The diagnosis of non-alcoholic steatohepatitis (NASH) requires liver biopsy. Patients with NASH are at risk of progression to advanced fibrosis and hepatocellular carcinoma. A reliable non-invasive ...tool for the detection of NASH is needed. We aimed at developing a tool to diagnose NASH based on a predictive model including routine clinical and transient hepatic elastography (TE) data. All subjects undergoing elective cholecystectomy in our center were invited to participate, if alcohol intake was < 30 g/d for men and < 15 g/d for women. TE with controlled attenuation parameter (CAP) was obtained before surgery. A liver biopsy was taken during surgery. Multivariate logistic regression models to predict NASH were constructed with the first 100 patients, the elaboration group, and the results were validated in the next pre-planned 50 patients. Overall, 155 patients underwent liver biopsy. In the elaboration group, independent predictors of NASH were CAP value adjusted OR (AOR) 1.024, 95% confidence interval (95% CI) 1.002-1.046, p = 0.030 and HOMA value (AOR 1.847, 95% CI 1.203-2.835, p < 0.001). An index derived from the logistic regression equation to identify NASH was designated as the CAP-insulin resistance (CIR) score. The area under the receiver operating characteristic curve (95%CI) of the CIR score was 0.93 (0.87-0.99). Positive (PPV) and negative predictive values (NPV) of the CIR score were 82% and 91%, respectively. In the validation set, PPV was 83% and NPV was 88%. In conclusion, the CIR score, a simple index based on CAP and HOMA, can reliably identify patients with and without NASH.
Central venous pressure measurement has been the standard for patient monitoring during hepatectomy to assure low pressure and reduce blood loss. Recently SVV has been employed to monitor preload and ...guide fluid replacement during liver surgery. The aim of the study is to determine if SVV correlates with CVP values and may replace CVP measurement.
From January 2021 to February 2022 thirty patients undergoing 32 liver resections were included in the study. Repeated paired data of CVP and SVV were determined every 10 minutes throughout liver resection. The Correlation between CVP and SVV values was calculated. Analysis was then stratified by surgical approach, hilar clamping tempus, operative timing and PEEP values.
A total number of 519 paired SSV/CVP values were recorded. Only a very weak correlation between SSV and CVP was detected (Pearson coefficient -0.122/ p=0.005). The results were unaltered after the stratified analysis by surgical approach, presence of hilar clamping, operative timing and PEEP use, revealing no correlation between SSV and CVP values.
The CVP /SVV values do not show a relevant correlation during liver surgery. CVP measurement is still of value and should not be replaced by SVV monitoring to conduct a safe hepatectomy.
Since morbidity of pancreaticoduodenectomy (PD) has been improved, concerns about late complications have raised. We present a review of long-term biliary complications after PD attended at our ...institution. The data of 86 patients operated on from January 2001 to May 2014 were examined and incidence of late biliary complications was recorded. The preoperative features of the patients, timing of symptoms appearance, results of diagnostic imaging test, and the management strategies were analyzed. Late biliary complications occurred in 14 patients (16.3%). The median time to diagnosis was 9.50 months. The preoperative peak bilirubin level, need for pre-operative drainage and intraoperative blood loss were not significantly different for patients with long-term biliary events. Eight patients (57.14%) developed true biliary strictures. Three of them (37.5%) had experienced a postoperative biliary leak (P < 0.0005) and resulted in benign strictures. The remaining five patients revealed tumor recurrence. Six patients had no biliary obstruction and cholangitis could only be explained through afferent-limb stasis. Late biliary strictures appear predominantly in the first postoperative year and develop more likely if a bile leak occurred in the postoperative period. However, biliary strictures are not always responsible for late biliary symptoms and afferent limb stasis may also be included in the differential diagnosis.
Postoperative morbidity after bile duct exploration with T-tube insertion is mainly related to tube removal and incomplete sinus-tract formation leading to serious complications. Laparoscopic surgery ...reduces abdominal adhesion formation and diminishes tissue trauma and inflammatory response to surgery, which is essential for sinus-tract formation. This study evaluates if complication rate of T-tube removal is increased after laparoscopic bile duct exploration.
Between January 2004 and January 2011, 94 patients underwent a T-tube insertion following choledocolithotomy (44 and 50 patients in the laparoscopic and open surgery group, respectively). Epidemiological data, preoperative characteristics, day of tube removal, and morbidity rates were analyzed.
Global T-tube removal-related biliary complication rate was 14.9% (18.2% in the laparoscopic group vs. 12% in the open surgery group). Although the day of T-tube removal was significantly delayed, there was a slight increased incidence of biliary peritonitis requiring reintervention in the laparoscopic surgery group (6.9% vs. 2%).
We reveal that T-tube removal is associated with significant morbidity. There was no statistical difference between the laparoscopic and the open surgery group, although global biliary complications after tube removal were slightly increased and bile spillage was worse delimited when T-tube was inserted laparoscopically. Laparoscopic approach may diminish inflammatory response and adherence development and impair, and therefore sinus-tract formation.
There are three choledochotomy closure methods available following laparoscopic common bile duct exploration: T-tube insertion, antegrade stenting, and primary choledochorrhaphy. We reviewed the ...experience of 12 years at our center searching for the optimal closure technique.
We analyzed retrospectively 146 patients that underwent one of the three closure methods from February 2004 to March 2016. Hospital stay, need for readmission, incidence of early and long-term complications, and biliary leakage development and their clinical impact were determined for each technique.
Hospital stay was more prolonged, and need for readmission was higher in the T-tube group. Nine patients of the T-tube group (17.3%), 5 patients (8.6%) of the antegrade stenting group, and 1 patient of the primary suture group (2.8%) developed Dindo-Clavien ≥3 complications (P = .076). The incidence of biliary leakage was 3.8%, 8.6%, and 16.7% for the T-tube group, antegrade stenting group, and primary suture group, respectively. There was no grade C biliary fistula in the primary suture group, and all grade B leaks in these patients were only due to prolonged duration. The T-tube removal caused adverse events in 21.1% of the patients, and complications directly related with stents occurred in 9.6%.
Antegrade stents or T-tube insertion do not provide any added value for choledochotomy closure but are charged with specific morbidity. On the contrary, despite biliary leaks being more frequent after primary suture, they are of little clinical consequence and may be managed on an outpatient basis.
most acute pancreatitis cases are of biliary origin and cholecystectomy is recommended to prevent recurrence. However, some patients will never be referred for surgery. In this study, the long-term ...follow-up of this group of patients was reviewed.
all new cases of biliary pancreatitis from January 2015 to December 2017 that did not undergo cholecystectomy were analyzed. Epidemiologic data and Charlson's comorbidity index (CCI) were recorded. Recurrent episodes of pancreatitis or biliary events and mortality during the follow-up period were recorded.
a total of 104 patients were included in the study (30.4 % of all biliary pancreatitis cases) and the median age was 82 years (range, 27-96). Average CCI was 5 (range, 0-18) and the median follow-up period was 37 months (range, 1-70). A total of 41 patients (39.4 %) had gallstone-related complications. Twenty-three patients (22,1 %) had recurrent pancreatitis and 34 (32,7 %) developed biliary events. Twenty-five patients died during follow-up (24 %) but only in 6 (5,8 %) was death due to gallstone-related complications. Non-related mortality was 15.5 % in patients who refused surgery and 25 % in multiple-comorbidity patients.
patients who did not undergo cholecystectomy were at high risk for biliary events and pancreatitis recurrence. Conservative treatment and surgical abstention should be individualized and reserved for patients with multiple comorbidities with a short life expectancy.
INTRODUCTIONCholedocholithiasis may be treated following an endoscopic approach or by laparoscopic common bile duct exploration (LCBDE). Stone recurrence following endoscopic management has been ...extensively investigated. We analyze the risk factors associated with stone recurrence following LCBDE. METHODSPatients who underwent LCBDE from February 2004 to July 2016 were examined in an univariate and multivariate analysis to assess the association of stone recurrence with the following variables: gender; age; hepatopathy; dyslipidemia, obesity or diabetes mellitus; previous abdominal surgery; presence of cholecystitis, cholangitis or pancreatitis; preoperative liver function tests, number of retrieved stones; method of common bile duct clearance and closure; presence of impacted or intrahepatic stones; conversion to open surgery and postoperative morbidity. RESULTSA total of 156 patients were included. Recurrence rate for choledocholithiasis was 14.1% with a mean time to recurrence of 38.18 month. Age was the only independent risk factor for stone recurrence at univariate and multivariate analysis. No patient aged under 55 years developed new common bile duct stones, and 86.4% of the recurrences occurred in patients aged above 65. CONCLUSIONSAge is the only independent risk factor associated to choledocholithiasis recurrence following LCBDE. Different mechanism in common bile duct stone development may be present for younger and older patients.
An exacerbated inflammatory response to post-operative infection could favor an environment in which residual viable tumor cells present in the surgical bed, bloodstream, or occult micrometastases ...can survive and progress to produce local or distant recurrence. In this regard, a surgical site infection (SSI) could be an important risk factor for disease progression. This study aimed to investigate the impact of SSI on long-term survival and recurrence of colorectal cancer.
Patients who underwent curative-intent resection for colorectal carcinoma between 2011 and 2013 were retrospectively analyzed. Overall and disease-free survival (DFS) and local recurrence rate for patients with and without SSI were analyzed.
One hundred and thirty-eight patients were included in the study. Fifty-one (37%) patients showed SSI but revealed no differences in recurrence rate and overall survival compared with non-infected patients. However, the stratified analysis revealed that patients with an intra-abdominal abscess or an organ-space-infection showed a higher recurrence rate and a decreased 5-year overall and DFS.
SSI may have an influence on the oncological prognosis and, therefore, could be considered a recurrence factor. Further multi-institutional studies are necessary to conclude a causal association.
Although surgery is frequently not the first treatment option in elderly patients diagnosed with common bile duct stones (CBDS) because of the fear of high morbidity and mortality rates, there are ...few data about the safety and efficacy of laparoscopic common bile duct exploration (LCBDE) in the elderly.
From February 2004 to January 2012, 94 patients underwent LCBDE at our center. Data about sex, age, comorbidity, American Society of Anesthesiologists (ASA) score, conversion to open surgery and bile duct clearance rate, postoperative complications, need for reoperation, and mortality were analyzed comparing patients of age 70 or older (group A, n=38) with patients aged under 70 (group B, n=56).
Elderly patients had significantly more preoperative risk factors. Stone extraction was equally successful in both groups (89.5% in group A vs. 96.4% in group B, P=0.176). Six patients developed medical complications (7.9% in group A vs. 5.4% in group B, P=0.621). Surgical morbidity was equivalent for both groups (13.2% in group A vs. 10.7% in group B, P=0.718). Four patients in each group experienced some grade of bile leakage. Three patients were reoperated (1 patient in group A because of a biliary peritonitis and 2 in group B after an intra-abdominal hemorrhage). There were no mortality cases directly related to surgery.
This study reveals that LCBDE is safe in the elderly patients and results are not different from those described in the general population. Patients with choledocholithiasis should be offered to undergo an LCBDE irrespective of their age at diagnosis.
INTRODUCTIONIn spite of the acquired experience with laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis management, there is still a risk of biliary leakage of 5% to 15% ...following choledochotomy closure. We evaluate the usefulness of fibrin-collagen sealants to reduce the incidence of biliary fistula after laparoscopic choledochorrhaphy. METHODSWe report a retrospective analysis of 96 patients undergoing LCBDE from March 2009 to March 2017, whose closure of the bile duct was completed by antegrade stenting and choledochorraphy or by performing a primary suture. The study population was divided into two groups according to whether they received a collagen-fibrin sealant covering the choledochorrhaphy or not, analyzing the incidence of postoperative biliary fistula in each group. RESULTSThirty-nine patients (41%) received a fibrin-collagen sponge while the bile duct closure was not covered in the remaining 57 patients (59%). The incidence of biliary fistula was 7.7% (3 patients) in the first group and 14% (8 patients) in the second group (P=.338). In patients who underwent primary choledochorraphy, the fibrin-collagen sealant reduced the incidence of biliary leakage significantly (4.5% vs. 33%, P=.020), which was a protective factor with an odds ratio of 10.5. CONCLUSIONFibrin-collagen sealants may decrease the incidence of biliary fistula in patients who have undergone primary bile duct closure following LCBDE.
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