Hepatobiliary Surgery - Science topic

Osaid Alser There are various modalities for diagnosing chronic pancreatitis including MRCP, EUS, ERCP and MD CT abdomen with pancreatic protocol. I think if available they can be used selectively or in combination to reach the diagnosis as each investigation has its role in terms of findings for diagnosing chronic pancreatitis like calcifications, size of the pancreas, pancreatic duct caliber, strictures, stones and collections etc.

We prefer a single stage, same anesthesia, lap chole with intraoperative cholangiogram and if common bile duct stone (s) is confirmed, ERCP during the same procedure. If endoscopist cannot do it, we proceed with laparoscopic exploration of the CBD and/or rendez-vous. Anyway, we try to complete the procedure at the same OR time.

We summarized the available evidence on this subject in a recent chapter.

Yes, we are doing it in the first step of open surgery for colorectal metástases.

Very interesting at such low doses

Our research was looking at use for anaesthesia (sedation/ analgesia) doses, combined with propofol at different ratios

We modelled on the McFarlan regime (initial bolus dose followed by an infusion) and then reductions in the McFarlan regime thereafter, and found rates of 15-50µcg/kg/min were satisfactory up to 90 min anaesthesia in combination with propofol.

So, pure analgesia use is 60 times lower dose, albeit as part of a multimodal strategy

I don't think our work is easily applicable to your patients – awake with pure analgesia aims. The ultra-low dose numbers are very interesting though.

Do you use a loading dose? We found LD 15-16 times the per minute dose rate were useful. Again, with an aim of early loss of conscious being the aim.

Cholecystectomy have to be considered if the patient general condition is well and good but if not as in emergency situations do cholecystostomy. 

Acalculous cholecystitis mostly occur in intensive care setting where patients are lying in bed for long periods of time and often given parenteral nutrition both of which cause gall bladder dysmotility. It is also common in the elderly with vascular diseases It also rarely occur in general setting. But generally the incidence is low i.e. less than 1% though mortality can be high.

There is no need for routine albumin infusion after right hepatectomy for HCC unless the underlying liver is cirrhotic. In cirrhotic patients, need for albumin infusion should be dictated by factors such as volume status, serum sodium and drain losses rather than the serum albumin levels. Almost all patients will have a drop in serum albumin after major hepatectomy (infact after any major operation) and it will recover spontaneously as the patient recovers from the operation.

Pre-cholecystectomy a) to decrease the risk of cholangitis during the waiting time of lap cho, b) if any complication occurs (0.02.0.04% duodenal perforation and bleeding) should be better to manage both procedures (complication and chocec)  in the same time. Another type of question ca be: how should be managed patients wiyh previous CBD but without current evidence of common bile duct stones?

A photo of a patient who underwent laparoscopic sigmoidectomy by an umbilical zigzag skin incision technique 1 year ago. Can you see the scar? Almost invisible!

Sometimes congestion of the liver remnant can be missed and regarded as hypertrophy. You can check also the angle between LHV and sagittal plane on preembolisation and posthepatectomy CT scans in order to evaluate the change in position of LHV.

There are a lot of publications that you can find at PubMed with the search term "bronchobiliary fistula". Pleace find below links to some search results:

It is not possible to make definitive recommendations

regarding treatment by PC or cholecystectomy in elderly or critically ill patients with acute cholecystitis, but pending the results of the CHOCOLATE trial, I think that in acute calculous cholecystitis, percutaneous cholecystostomy can be used like "bridge to surgery", instead the same method in acute acalculous cholecystitis can be considered, on the basis of each patient, a definitive method

RAG knockout mice would be an alternative. This is a good model as CD4 KO, CD8 KO and B cell (mu) KO mice are available on the same background (C57/Bl6). If you can get the animals they are much easier to look after. We have used a heterotopic heart transplant model as described:

Chen Z. (1991) A technique of cervical heterotopic heart transplantation in mice. Transplantation 52: 1099-1101

Dear Dr Becker,

Thank you very much for your comment. It provides an important insight with respect to the overall treatment plan that is not infrequently overlooked.

In rectal cancer, the presence of a fibroinfiammatory response to neoadjuvant RT-CHT is associated with a trend versus better DFS and OS, as shown by the work of Debucquoy et al (Europ J Can 4 4 ( 2 0 0 8 ) 7 9 1 –797) By analysing variations in the resection specimen of 95 patients included in the EORTC trial 22921, the authors observed a significantly more prominent inflammatory component in patients with T-downstaging compared with non responders. They concluded that patients with a marked inflammatory component in the stroma have a lower chance of recurrence.

End to side, submucosal, single layer hepaticojejunostomy with interrupted absorbable (3/0 to 5/0) sutures, knots inside, no routine use of transanastomotic stents (only if the duct is very tiny just for postopoperative cholangio, max. stay 2 wks).

Hi Anthony and Gustavo!

The use of metal clips are safety. The most important point is that both the laparoscopic clip applier with twenty automatically advancing clips or a single load clip applier can not present any failure such as when arms keeps away even with the device closure.  Other cause is a poor dissection of Callot's triangule with excessive traction of the cystic when it is cut.

A routine test have to be made to secure that the laparoscopic applier is working and secure.

Immediate recognition is the best scenario and primary repair is preferred option. However it largely depends on the surgeon’s experience. The problem is that dealing with this complication of one of the simplest operations in abdominal surgery frequently requires expertise gained in major HPB surgery. So if you an expert the possible solutions are clear. If you do not feel confident, first ask immediately for an advice more experienced colleague. If there is any doubt on the possibilities to safely resolve the problem on site – just put drains and refer patient to tertiary center. The patient safety is on highest priority.

Again, I think that in this issue the single Center or Surgeon experience play a big role. In my opinion, excluding some complicated multiple bile duct reconstruction, the stend is not mandatory.

Dear Drs.

I think NOTES is feasible procedure at least in the procedure EFTR:endoscopic full thickness resection. Our univesity:Kagawa University has already developped Full thickness suturing devices and couter traction devices. I think EFTR will be developped gradually toward pure NOTES. In Japan, ESD is already ordinal treatment procedure for digestive cancer. So, Our group:Kagawa NOTES project is going to the next step. We: endoscopists,have now already learn Surgery for 4 years because it is need to study surgical anatomy to perform pure NOTES and open surgery if needed. Historically,from the surgical point of view, new procedure replace old one. At first, we modestly learn surgery and at the same time we developed new flexible endoscopic devices.

It is better to do an early laparoscopic surgury after a short corse of medical resuscitation. But in your special poorly medical condition a percutaneous gall bladder drainage with local anesthesia is prefered.

ALPPS is a method to induce a rapid hypertrophy of the remnant liver. It might provide chance of R0 resection in patients with several lesions and a small future liver remnant. As the hypertrophy develops in few days, and the surgery colud be completed quickly, can solve the problem of tumor progression found in other procedures to increase liver volume as portal vein embolization.

In our experience in patients with multiple CLM, this approach has achieved R0 resection in all the patients but is a technically very demanding procedure with important high grade morbility, as shown in published papers.