female patients with a mean age of 50.2 years. 17 cystogastrostomy, 17 Roux-en-Y cystojejunostomy, 1 cystoduodenostomy, 1 distal pancreatectomy and 1 total pancreaticoduo-denectomy were performed as surgical treatment. The remaining 2 patients were treated with laparoscopic cystogastrostomy. 2 of these 39 cases were re-operated for recurrence after the cystogastrostomy. 1 of these patients was treated with Roux-en-Y cystojejunostomy, whereas total pancreatico-duodenectomy was performed in the other case.
Results: The mean hospital stay was 7.5 and 4.5 days in conventional and laparoscopic approaches, respectively. There was no mortality or recurrence in any of the approaches. No major complication occurred in any of the patients. The follow-up period ranged from 10 years to 6 months.
Conclusion: Percutaneous and endoscopic interventions have been gaining acceptance in the treatment of pancreatic pseudocysts, due to the advantage of being minimally invasive methods. The laparoscopic approach is as minimally invasive as these methods, but series of laparoscopic treatments include limited numbers of cases and long-term results are not available yet as it is in our series. Satisfactory short-term results suggest that laparoscopic treatment can be used safely as an alternative to both endoscopic and percutaneous techniques in selected patients.
Session 29
Laparoscopic Cholecystectomy – 2
(DOI 10.1080/16515320310001066)
211
IS THERE ANY ROLE FOR DRAINS IN LAPAROSCOPIC CHOLECYSTECTOMY? INTERIM ANALYSIS OF A PROSPECTIVE RANDOMISED TRIAL
Tzovaras G, Theodoropoulos T, Michalitsis S, Hatzitheofilou C
Department of Surgery, University Hospital of Larissa, University of Thessaly, Larissa, Greece
Aim: The use of drains in cholecystectomy depends on personal experience rather than scientific evidence. A randomised trial including patients undergoing elective laparoscopic cholecystectomy raised the question of usefulness of routine drainage in this setting. We conducted a prospective randomised trial including all patients undergoing attempted laparoscopic cholecystectomy either as elective or emergency cases.
Methods: From January 2002, all patients with symptomatic gallstone disease under the care of one consultant, provided they had no contraindication for the laparoscopic approach and no need for laparoscopic bile duct exploration, were randomised to have a gravity drain in the subhepatic space or no drain. The operations were performed or supervised by the same surgeon. Endpoints of the study were to detect any difference in morbidity, postoperative pain and hospital stay between the two groups by analysing the results on an intention-to-treat basis.
Results: 60 patients were randomised to have a drain (group A) and 53 not to have a drain (group B). The two groups were similar regarding demographics. 9 group A patients and 11 group B patients were operated on as an emergency for acute cholecystitis and there were 2 conversions to open procedure, 1 in each group. There was no significant statistical difference between the two groups in terms of median operative time: 50 min (25–100) vs 45 min (25–120); median duration of hospital stay: 1 day (1–14) vs 1 day (1–4); median pain score: 3.75 (1–6) vs 3.5 (2–5.5); and morbidity: 6 vs 2 complications (Mann-Whitney U test and Fisher's exact test were used as appropriate, 2-sided p value <0.05 was considered statistically significant).
Conclusion: It appears that the use of a drain in laparoscopic cholecys-tectomy, even in acute cases, serves no purpose and the practice of routine drainage in laparoscopic cholecystectomy should be abandoned.
212
A PROSPECTIVE RANDOMIZED TRIAL OF POSTOPERATIVE PAIN IN LOW PRESSURE PNEUMOPERITONEUM VS CONVENTIONAL LAPAROSCOPIC CHOLECYSTECTOMY
Koc M, Aslar AK, Gocmen E, Kocpinar M, Ertan T, Kilic M
Ankara Numune Teaching and Research Hospital, 5th Department of Surgery, Ankara, Turkey
Aim: The present study was designed to test the influence of low pressure p neu mope rite neum on the frequency and intensity of postoperative pain in patients undergoing laparoscopoic cholecystectomy (LC).
Methods: 53 elective cases, with symptomatic gallstones confirmed by abdominal ultrasonography, were enrolled into the study. Patients were randomised to low or high pressure pneomoperitoneum groups. Pneumo-peritoneum was created with CO2. In all patients, gas pressure was set at 15 mmrig during placement of ports. Then in the low pressure group the rest of the procedure was performed at 10 mmrig pressure. Postoperative analgesia was standardised, but patients were also told that they could request further analgesic. At 6 and 24 h after operation a short-form McGill questionnaire was obtained from all patients. Then patients were asked to complete a 10 cm visual analogue scale (VAS) for abdominal pain.
Results: Pain scores were generally low for both groups. Comparisons of mean cumulative McGill score and VAS abdominal pain score values in both groups did not reach statistical significance at 6 and 24 h after operation. There were no severe complications in either group. In a comparison of patients who required extra analgesics with patients who did not, there was no significant difference in terms of demographic, clinical and operative data.
Conclusion: Our results suggest that there was no correlation between peritoneal stretching and postoperative pain after LC. Peritoneal stretching may be responsible for shoulder pain but has less effect on the intensity of abdominal pain or incisional pain. On the basis of our negative findings we do not recommend routine use of low pressure pneumoperitoneum for LC.
213
THE SUFFICIENCY OF SURGEON ON DETERMINING INCIDENTAL PATHOLOGIES OF THE GALLBLADDER AT LAPAROSCOPIC CHOLECYSTECTOMY
Irkorucu O, Akyurek N, Erdem O, Dalgic A, Sare M, Tatlicioglu E
Department of General Surgery, Gazi University Medicine School, Ankara, Turkey
Aims: The aim of this study was to investigate the surgeon's sufficiency to determine incidental pathologies of the gallbladder on the operation table in patients who underwent laparoscopic cholecystectomy for cholelithiasis. Methods: Between 1 May 2002 and 31 October 2002, 181 laparoscopic cholecystectomies were performed at the Medical School of Gazi University. The surgeon routinely opened the gallbladder after removing it from the abdominal cavitiy to look for unsuspected pathologies and the abnormal areas of the specimens were marked by a silk suture. Permanent histopathologic examination of specimens was evaluated and the sufficiency of surgeons to determine incidental pathologies of the gallbladder was investigated.
Results: 34 of 181 laparoscopic cholecystectomy specimens were found to be suspicious for incidental pathology by the surgeon and the suspicious areas were marked. At histopathologic examination 8 of these specimens revealed incidental pathologies; strikingly, 1 of them was gallbladder cancer. The other 147 laparoscopic cholecystectomy specimens were not found to be suspicious by the surgeon, but 3 of 147 specimens revealed incidental pathologies at histopathologic examination. The sensitivity and specifity of the procedure was 72.7% and 84.7% respectively.
Conclusion: Gallbladder cancer may be silent for a long time, and the commonest diagnosis is made postoperatively in gallbladders removed for stone disease. In order not a miss such a diagnosis, opening the gallbladder to look for an unexpected pathology is mandatory in patients treated by laparoscopic cholecystectomy.
214
COMPARATIVE ANALYSIS OF ENDOLAPAROSCOPIC AND CONVENTIONAL SURGERY METHODS IN THE TREATMENT OF COMPLICATED FORMS OF BILE STONE DISEASES
Damyanov D, Lozanov R, Vladimirov B, Zaharieva TAG, Angelov G
“Queen Joanna” University Hospital, Clinic of Surgery, Clinic of Gastroenterology, Sofia, Bulgaria
Within a period of 10 years (1992–2002), 709 patients with bile stone disease were operated on by the laparoscopic method and 852 by classic surgical techniques. The 321 patients in the first group had different complicated forms of bile stone disease as follows: 250 with complications of the bile bladder, 51 with pathology of the general bile passage and 20 with double pathology. In the second group, 415 patients had a complicated form of this malady, as well as 221 with bladder complications, 106 of the bile channels, and 98 with both complaints. Among 111 patients who had laparoscopic operations, for a detailed appraisal of the complications, there were 192 intraoperative cholangiography, intraoperative ultrasound, endoscopic ultrasound, choledoscopy. In 22 cases laparoscopic exploration of the common bile duct (CBD) was successful with resolution of the choledocholithiasis and in 28 cases planned conversion was carried out. 33 patients in this group had preoperative ERCP with PST and EE for pathology of distal CBD and consecutive laparoscopic operation. Comparative results are available for the two surgical methods in different pathologic groups. Clinical parameters have been indicated as well as allowed limits for laparoscopic solution of complicated forms of bile stone disease. Complications among the patients in the laparoscopic group amount to 5% and within the framework of open methodology they amount to 12%. On the basis of the long-term results, one may come to the conclusion that detailed intraoperative laporoscopic diagnosis is a pledge for avoidance of relapses of the malady.
215
PREOPERATIVE INCISIONAL AND INTRAPERITONEAL INFILTRATION FOR PAIN RELIEF AND NAUSEA AFTER LAPAROSCOPIC CHOLECYSTECTOMY
Sophianou A, Papakitsos G, Kutsodima Ch, Konstantinou K, Denaxa M, Belmahou K
Department of Anesthesiology, General Hospital of Athens – KAT, Kifisia, Greece
Aim: Pain and nausea are dominant complaints after laparoscopic cholecystectomy. We investigated the effects of a somato-visceral local anesthetic blockade on pain and nausea in patients undergoing elective laparoscopic cholecystectomy.
Method: In a randomized, double-blind, placebo-controlled trial, we evaluated the use of preoperative local anesthesia with regard to postoperative pain and nausea. Before surgery in 63 patients ASA I, II, the abdominal wall along the proposed areas of incision and intraper-itoneally were infiltrated by the same surgeon with 20 ml of Levobupiva-caine 0.5% 100 mg (group L, 21 patients), or with 20 ml of Ropivacaine 0.75% 150 mg (group R, 21 patients), or with 20 ml of saline (placebo group, 21 patients). Wound pain at rest, wound pain during mobilization and nausea were assessed after 2, 3, 6, 24, 74 h and after 7 days. Consumption of analgesics and antiemetics was recorded.
Results: In group L pain was reduced overall for the first 2 h and incisional pain for the first 3 postoperative hours (p < 0.01). Ropivacaine had no apparent effects on intra-abdominal pain. During the first 3 postoperative hours analgesic requirements were lower (p < 0.05) and nausea was reduced in the L and R groups. At the 6-h assessment, there was a statistically significant dose-related decrease in wound pain during mobilization (p = 0.001). Throughout the first postoperative week, incisional pain dominated in all groups (p < 0.01).
Conclusions: We conclude that the somato-visceral local anesthetic blockade reduced pain and nausea during the first postoperative hours. A combination of incisional and intra-abdominal local anesthetic treatment reduced incisional pain, but had no effect on deep intra-abdominal pain in patients undergoing laparoscopic cholecystectomy. The study gives support to the hypothesis that preoperative local anesthetics dampen the inflammatory response and ensuing hyperalgesia. No signs of central nervous or cardiovascular toxicity from local anesthetics were observed. Patients, as well as the surgeon, were very satisfied with the procedure.
216
LAPAROSCOPIC CHOLECYSTECTOMY: A DOUBLE PERIOD ANALYSIS IN RELATION TO THE COMPLICATIONS AND THE CONVERSION RATE
Di Carlo I, Randazzo V, Rodolico M, Toro A, Di Stefano A, La Greca G, Russello D
Department of Surgical Sciences, Organs Transplantation And Advanced Technologies, University of Catania, Catania, Italy
Aim: Since 1987 laparoscopic cholecystectomy has replaced open cholecystectomy and is actually the gold standard for the treatment of gallbladder disease in acute and elective surgery. The aim of this study was to analyse two different periods in relation to the complications and conversion rate.
Methods: Age, sex, mean operative time, rate of conversion to open surgery, abdominal drainage, mortality and morbidity of the patients submitted to LC from June 1992 to June 2002 were studied. Two periods were analysed, froml992 to 1999 and from 1999 to 2002.
Results. During the first period we treated 415 patients (51.8%), 123 males (29.6%) and 292 females (70.4%) aged 23–96 years with a conversion rate of 11%. In the second period we operated 386 patients (482%), 137 males (35.5%) and 249 females (64.5%), aged 18–95 years, with a conversion rate (1.8%) that is due to a great number of training young surgeons.
From 1992 to 1999 we recorded 12 complication cases (29%): 2 common bile duct lesions, 2 bleedings, 1 abscess, 1 gastric perforation, 1 choleperitoneum and 5 minor complications. From 1992 to 1999 we did not record complications.
Conclusions: According to literature dates we maintain that laparoscopic cholecystectomy is currently the best way to treat gallbladder disease and the results are strictly related to the surgeon's experience.
217
DELAYED LAPAROSCOPIC CHOLECYSTECTOMY AND PRECEDING PERCUTANEOUS GALLBLADDER DRAINAGE IN CRITICALLY ILL PATIENTS WITH ACUTE CHOLECYSTITIS WITH GALLBLADDER PERFORATION
Kim HC
Soon Chun Hyang University Hospital, General Surgery, Seoul, Korea
Aims: Currently the ultimate treatment for acute cholecystitis (AC) is laparoscopic cholecystectomy (LC). However, in critically ill elderly patients the mortality of emergency cholecystectomy may reach up to about 30% and emergency LC also may have a high conversion rate and high complication rate. Indication and optimal timing of LC for AC are still controversial. But in complicated cholecystitis including AC with gallbladder perforation, open cholecystostomy performed under local anesthesia was considered to be the procedure of choice for high-risk-patients. In recent years, percutaneous gallbladder drainage (PTGBD) under ultrasound guidance replaced open cholecystostomy for the treatment of complicated cholecystitis. Here, we report the safety and clinical significance of combination therapy of PTGBD and delayed LC for acute complicated cholecystitis with gallbladder perforation.
Methods: We evaluated 21 patients who underwent delayed LC preceding PTGBD at this hospital from February 2001 to December 2002. The male:female ratio was 11:10; median age was 71 years, range 36–83. Results: All the patients showed toxic symptoms and signs (fever, leucocytosis, localized peritonitis). We could find the distended gallbladder, thickened wall, pericholecystic fluid collection and hole sign on ultrasound or CT scan. The overall success rate of PTGBD was 100%. The interval from PTGBD to delayed LC was 19.5 days. The rate of conversion from LC to open surgery was 1/21 (4.8%). The mortality was none and there was one complication (bile leakage from cystic duct).
Conclusion: Preceding PTGBD and delayed LC seems to be a relatively safe and effective method for avoiding open cholecystectomy and decreasing the rate of mortality and morbidity in critically ill patients with acute complicated cholecystitis with gallbladder perforation.