Is Laparoscopic Cholecystectomy Safe in Octogenarians?

PURPOSE: Biliary tract disease is one of the most common causes of acute abdominal pain in elderly patients, but there is still some debate over treatment. The aim of this study is to determine the safety and surgical outcomes of laparoscopic cholecystectomy (LC) for benign gallbladder disease in octogenarian patients. METHODS: We selected 42 patients of 80 years or older who underwent LC or open-converted cholecystectomy (OC) from February 1992 to November 2006. We evaluated clinicopathological features, treatment modalities, and surgical outcomes retrospectively. RESULTS: The patients included 17 males and 25 females. The mean age of the patients was 83.3 and 83.7, respectively. Right upper quadrant pain was the most common symptom, present in 85.7% of the patients. Gallstones were present in 85.7%. ASA class II and III comprised 92.9% of the patients. Comorbidities included hypertension, cardiac disease, pulmonary disease, and diabetes mellitus. Preoperatively biliary drainage was performed in 12 cases (endoscopic drainage in 8, percutaneous drainage in 4 cases). Preoperative cholecystostomy was performed in 5 cases. Emergency operations were more frequent than elective surgery (25 vs. 17). Mean hospital stay of LC patients was 5 days, whereas that of OC patients was 13 days. Open conversion rate was 16.7%. No surgical mortality was present and postoperative morbidity included acute myocardial infarction in one patient and wound infection in one patient. CONCLUSION: LC in octogenarian patients was safe. However, since the incidence of comorbidities is high in these patients, great care should be taken to evaluate and manage the comorbidities before surgery.

Bioartificial Liver System using a Fluidized-Bed Bioreactor

PURPOSE: Acute fulminant hepatic failure (FHF) is associated with high mortality. Recent studies have shown that a liver support system based on viable hepatocytes can prolong life in animal models of FHF and also in some FHF patients who were successfully bridged to liver transplantation. To be applied in humans, the bioartificial liver (BAL) system should have sufficient liver cell mass to provide adequate bioactive support. The most widely investigated bioreactor at present is based on hollow fiber membrane. However, it is difficult to build a scaledup module of this model. We devised a fluidized-bed bioreactor that is packed with isolated porcine hepatocytes, and these hepatcytes are immobilized in Ca-alginate hydrogel. METHODS: We isolated fresh porcine hepatocytes using a 2-step collagenase perfusion method, and they were suspended in 1.5% alginate solution. Through a drop-generator, this mixture was gelled in 135mM Cacl2. The resulting spherical beads (mean size: 500 micrometer) were embedded in a module. An average of 2x10(10) hepatocytes were present in the module. The efficacy of our design was tested in pigs that had undergone total hepatic devascularization and portocaval shunt. RESULTS: The BAL-treated group showed a significantly lower ammonium build-up rate compared to the control group (598.6+/-344.2 microgram/dl vs 1937.6+/-744.1 microgram/dl, respectively, at 8 hours after connecting to BAL). In addition, the intracranial pressure was well controlled in the BAL-treated group, whereas the control group showed a progressive increase of the intracranial pressure (16.9+/-1mmH2O vs 21.9+/-2.6mmH2O, respectively, at 8 hours after connecting to BAL). CONCLUSION: Our bioartificial liver system is a fluidized-bed bioreactor packed with immobilized porcine hepatocytes, and it seems to be a more effective scaled-up module.

Gallbladder Carcinomas found after a Laparoscopic Cholecystectomy

PURPOSE: An laparoscopic cholecystectomy (LC) is being increasingly performed for benign gallbladder disease. Accordingly, gallbladder carcinomas have been increasingly reported in patients after undergoing an LC. This study aims to reveal the clinicopathological features and prognosis of gallbladder carcinomas found after an LC. METHODS: Between April 1994 and March 2007, 2714 patients underwent an LC and 1.5% of the patients were diagnosed histologically as having a gallbladder carcinoma. We retrospectively evaluated the clinicopathological features and long-term survival of the patients. RESULTS: There were 19 male patients and 21 female patients, with a mean age of 60.7 degrees+/-12.3 years. The indications for LC included acute calculous cholecystitis, chronic calculous cholecystitis and polypoid lesions of the gallbladder (PLGs). An LC only was performed in 26 patients (13 pT1a, 7 pT1b and 6 pT2 cases) while additional surgery including gallbladder bed resection and lymph node dissection was performed in 14 patients (2 pT1a, 2 pT1b, 8 pT2 and 2 pT3 cases). The patients with a carcinoma associated with PLGs were younger, had more incidence of pT1a and had well differentiated carcinomas and a better 5-year survival rate as compared to patients with a non-polypoid carcinoma. Whereas no recurrences or deaths occurred for the 24 pT1 patients, two of the 14 pT2 patients had a recurrence. Both pT3 patients had a recurrence despite additional surgery. In patients with pT2 or more, additional surgery did not improve survival (p = 0.82). CONCLUSION: The polypoid morphology of gallbladder carcinoma, but not additional surgery, favorably affects survival of gallbladder carcinoma patients following an LC. However, a further multi-institutional study may be needed to determine the benefit of additional surgery.

A Comparison of the Clinicopathologic and Prognostic Differences in Patients Who Underwent Hepatic Resection with Hepatitis B- versus Hepatitis C-related Hepatocellular Carcinoma / 한국간담췌외과학회지

BACKGROUND/AIMS: The surgical outcomes for patients with HCC according to different hepatitis viral status have been inconsistently reported. This study evaluated the clinico-pathological and prognostic differences in patients with HBV- and HCV-related HCC. METHODS: Two hundred and eleven patients with HCC who underwent curative hepatic resection were categorized into three groups according to viral status: Group I (Hbs Ag (+) HCV Ab (-), n=116); Group II (Hbs Ag (-) HCV Ab (+), n=74); Group III (Hbs Ag (-) HCV Ab (-), n=17). The clinical manifestations, pathologic features, and treatment outcomes were compared. RESULTS: The average age at onset of HCV-related HCC is older than that of HBV-related HCC. Most HCV-related HCC is associated with liver cirrhosis as reflected by lower albumin level, platelet count, higher ICG R15 value, ALT levels. and frequency of minor resection (P<0.05). The incidence of portal vein invasion or intrahepatic metastasis did not differ among groups. In addition, HCV Ab (+) group had significantly lower disease free survival rates (P<0.05). CONCLUSION: This study suggests that the patients with HCV- related HCC have poorer liver function with more frequent recurrence.