Hepatobiliary and Pancreatic Surgery

INTRODUCTION
Operative biliary tract injury (TOVB) is a complication encountered mainly after cholecystectomy (CH), whether laparoscopic (CH-L) or open (CH-O), the incidence of TOVB is close to 2 for 103 CH.
MATERIALS AND METHODS
An analytic study carried out including all patients admitted and treated for TOVB at the hepatobiliary surgery and liver transplant department of EHU-1 November 1954, Oran, from January 2010 to May 2018. The objectives were: the study of the epidemiological characteristics of patients, the description of the factors favoring the occurrence of TOVB, the description of the anatomic lesions caused by TOVB, and the analysis of the postoperative morbidity and mortality of patients receiving biliary repair for TOVB.
RESULTS
During this period, 63 patients were admitted for TOVB, the sex ratio was 0.23 with an average age of 45.52 ± 14.02, TOVB was due to CH-L in 50.8%, CH-O in 39.7%, common bile duct lithiasis in 3.2%, liver hydatid cyst surgery in 3.2% and surgery for gallbladder cancer at 3.2%. More than 36% of our patients had undergone a repair before reference and
14.3% were urgently treated at admission for intraperitoneal biliary collection. The most important contributing factor found was acute cholecystitis (42.6%). The biliary lesions were classified according to the "Strasberg" classification, Type A accounted in (3.2%) of the cases,
B (0%), C (3,2%), D (1.6%), E1 (6.3%), E2 (36.3%), E3 (31.7%), E4 (14.3%), E5 (3.2%),
vascular injury was present in 8.8 % of patients. The median repair time was 06 months [0-171 months].
Fifty-seven patients had biliary repair, immediate postoperative mortality was 3.5%, postoperative complications were found in 31.6% of patients, median postoperative stay was 8 days. All of our patients had grade I and grade II repair results according to the Terblanche classification. The mean recoil in our patients was 36.12 ± 25.99 months.
CONCLUSION
The epidemiological characteristics of our patients are similar to those of the international publications, the results of our repairs are good and that would be explained by the respect of the recommendations by our team to ensure a good repair, the low rate of vascular lesion, and the retreat considered to be average. The long repair delay is due to the delay of transfer.

Jaundice is one of the most prevalent symptom in hepatobiliary disorders. The nature of jaundice may vary from hepatocellular to obstructive pattern. In a few cases, it may be haemolytic in nature. Identifying and ascertaining the type is pivotal for further investigation. A combination of haematological and radiological investigations will not only provide information on the severity and the impact of obstructive jaundice on various organ systems of the body but also help in determining the prognosis. Endoscopy can also provide diagnostic as well as a therapeutic benefit in obstructive jaundice. The pathophysiology, clinical evaluation and investigations in a case of obstructive jaundice is discussed in this paper.

Minimally invasive surgery (MIS) for gallbladder cancer (GBC) has been increasingly performed, including an increasing number of reports of radical cholecystectomy with hepatectomy, lymphadenectomy and excision of the extrahepatic biliary tree, but continues to be controversial. Here, we highlight these controversies and review the management of incidental GBC, and the MIS management of early and advanced nonincidental GBC. While initial results are promising, and are likely to improve, adequate long-term survival data are lacking and for now MIS for GBC should be limited to high-volume centers with adequate expertise in both MIS and hepatobiliary surgery.

INTRODUCCIÓN: Con respecto al abordaje de las lesiones hepáticas, estas han sido tratadas con mucho respeto por los cirujanos por las posibles perdida hemáticas que  representa, y la necesidad de grandes incisiones, de tal manera que lesiones como los quistes congénitos se han manejado con técnicas conservadoras como el destechamiento.  En las lesiones solidas  y el conocimiento de la anatomía hepática  y los instrumentos  de diseccion y sellamiento de vasos  dan seguridad en el control de las perdidas hemáticas.
Nosotros queremos destacar que el uso del ultrasonido de alta frecuencia y el bipolar  avanzado nos permiten  hacer una resección más radical y definitiva de las lesiones por video laparoscopia.

Tradicionalmente, los pacientes con fístulas externas crónicas pancreáticas han sido tratados con catéteres percutáneos durante largos períodos o en forma quirúrgica ya sea con resección o dre-naje abierto. Con el tratamiento quirúrgico resec-tivo, tanto la función exocrina como endocrina del tejido pancreático removido se sacrifican, con el riesgo adicional de efectuar una resección glandular sobre un territorio afectado por posibles cam-bios inflamatorios del páncreas. La embolización intraoperatoria del conducto pancreático para pre-vención o tratamiento de las fístulas pancreáticas ha sido descrita esporádicamente en la literatura europea y japonesa 6 desde la introducción de la embolización intraoperatoria en 1977 3, 4, 9. La embolización del conducto pancreático remanen-te durante la duodenopancreatectomía fue des-cripta por Gall 3 para reducir la frecuencia de fístu-la anastomótica pancreaticoyeyunal. En series su-cesivas, otros autores 9 demostraron que con esta conducta se preservaba la función endocrina y se lograba la atrofia de la función exocrina. El abor-daje percutáneo para embolizar un conducto pancreático a través de una fístula cutánea fue descripto por primera vez por Buecker en 1997 1. El objetivo de esta comunicación es presentar un caso en el cual se realizó la embolización del conducto pancreático con un monómero del n-butil 2 cianocrilato (hystoacryl ®) en un paciente con fís-tula pancreática crónica por síndrome de ducto desconectado posterior a cirugía abdominal.

Traumatic injuries affecting the pancreas have a statistic or percentage of between 2 and 12% of all injuries in the abdomen (1) in 2/3 of the cases caused by road accidents and a third of cases from wounds, the purpose of this work is to expose the experience gained in a retrospective review of the cases treated pancreatic traumatic pathology asking the guidance and direction to the disease treatment Materials and methods :In the first group were observed 12 patients cu n n n 4 8 blunt trauma and penetrating trauma, injuries associated n 2 cases related to the spleen, liver n 4, n 1 n 1 duodenum transverse colon. In the second group we were n is observed 6 cases of which was present in 4 cases n: n 1 a laceration of the body, n 1 case laceration of the tail, n 2 cases a complete resection of the pancreatic duct observed In cases where were present the traumas blunt: treatment in No 8 cases in which there was a bruise or tear without parenchymal involvement product was done by a simple drainage with a residual n 2 pancreatic fistulas treated with NPT and healed in n n 1 respectively in 30 days , and in 'more in 90 days. In the remaining 10 patients in n n 6 cases in which there was a laceration body and tail with complete detachment of the pancreatic duct associated with the irreparable injury of the spleen we proceeded to a distal pancreatic resection with splenectomy. Results :in the choice of treatment was carried out with a distinction and evaluation of the following criteria: A) evaluation of bruising or tearing, B) the absence or complete or incomplete rupture of the pancreatic duct. c) destruction of the pancreatic head and involvement of the common bile duct. the stage I and II (65-75%). The initial symptoms were absent due to the failure to irritation of the posterior peritoneum, whereby the abutment of the blunt trauma pancreatic at early stage was observe initially following the repairs of the associated lesions. (Colon.milza, bleeding. Instrumental examinations which the CT, MRI, have reduced diagnostic time and rendered obsolete the echo abdomen and video laparoscopy, surveys that collect indirect signs. the lesions of the duct ductal with loss of enzymes resulted in the castings, like cysts and relapsing pancreatitis. lL surgical treatment required further evaluation of parameters such as the site of the lesion, the age that has guided the conservative treatment in young people. Discussion. The instrumental exams (CT and MRI) have reduced the diagnostic and obsoleted times the echo abdomen and video laparoscopy, surveys that collect indirect signs (loss of the contour of the psoas muscle, bleeding retroperitoneal) of the lesion. It is still useful in cases of perforation of the duodenum associated with the X-ray with gastrografin.. The decision on the type of treatment remains bound to the experience, the technical skills, to 'clinical analysis of the case of the' surge capacity of choice related by the possibilities of success when the traumatic event is evolving. The success of the surgical treatment had need of complementary therapy. The NPT with the suspension of food transit, pharmacological reduction of pancreatic secretion, the contribution of parenteral nutrition with a low-fat diet has provided advantages in terms of reduction of complications. during surgery mortality ranges from a statistical check by 12.3% to 29.6% depending on whether it's a simple drainage or DPC. In the cases it considered the values were slightly higher from 16.2% to 32.5% Conclusions The incidence of pancreatic trauma is steadily increasing due to the presence of a massive motorization that involves an increase in the number of road accidents. the use of digitized diagnostic (CT and MRI) has reduced the time and diagnostic delays especially in blunt trauma, with the identification of the major pancreatic duct lesions. It remains to define the problem of identification of minute lesions due to pancreatic fistulas. The success of surgical treatment remains anchored to trauma treatment in the developmental phase, associated with the experience and technical and analytical ability to choose what and when to implement the most appropriate therapeutic treatment.

Background Liver metastases are a major cause of death
in patients with colorectal carcinoma. The only curative
option available at present is surgery. This review article
discusses the current state of evidence for the effectiveness
of liver resection for patients with liver metastases
from colorectal cancer.
Methods Medline, Embase, Current Contents and
Science Citation Index databases were used to search
English language articles published on the subject of liver
resection for colorectal metastases in the last 20 years.
Results Liver resection has a ®ve year survival of 16±49%
and 10 year survival of 17±33% with an operative
mortality rate of 0±9%. Two factors appear to be clearly
associated with poorer outcome ± involved resection
margins and the presence of extrahepatic disease (including
hilar and coeliac axis lymph nodes) at the time of
liver resection. None of the other factors related to the
patients, their primary tumour or the metastases themselves
have been conclusively shown to adversely effect
long-term survival.
Conclusions Liver resection is a feasible, safe and
effective procedure which carries an acceptable morbidity
and mortality and does have a major impact on the
survival of these patients. The decision on resectability of
colorectal metastases should be decided by the ability to
leave at least 2±3 segments of liver free from metastases
with uninvolved resection margins, together with the
general ®tness of the patient to undergo a major surgical
procedure

Background: Primary tumors of the abdominal wall are rare and usually metastasize from previous surgical procedures. Port-site metastasis (PSM) is a complication of laparoscopic surgery in patients with malignancy. Case Presentation: We report a case of a female patient with PSM from gallbladder adenocarcinoma definitively diagnosed 5 years after laparoscopic cholecystectomy (LC). Two years after she first noticed a mass, fine-needle aspiration cytology of the mass yielded a definitive diagnosis and repeat histology of a gallbladder specimen from LC showed chronic cholecystitis during the postoperative histopathological examination 5 years prior.

The congenital anomalies of the common bile duct (CBD) represent a real challenge for the surgeon, and not recognizing them may have two consequences: either generate incomplete or incorrect surgical solutions, or, even worse, lead to iatrogenic pathology. The association between the anomalies of the CBD and biliary lithiasis, biliary cancer or other hepatobiliopancreatic pathology may lead to a pre/perioperative diagnosis; frequently, the incertitude persists. We present 2 cases: one with an incomplete duplication of the CBD and the other with a false duplication. We wish to underline the sovereign value of cholangio-MRI with 3 D reconstructions in the diagnosis and description of the anatomy of the biliary ducts, superior, in some cases, to the intraoperative cholangiography or ERCP.

Este es un artículo de acceso abierto bajo una Licencia Creative Commons-BY-NC-ND https://creativecommons.org/licenses/by-nc-nd/4.0/deed.es 163 Manejo del drenaje percutáneo guiado por imágenes en un hospital de tercer nivel Management of imaging guided percutaneous drainage at a third level of care Colombian hospital Resumen Introducción. El drenaje percutáneo de las colecciones intraabdominales, guiado por ultrasonografía o por tomo-grafía computadorizada, ha sido el tratamiento de elección para los abscesos abdominales o pélvicos, entre otros. Objetivo. Describir la experiencia en el manejo percutáneo de colecciones abdominales en pacientes del Hospital Universitario San José de Popayán entre octubre de 2014 y abril de 2016. Materiales y métodos. Se trata de una serie de casos de 79 pacientes a quienes se les hizo manejo intervencionista de colecciones abdominales por medio de cirugía percutánea guiada por imágenes, los cuales cumplieron con los criterios de inclusión y exclusión. El análisis estadístico se hizo con el programa SPSS Statistics™. Resultados. Se realizaron 106 procedimientos percutáneos para drenar diferentes colecciones intraabdominales. La intervención más frecuente fue el drenaje de colecciones hepáticas (32,1 %), en su mayoría, abscesos hepáticos, seguida del drenaje de abscesos posquirúrgicos de cirugías abiertas o laparoscópicas. Conclusiones. Las técnicas intervencionistas en manos de un cirujano entrenado son un tratamiento eficaz y seguro para las diferentes colecciones intraabdominales. El procedimiento fue exitoso en el 99 % de los pacientes de la presente serie. Palabras clave: infecciones intraabdominales; absceso abdominal; drenaje; diagnóstico por imagen; ultrasono-grafía intervencional; tomografía computarizada.

The ideal technical pancreatic reconstruction following pancreaticoduodenectomy (PD) is still debated. The aim of the study was to assess the surgical outcomes of duct to mucosa pancreaticojejunostomy (PJ) (G1) and invagination PJ (G2) after PD. Consecutive patients treated by PD at our center were randomized into either group. The primary outcome measure was the rate of postoperative pancreatic fistula (POPF); secondary outcomes included; operative time, day to resume oral feeding, postoperative morbidity and mortality, exocrine and endocrine pancreatic functions. One hundred and seven patients treated by PD were randomized. The median operative time for reconstruction was significantly longer in G1 (34 vs. 30 min, P=0.002). POPF developed in 11/53 patients in G1 and 8/54 patients in G 2, P=0.46 (6 vs. 2 patients had a POPF type B or C, P=0.4). Steatorrhea after one year was 21/50 in G1 and 11/50 in G2, respectively (P=0.04). Serum albumin level after one year was 3.4 gm% in G1 and 3.6 gm in G2 (P=0.03). There was no statistically significant difference regarding the incidence of DM preoperatively and one year postoperatively. Invagination PJ is easier to perform than duct to mucosa especially in small pancreatic duct. The soft friable pancreatic tissue can be problematic for invagination PJ due to parenchymal laceration. Invagination PJ was not associated with a lower rate of POPF, but it was associated with decreased severity of POPF and incidence of postoperative steatorrhea. NCT02142517.

Background. Acceptance of dual kidney transplantation (DKT) has proven difficult, due to surgical complexity and concerns regarding long-term outcomes. We herein present a standard technique for ipsilateral DKT and compare outcomes to single-kidney transplant (SKT) recipients. Methods. A retrospective single-center comparison of DKT and SKT performed between February 2007 and July 2013. Results. Of 516 deceased donor kidney transplants, 29 were DKT and 487 were SKT. Mean follow-up was 43 ± 67 months. DKT recipients were older and more likely than SKT recipients to receive an extended criteria graft (p < 0.001). For DKT versus SKT, the rates of delayed graft function (10.3 versus 9.2%) and acute rejection (20.7 versus 22.4%) were equivalent (p = ns). A higher than expected urologic complication rate in the DKT cohort (14 versus 2%, p < 0.01) was reduced through modification of the ureteral anastomosis. Graft survival was equivalent between DKT and SKT groups (p = ns) with actua...

After the Institute of Medicine (IOM) report To Err Is Human highlighted the impact of medical errors, the Agency for Healthcare Research and Quality (AHRQ) developed Patient-Safety Indicators (PSI) to improve quality by identifying potential inpatient safety problems. PSI-15 was created to study accidental punctures and lacerations (APL), but PSI-15 may underestimate APLs in populations of patients. This study compares PSI-15 with a more inclusive approach using a novel composite of secondary diagnostic and procedural codes. We used Nationwide Inpatient Sample (NIS) data (2000-2012) from AHRQ's Healthcare Cost and Utilization Project (H-CUP). We analyzed PSI-15-positive and -negative cholecystectomies. Cross tabulations identified codes that were significantly more frequent among PSI-15-positive cases; these secondary diagnostic and procedural codes were selected as candidate members of a composite marker (CM) of APL. We chose cholecystectomy patients for study because this is ...

ORIGINAL SUMMARY The surgical injuries of the biliary tract keep being the most severe complication of the laparoscopic cholecystectomy and with higher incidence than in open cholecystectomy. The incidence of vascular asymptomatic injuries of the hepatic right artery associated with injuries of the biliary tract is not despicable and the reports in the literature are scarce. The aim of this work is to evaluate the frequency of asympto-matic injuries of the hepatic right artery associated with injuries of the biliary tract and its relation with different factors. Digital angiography was performed in 39 patients with a history of injuries in the biliary tract, finding injuries of the he-patic right artery in 33.3 % of the cases. We believe that it is important to know the vascular anatomy of the hepatic confluence in patients with distal injuries of the biliary tract or with precedents of complex surgeries due to injuries of the biliary tract, because it could determine the following treatment. KEY WORDS Biliary injury, arterial injury, digital arteriography, laparoscopy. RESUMEN Las lesiones quirúrgicas de la vía biliar (LQVB) siguen sien-do la complicación más grave de la colecistectomía laparos-cópica y con mayor incidencia que en la colecistectomía abierta. La incidencia de lesiones vasculares asintomáticas de la arteria hepática derecha (LAHD) asociada a LQVB no es despreciable y las referencias en la literatura son escasas. El objetivo de este trabajo es evaluar la frecuencia de LAHD asintomáticas asociadas a LQVB y su relación con diferen-tes factores. Se realizaron 39 arteriografías digitales en pa-cientes con antecedentes de LQVB encontrando LAHD en el 33.3%. Creemos que es importante conocer la anatomía vascular del hilio hepático en pacientes con LQVB altas o con anteceden-tes de cirugías complejas por LQVB, porque puede condi-cionar el tipo de tratamiento a seguir. PALABRAS CLAVE Lesión biliar, lesión vascular, arteriografía digital, laparoscopia.

Common bile duct stones (CBD) continue to pose the greatest challenge to the general surgeon. The morbidity associated with CBD stones is extremely high. Management of CBD calculi requires a systematic approach to keep the morbidity and mortality associated with this condition to a bare minimum. With the advent of advances in interventional endoscopy to manage CBD calculi, selecting the best approach is the biggest challenge. The article discusses the complexities underlying the pathophysiology and management of CBD calculi.

Background After the Institute of Medicine (IOM) report To Err Is Human highlighted the impact of medical errors, the Agency for Healthcare Research and Quality (AHRQ) developed Patient-Safety Indicators (PSI) to improve quality by identifying potential inpatient safety problems. PSI-15 was created to study accidental punctures and lacerations (APL), but PSI-15 may underestimate APLs in populations of patients. This study compares PSI-15 with a more inclusive approach using a novel composite of secondary diagnostic and procedural codes. Methods We used Nationwide Inpatient Sample (NIS) data (2000–2012) from AHRQ's Healthcare Cost and Utilization Project (H-CUP). We analyzed PSI-15-positive and-negative cholecystectomies. Cross tabulations identified codes that were significantly more frequent among PSI-15-positive cases; these secondary diagnostic and procedural codes were selected as candidate members of a composite marker (CM) of APL. We chose cholecystectomy patients for study because this is one of the most common general operations, and the large size of NIS allows for meaningful analysis of infrequent occurrences such as APL rates. Results CM identified 1.13 times more APLs than did PSI-15. Patients with CM-detected APLs were significantly older and had worse mortality, comorbidities, lengths of stay, and charges than those detected with PSI-15. Further comparison of these two approaches revealed that time-series analysis for both APL markers revealed parallel trends, with inflections in 2007, and lowest APL rates in July. Conclusions Although CM may yield more false positives, it appears more inclusive, identifying more clinically significant APLs, than PSI-15. Both measures presented similar trends over time, arguing against inflation in PSI-15 reporting. While arguably less specific, CM may increase sensitivity for detecting APL events during cholecystectomies. These results may inform the interpretation of other large population studies of APLs following abdominal operations.

Background. Acceptance of dual kidney transplantation (DKT) has proven difficult, due to surgical complexity and concerns regarding long-term outcomes. We herein present a standard technique for ipsilateral DKT and compare outcomes to single-kidney transplant (SKT) recipients. Methods. A retrospective single-center comparison of DKT and SKT performed between February 2007 and July 2013. Results. Of 516 deceased donor kidney transplants, 29 were DKT and 487 were SKT. Mean follow-up was 43 ± 67 months. DKT recipients were older and more likely than SKT recipients to receive an extended criteria graft (í µí± < 0.001). For DKT versus SKT, the rates of delayed graft function (10.3 versus 9.2%) and acute rejection (20.7 versus 22.4%) were equivalent (í µí± = ns). A higher than expected urologic complication rate in the DKT cohort (14 versus 2%, í µí± < 0.01) was reduced through modification of the ureteral anastomosis. Graft survival was equivalent between DKT and SKT groups (í µí± = ns) with actuarial 3-year DKT patient and graft survivals of 100% and 93%. At 3 years, the groups had similar renal function (í µí± = ns). Conclusions. By utilizing extended criteria donor organs as DKT, the donor pool was enlarged while providing excellent patient and graft survival. The DKT urologic complication rate was reduced by modification of the ureteral anastomosis.

Introduction. Pancreatic injury can manifest after major hepatectomy under vascular control. The main mechanism involved seems to be remote oxidative injury due to " spillage " of reactive oxygen species and cytokines from the liver. The aim of this study is to evaluate the role of desferrioxamine in the prevention of pancreatic injury following major hepatectomy. Methods. Twelve Landrace pigs were subjected to a combination of major hepatectomy (70–75%), using the Pringle maneuver for 150 minutes, after constructing a porta-caval side-to-side anastomosis. The duration of reperfusion was 24 hours. Animals were randomly divided into a control group (n = 6) and a desferrioxamine group (DFX, n = 6). DFX animals were treated with continuous IV infusion of desferrioxamine 100 mg/kg. Pancreatic tissue injury, c-peptide and amylase concentrations, and pancreatic tissue oxidative markers were evaluated. Results. Desferrioxamine-treated animals showed decreased c-peptide levels, decreased acinar cell necrosis, and decreased tissue malondialdehyde levels 24 hours after reperfusion compared with the control group. There was no difference in portal pressure or serum amylase levels between the groups. Conclusions. Desferrioxamine seems to attenuate pancreatic injury after major hepatectomy under vascular control possibly by preventing and reversing production and circulation of oxidative products.

Gallbladder adenomyomatosis is an uncommon and benign condition that can exist with or without lithiasis and does not, usually , present any symptoms. We report a case of symptomatic gallbladder adenomyomatosis in which adenomyomatosis had altered the shape of the gallbladder to an " hourglass "-shaped form, as shown during the preoperative imaging control. The patient was treated with laparoscopic cholecystectomy and no further treatment was needed. This morphological type of the gallbladder adenomyomatosis is rare and it can alter the shape of the cyst, as shown in our case. The accurate diagnosis is set only after pathologic examination and the last it is important in order to exclude probable gallbladder malignancies.

Abstract
BACKGROUND:
Obesity is a growing worldwide epidemic. There is association between obesity and pancreatic cancer risk. However, the impact of obesity on the outcome of pancreatoduodenectomy (PD) is controversial. The aim of this study was to elucidate effect of obesity on surgical outcomes of PD.
STUDY DESIGN:
A case-control study.
PATIENT AND METHODS:
We retrospectively studied all patients who underwent PD in our center between January 2000 and June 2012. Patients were divided into two groups; Group A (patients with BMI <25) and Group B (patients with BMI > 25). Preoperative demographic data, intraoperative data, and postoperative details were collected.
RESULTS:
Only 112/471 patients (25.9%) had BMI > 25. The median intraoperative blood loss was more in overweight patients (P = 0.06). The median surgical time in group B was significantly longer than that in group A (P = 0.003). The overall incidence of complications was higher in the overweight group (P = 0.001). The severity of complications was also higher in the overweight group (P = 0.0001). Postoperative pancreatic fistula (POPF) (P = 0.0001) and hospital mortality (P = 0.001) were significantly higher in overweight patients. Oral intake was significantly delayed in overweight patients in comparison to normal weight group (P = 0.02). Postoperative stay was significantly longer in overweight patients (P = 0.0001).
CONCLUSION:
PD is associated with an increased risk of postoperative morbidity in overweight patient. Overweight patients must not be precluded from undergoing PD. However, operative techniques and pharmacological prophylaxis to decrease POPF should be considered in overweight patients.