Gastroenterology surgical unit experience in hepatic resection for liver tumors

Hepato-cellular carcinoma [HCC] is the fourth most common malignant tumor in the world and is responsible for an estimated one million deaths annually. This study was carried out on 35 patients with hepatic tumors. The aim was to study the impact of the underlying liver disease, tumor pathology, and extent of resection on the outcome of hepatic resection for liver tumors. All patients were subjected to complete history taking, thorough clinical examination, laboratory and imaging studies followed by hepatic resection based on the preoperative data. Follow up of patients was done to determine the perioperative complications, disease-free period, overall survival, tumor recurrence and tumor-related deaths in cases of malignant liver tumors. The indications for hepatic resection were haemangioma [in 2 patients], HCC [in 27 patients] and secondary malignancy [in 6 patients]. Hepatic resections were hemi-hepatectomy in 16, extended hepatectomy in 4 and left lateral lobectomy in 7. The remaining 8 cases included resections of one to three segments or consisted of non-anatomical wedge resections. 23 patients had no perioperative complications. Minor morbidity occurred in 8 patients and major morbidity in 4 patients. There were 2 perioperative deaths. The median survival in patients who underwent hepatic resection for HCC was 30.6 months [15.07-46.17] and the survival rates at 1, 3 and 5 years were 83.3, 63.6 and 34.1% respectively. There is now ample evidence that surgical resection, if possible, remains the best option for treating malignant liver tumors as it offers the best hope of cure in such patients

Single-step treatment of gall bladder and bile duct stones: a combined endoscopis-laparoscopic technique

The advent of endoscopic techniques changed surgery in many regards. In the management of cholelithiasis laparoscopic cholecystectomy [LC] is today the treatment of choice. This has created a dilemma in the management of choledocholithiasis. Today a number of options exist for patients with suspected common bile duct [CBD] stones, these includes: endoscopic sphincterotomy [ES] before LC stones, laparoscopic common bile duct exploration [LCBDE] by the trans-cystic approach or laparoscopic choledocotomy, open CBD exploration and post-operative ERCF. A major concern regarding both pre-and post-operative extraction of CBDS by the ERCP is the risk of development of pancreatitis, also more than 10% of the pre-operative ERCP are normal. More recently the alternative technique of combined LC with intraoperative ERCP [LC+IO-ERCP] and ES is emerging in an attempt to manage cholecysto-choledocholithiasis in a single-step procedure. The aim of this study was to assess the treatment of common bile duct stones [CBDS] in a one stage operation by Laparoscopic cholecystectomy [LC] and intraoperative endoscopic retrograde cholangio-pancreatography and endoscopic sphincterotomy [ES]. Fifteen patients with gall bladder stones and suspected, or confirmed CBDS were included in this study. They were treated by a single-step procedure combining LC and IO-ERCP. Laparoscopic intraoperative cholangiography [IOC] 'was carried out to confirm the presence of CBDS. A soft tipped guide wire was passed through the cystic duct and papilla into the duodenum. A papillotome was inserted endoscopically over the guide wire. Endoscopic sphincterotomy was performed and the stones were extracted with a retrieval balloon or a dormia basket. The surgical operating time, surgical success rate, postoperative complications, retained CBDS, and postoperative length of hospital stay were assessed. There were 10 females and 5 males. Their mean age was 45.07 +/- 11.3 years [ranged from 27 to 65years]. Nine patients had confirmed CBDS by preoperative ultrasound [US] and/or MRCP. Six patients were suspected for CBDS on clinical, laboratory and/or US basis. Conversion to open cholecystectomy occurred in one case due to severs adhesions at the Callot's triangle. The conversion rate in this study was accordingly 6.67%. IOC was performed in 14 patients and revealed the presence of CBDS in 12 patients. Cannulation of the papilla failed in one patient. IO-ERCF with ES was performed successfully in eleven patients and stones were extracted .endoscopically. Success rate was 91.67%. Cholecvstectomy was completed laparoscopicallv in 14 patients. The mean operative time was 119 +/- 14.4 mm [ranged from 100 to 150 mm]. Minor postoperative complications occured in 5 patients. No postoperative complications related to the procedure i.e. pancreatitis, bleeding, perforation were encountered. Patients regained their bowel motion on the next day and were discharged after a mean hospital stay of 2.55 +/- 0.89 days. None of the patients presented on the postoperative follow-up with symptoms, signs, laboratory or radiological evidence of retained CBDS. The mean duration of the postoperative follow-up was 9 +/- 4.07 months [ranged from 3 to 14 months]. The current study suggests that LC+JO-ER CF for the management of cholecysto-choledocholithiasis are a safe and effective technique with a low rate of post-ERCP pancreatitis. It offers another alternative for surgeons especially those who do not practice LCBDE to treat patients in a single setting. However, additional studies with larger patient populations are needed keeping in mind that the limiting characteristic is the proximity and availability of the endoscopic settings

Anterior abdominal wall fistula: a clinicopathological challenge

Aim of the work was to study the anterior abdominal wall fistulae connected to the gut from etiological, clinical and therapeutic aspects regarding their incidence, presentations, response to conservative or surgical treatment and final outcome. This study was carried out on 30 patients with external fistulae connecting the anterior abdominal wall and Originating from the intestine, biliary radicles and the pancreas. All patients were admitted to Department of Surgery, Main Alexandria University Hospital There were 18 males and 12 females, the age ranged from 12 to 65 years with a mean value of 48.15 +/- 3.24 years. Eleven patients [36.7%] were of high output fistulae, 4 patients [13.3%] were of moderate output fistulae and 15 patients [50%] were of low output fistulae. The complications were sepsis in 10 patients [33. 3%], fever in 10 patients [33.3%], electrolyte depletion and weight loss in 4 patients [13.3%] and skin complications in 22 patients [73.3%]. Abdominal ultrasound and CT scans were done in all cases and revealed internal collection in 7 patients [23.3%], fistulogram was done in 7 cases [23.3%] and endoscopic retrograde cholangiopancreatography [ERCP] in one case. The origin of fistulae was the small intestine In 10 patients [33.3%], the colon in l6 patients [53.3%], from biliary- enteric anastomosis in 3 patients [10%] and from pancreatic duct in one patient [3.3%]. The etiological factors were gut carcinoma in 8 patients [26.7%], hernia repair in 10 patients [33.3%], neglected appendicitis in 3 patients [10%], post Whipple operation in 3 patients [10%], post pancreatic necrosectomy in one case [3.3%], iatrogenic trauma to sigmoid colon during gynaecological surgery in 2 cases [6.7%], rupture sigmoid diverticulitis in 2 patients [6.7%] and one case [3.3%] following typhoid perforation. Spontaneous closure was achieved in 25 patients [83.3%] by conservative treatment which included total parenteral nutrition, enteral nutrition, somatostatin analogue and antibiotics. Surgical intervention was required in spatients [16.7%] in the form of resection of the fistula- bearing segment and anastomosis of the two healthy ends. Five fistulae [16.7%] closed between 2 and 4 weeks, 8 fistulae [26.67%] between 4 and 8 weeks, 9 fistulae [30%] between 6 and 8 weeks and 8 fistulae [26.7%] closed after more than 8 weeks. Only one patient [3.3%] died from sepsis and multiple organ failure. spontaneous closure is depending on a number of factors which include anatomical site, distal obstruction, presence of inter current disease and whether or not the fistulous track is simple or complex. Sepsis in the peritoneal cavity is the major cause of mortality. The use of octreotide is highly recommended as It definitely converts high output to low output fistulae. The enterocutaneous fistulae that fail to resolve within 4 to 6 weeks under conservative treatment require surgical intervention

Effect of cholecystectomy on sphincter of oddi motility in dogs

Gallbladder and sphincter of Oddi [SO] function are controlled by a balance of both hormonal and neuronal factors. Neuronal connections pass between the gallbladder and the SO via the cystic duct. It is therefore possible that cholecystectomy may alter SO motility. The present study investigated the effect of cholecystectomy on SO function in anesthetized dogs. Biliary manometry was performed in a group of anesthetized dogs undergoing cholecystectomy and compared with a control group of matched weight and sex. The cholecystectomized dogs compared with the controls showed a significant increase in mean common bile duct [CBD] pressure together with a significant decrease in mean basal SO pressure and SO phasic frequency. There was also a significant increase in the duration of phasic contractions in the cholecystectomy group compared with the control group. No significant change was noticed in the amplitude of phasic contractions and in the duodenal pressure when comparing both groups. These findings show that the gallbladder serves as a reservoir dampening increases in common duct pressure. The increase in intraductal tension following cholecystectomy in the canine model could overcome the choledochoduodenal sphincter resistance resulting in a drop in SO basal pressure associated with a decrease in the frequency of phasic contractions. It is also possible that ductal distension inhibits SO function by local reflexes. Removal of the gallbladder itself may eliminate a significant component of the neural circuity modulating biliary function. Such effects may ultimately lead to the SO manometric abnormalities, which have been described for SO dysfunction