Routine laparoscopic ultrasound can significantly reduce the need for selective intraoperative cholangiography during cholecystectomy.

BACKGROUND: The use of intraoperative cholangiography (IOC), routinely rather than selectively, during laparoscopic cholecystectomy (LC) is controversial. Recent findings have shown laparoscopic ultrasound (LUS) to be safe, quick, and effective not only for screening of the bile duct for stones, but also for evaluating the biliary anatomy. This study aimed to evaluate, on the basis of the LC outcome and the cost of LUS and IOC, whether and how much the routine use of LUS would be able to reduce the need for IOC. METHODS: During LC, LUS was used routinely to screen the bile duct for stones and to evaluate the biliary anatomy, whereas IOC was used selectively only when LUS was unsatisfactory or unsuccessful. RESULTS: For 193 (96.5%) of 200 patients, LUS was completed successfully, whereas IOC was needed for 7 patients (3.5%). Bile duct stones were identified in 20 patients (10%). For the detection of bile duct stones, LUS yielded 19 true-positive, 175 true-negative, 0 false-positive, and 1 false-negative results. It had a sensitivity of 95%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 99.4%. The postoperative complications included bile leaks from the liver bed in two patients and a retained bile duct stone in one patient. If IOC had been used selectively in a traditional manner on the basis of preoperative risk factors, IOC would have been needed for 77 patients (38.5%). The total cost of LUS plus IOC for the current 200 patients was 26,256 dollars. The total estimated cost of selective IOC, if it had been performed for the 77 patients, would have been 31,416 dollars. CONCLUSIONS: Routine LUS accurately diagnosed bile duct stones and significantly reduced the need for selective IOC from a potential 38.5% to an actual 3.5% without adversely affecting the outcome of the LC or increasing the overall cost. The routine use of LUS during LC is accurate and cost effective.

Safety and efficacy of radiofrequency thermal ablation in advanced liver tumors.

HYPOTHESIS: Radiofrequency thermal ablation (RFA) can be performed safely and effectively to control local disease in patients with advanced, unresectable liver tumors. DESIGN, SETTING, AND PATIENTS: Prospective study of 76 patients with unresectable liver tumors who underwent RFA at a private tertiary referral hospital. INTERVENTIONS: Ninety-nine RFA operations were performed to ablate 328 tumors. MAIN OUTCOME MEASURES: Complications and local recurrence. RESULTS: There was 1 death (1%), major complications occurred in 7 operations (7%), and minor complications occurred in 10 operations (10%). Local recurrence was identified in 30 tumors (9%) at a mean follow-up of 15 months. Size (P<.001), vascular invasion (P<.001), and total volume ablated (P<.001) were associated with recurrence but the number of tumors was not (P =.39). CONCLUSION: Radiofrequency thermal ablation provides local control of advanced liver tumors with low recurrence and acceptable morbidity.

Ultrasound-guided radiofrequency thermal ablation of liver tumors: percutaneous, laparoscopic, and open surgical approaches.

Only 10% to 20% of patients with primary and colorectal metastatic liver tumors are candidates for curative surgical resection. Even after curative treatment, tumors recur commonly in the liver. As a less invasive therapy, radiofrequency thermal ablation (RFA) of primary, metastatic, and recurrent liver tumors was performed under percutaneous, laparoscopic, or open intraoperative ultrasound guidance. The safety and local control efficacy of RFA were investigated. RFA was performed mostly in patients with unresectable hepatomas or metastatic liver tumors. Patients with large tumors, major vessel or bile duct invasion, limited extrahepatic metastases, or liver dysfunction were not excluded. An RFA system with a 15-gauge electrode-cannula with four-pronged retractable needles was used. All patients were followed for more than 8 months to assess morbidity and mortality, and to determine tumor recurrence. Sixty RFA operations were performed in 46 patients: 11 patients underwent repeat RFA once or twice. A total of 204 tumors were treated: 70 hepatomas and 134 metastatic tumors. Tumor size ranged from 5 mm to 180 mm (mean 36 mm). RFA was performed in 29 operations for 81 tumors percutaneously, in seven operations for 14 tumors laparoscopically, and in 24 operations for 109 tumors by open surgery. Combined colorectal resection was carried out in five operations and combined hepatic resection was carried out in three operations. There was one death (1.7%) from liver failure, and there were three major complications (5%): one case of bile leakage and two biliary strictures due to thermal injury. There were no intra-abdominal infectious or bleeding complications. The length of hospital stay ranged from 0 to 2, 1 to 3, and 4 to 7 days for percutaneous, laparoscopic, and open surgical RFA, respectively. During a mean follow-up period of 20.5 months, local tumor recurrence at the RFA site was diagnosed in 18 (8.8%) of 204 tumors. The risk factors for local recurrence included large tumor size and major vessel invasion: recurrence rates for tumors less than 4 cm, 4 to 10 cm, and greater than 10 cm, and for those with vessel invasion were 3.3%, 14.7%, 50%, and 47.8%, respectively. Ten of 18 tumors recurring locally were retreated by RFA, and eight of them showed no further recurrence. Ultrasound-guided RFA is a relatively safe, well-tolerated, and versatile treatment option that offers excellent local control of primary and metastatic liver tumors. The appropriate use of percutaneous, laparoscopic, and open surgical RFA is beneficial in the management of patients with liver tumors in a variety of situations.

Simple laparoscopic ultrasound technique for prevention of bile duct injuries.

BACKGROUND: Bile duct injuries are serious complications of laparoscopic cholecystectomy. Laparoscopic ultrasonography (LUS) has been utilized over the last several years to screen for bile duct calculi and to delineate biliary anatomy. We have found a simple LUS scanning technique that can be useful for preventing bile duct injuries. METHOD: After initial scanning for screening, laparoscopic dissection is continued, isolating the cystic duct. If necessary, scanning can be performed to assure the location of the cystic duct before clipping. After clips are applied to the cystic duct, prior to its incision or transection, LUS is repeated to examine the cystic and bile ducts. RESULTS: This postclipping study can confirm that the clips are applied to the cystic duct and that the hepatic and common bile ducts are intact without occlusion. CONCLUSION: This additional LUS scanning maneuver is simple and quick and may help prevent bile duct injuries.

Laparoscopic ultrasonography versus operative cholangiography during laparoscopic cholecystectomy: review of the literature and a comparison with open intraoperative ultrasonography.

BACKGROUND: Laparoscopic ultrasonography (LUS) has been used increasingly over the last several years as a new imaging modality. To define the role of LUS during laparoscopic cholecystectomy, we evaluated LUS by prospectively comparing it with operative cholangiography (OC), by reviewing the literature on LUS, and by retrospectively comparing it with intraoperative ultrasonography performed during open cholecystectomy. STUDY DESIGN: LUS and OC were compared prospectively in 100 consecutive patients during laparoscopic cholecystectomy. The success rate of examination, the time required, the accuracy in diagnosing bile duct calculi, and the delineation of biliary anatomy were evaluated. RESULTS: The success rate of examination was 95% for LUS and 92% for OC. The main reason for unsatisfactory LUS was incomplete visualization of the distal common bile duct. The time required was 8.2 minutes for LUS and 15.9 minutes for OC (p<0.0001). Nine patients had bile duct calculi. LUS had one false-negative result and OC had two false-positives and one false-negative. The accuracies of LUS and OC were comparable except for a slightly better positive predictive value of LUS (100% versus 77.8%; p>0.1). In a literature review, 12 recent prospective studies comparing LUS and OC and three studies on open intraoperative ultrasonography were reviewed. Twelve studies of LUS with a total of 2,059 patients demonstrated results similar to the present study. The success rate was 88% to 100% for both tests. The time for LUS was approximately 7 minutes, about half of the time needed for OC. Overall, LUS was associated with fewer false-positive results than OC; the positive predictive value and specificity of LUS were better, while the sensitivity and negative predictive value of LUS and OC were comparable. OC detected ductal variations or anomalies more distinctly than LUS. Compared with open intraoperative ultrasonography, LUS had a slightly lower success rate and required a slightly longer time because it was technically more demanding, but the two procedures had a similar accuracy for diagnosing bile duct calculi. CONCLUSIONS: Because of their different advantages and disadvantages, LUS and OC can be used in a complementary manner. There is a learning curve for LUS because of its technical difficulty. Once learned, however, LUS can be used as the primary screening procedure for bile duct calculi because of its safety, speed, and cost-effectiveness. OC can be used selectively, particularly when ductal anatomic variations or anomalies or bile duct injuries are suspected.

Laparoscopic inguinal herniorrhaphy: the new gold standard of hernia repair?

The surgical treatment of the common inguinal hernia has been one of the most analyzed and debated topics in medicine. Recently, with the success of laparoscopic cholecystectomy, interest in minimally invasive surgical techniques has led to it's application for inguinal hernia repair. Current laparoscopic herniorrhaphies are based on the principles of conventional open preperitoneal repairs and are classified into two types: 1) transabdominal preperitoneal repair (TAPP) and 2) totally extraperitoneal repair (TEP). Common advantages to both techniques include a decrease in postoperative pain, earlier return to normal activity, and improved cosmesis. Both laparoscopic techniques have the disadvantage of requiring general or regional anesthesia and increased procedural costs. Lastly, there is a concern that laparoscopic hernia repair has not been around long enough to know the risk of late recurrences. Laparoscopic herniorrhaphy, however, is a viable alternative to standard open inguinal hernia repair.

Alterations in carrier-mediated glutamine transport after a model of canine jejunal autotransplantation.

The effects of small bowel transplantation (SBTx) on absorptive function are unknown. Preliminary experiments showed a decrease in absorption of glutamine. Our aim was to determine mechanisms of decreased ileal transport of glutamine utilizing a model of intestinal autotransplantation. Seven dogs were studied before and after a model of jejunoileal autotransplantation. In vivo absorption experiments were performed before and two and eight weeks postoperatively with an electrolyte solution containing glutamine (20 mM). In vitro glutamine transport was studied using brush-border membrane vesicles (BBMV) prepared from ileal mucosa obtained from six other dogs and compared to a controls. In vivo net absorptive flux of glutamine decreased at two weeks but returned toward baseline by eight weeks (P = 0.06). Transport of glutamine into BBMVs was decreased at two weeks and remained decreased at eight weeks. KmaxNa+, a measure of carrier affinity was unchanged but VmaxNa+, a function of the number of transporter was decreased at two and eight weeks. Glucose transport was unchanged. It is concluded that jejunoileal autotransplantation decreases ileal absorption of glutamine by a decrease in carrier-mediated transport of glutamine.

Long-term outcome of cholecystoenterostomy as a definitive biliary drainage procedure for benign disease.

Our aim was to examine the long-term success of cholecystoenterostomy performed for the relief of benign extrahepatic biliary obstruction. Concern about the ability of cholecystoenterostomy to provide reliable long-term biliary decompression has led many to abandon its use for benign biliary obstruction. Thirty-four patients who underwent cholecystoenterostomy for benign biliary obstruction over a 17-year period were reviewed. Patients were followed until cholecystoenterostomy failure, death, or to date. Failure was defined as recurrent biliary obstruction or cholangitis requiring therapeutic intervention. Mean follow-up was 8.0 years. Early postoperative morbidity occurred in 11 patients (32%), but only one early complication (cholangitis) was related directly to the cholecystoenteric anastomosis. Five patients (15%) experienced late biliary tract complications related directly to the cholecystoenterostomy including recurrent biliary stones with biliary obstruction in four and anastomotic stricture in one. All required reoperation and conversion to choledochoenterostomy at a mean of 112 months. Cholecystoenterostomy can provide reasonably effective long-term biliary decompression in selected patients with benign biliary obstruction.

Intestinal transplantation: effects on ileal enteric absorptive physiology.

BACKGROUND: The effects of small intestine transplantation on enteric physiology are poorly understood. After orthotopic jejunoileal autotransplantation, dogs develop a severe watery diarrhea and lose up to 15% of their body weight. The cause of these changes has not been explained. Our aim was to determine the influence of jejunoileal autotransplantation on ileal absorption of water, electrolytes, and bile salts and the effects of proabsorptive and prosecretory agents on ileal transport. METHODS: Seven dogs were studied before and at 2 and 8 weeks after in situ jejunoileal neural and lymphatic isolation (a model of small intestine autotransplantation). With a triple-lumen perfusion technique, net ileal fluxes of water, electrolytes, and bile salts were measured before and at 2 and 8 weeks after this model of jejunoileal autotransplantation. In addition, the effects of an intravenous infusion of vasoactive intestinal polypeptide (a prosecretory agent) and norepinephrine (a proabsorptive agent) on net transport were evaluated. RESULTS: Dogs developed a profuse diarrhea after this model of autotransplantation. Ileal absorption of water and electrolytes decreased immediately (measured during operation), remained decreased for 2 weeks, and returned toward baseline by 8 weeks. A similar decrease in net flux of bile salts was shown at 2 weeks after transplantation and returned toward baseline by 8 weeks. The prosecretory response of vasoactive intestinal polypeptide on ileal fluxes of water and electrolytes was unchanged, whereas the proabsorptive response to norepinephrine increased after this model of autotransplantation. CONCLUSIONS: Jejunoileal autotransplantation decreases ileal absorption of water, electrolytes, and bile salts. The profuse watery diarrhea observed in dogs after small intestine autotransplantation may be a secretory and/or a bile salt-induced diarrhea related to the effects of jejunoileal denervation.

Pancreatic cancer.

Pancreatic cancer is a devastating disease for the patient and presents challenging diagnostic and management problems for the physician. A range of serologic and radiologic studies are available for evaluation and staging of this disease. However, invasive studies, including laparotomy, are often necessary to establish the diagnosis and resectability. Despite advances in diagnostic technology that have shortened the interval between onset of symptoms and definitive treatment, no appreciable impact on survival has been demonstrated conclusively. Operative resection offers the only hope for cure, but fewer than 15 percent of patients have resectable disease at the time of diagnosis. Palliative therapy, whether operative or nonoperative, can be performed with low morbidity and provides significant relief of symptoms. Combined-modality treatment with chemotherapy and radiation therapy prolongs survival following curative resection.

Portal hypertension, variceal bleeding, and high output cardiac failure secondary to an intrahepatic arterioportal fistula.

Intrahepatic arterioportal fistulas (APF) are uncommon complications following hepatic trauma. Large fistulas can result in portal hypertension and cardiovascular compromise. A 46-year-old patient is described who presented with portal hypertension, variceal bleeding, and high output cardiac failure due to a large intrahepatic APF. Surgical closure of the APF by hepatic resection successfully resolved the portal hypertension, prevented further variceal hemorrhage, and restored normal cardiovascular function.