Routine laparoscopic ultrasonography in biliary surgery

A new technique of intraoperative imaging of the biliary tract in laparoscopic cholecystectomy is described. A specifically designed laparoscopic ultrasonographic probe is used to obtain both transverse and longitudinal views of the entire extrahepatic biliary tract. This technique was successfully used in 28 patients. The ultrasonographic imaging quality achieved equals our experience with intraoperative ultrasonography in open biliary surgery. It may be assumed, therefore, that the advantages of ultrasonography over cholangiography as documented in conventional open surgery will also apply to laparoscopic operations.     

Contrast-enhanced intraoperative ultrasonography during hepatectomies for colorectal cancer liver metastases

Preliminary reports showed that contrast-enhanced intraoperative ultrasonography (CEIOUS) provides information on primary or metastatic tumors of the liver that is not obtainable with conventional intraoperative ultrasonography (IOUS). This study validates the impact of CEIOUS, focusing on resective surgery for colorectal cancer (CRC) liver metastases. Twenty-four consecutive patients underwent liver resection using IOUS and CEIOUS for CRC liver metastases. CEIOUS was accomplished with intravenous injection of 4.8 mL of sulphur-hexafluoride microbubbles. CEIOUS found lesions missed at preoperative imaging and at IOUS in four patients and confirmed all of the new findings of IOUS in four patients. In addition, CEIOUS helped to define the tumor margins of the main lesion in 29% of patients with CRC liver metastases. No adverse effects were observed in relation with CEIOUS. In conclusion, CEIOUS improves IOUS accuracy with a significant impact on surgical strategy and radicality in patients who undergo surgery for CRC liver metastases. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (oral presentation).     

术中超声在原发性肝癌再次肝切除治疗中的价值

目的 评价术中超声(IOUS)在原发性肝癌首次肝切除及再次肝切除中的有效性.方法 对430例原发性肝癌、555次肝切除患者资料进行回顾性分析,观察IOUS在第一次和第二次肝切除中的作用,随访患者手术后的远期效果.结果 在目前所用常规影像学检查中,IOUS的诊断率最高.在第二次肝切除手术中,各项影像学检查的诊断率都有轻度降低.在第一次肝切除手术组,IOUS在30例患者共发现56个新肿瘤(7.0％);第二次肝切除手术组,IOUS在8例患者共发现13个新肿瘤(7.3％).第一次和第二次肝切除术手术中,肿瘤的平均直径分别为(8.7±3.8) mm和(9.0±5.2) mm.由于IOUS的缘故,第一次及第二次肝切除手术组中分别有24例(5.6％)和7例(6.4％)患者改变了手术方案.尽管第一次肝切除手术时IOUS发现新肿瘤的患者术后复发率较高,但术后经适当治疗,其远期效果与IOUS未发现新肿瘤的患者并无显著差异.结论 尽管影像技术不断发展,但IOUS仍为目前最敏感的检查手段.在复发性肝癌行再次肝切除时,IOUS对于发现新的肿瘤同样重要.IOUS发现新肿瘤的患者术后极容易复发,术后定期随访对延长患者生存期非常重要.     

Left-hand-assisted laparoscopic resection of hepatocellular carcinoma in an accessory liver

We report a left-hand-assisted laparoscopic resection of hepatocellular carcinoma that developed in an accessory liver in a 47-year-old man. Preoperative assessment of the location of the tumor and the feeder vessels by combined selective angiography and computed tomography studies predicted the feasibility of laparoscopic procedures for complete removal of the tumor. In an attempt to avoid direct contact of the tumor capsule with rigid instruments during the operation, left-hand-assisted procedures were attempted. The encapsulated mass, 6 × 5 × 3 cm in size, was located on the posterior side of the left diaphragm, and a thin stalk between the tumor and the margin of the left lateral segment of the liver proper was recognized. Hand-assisted procedures ensured the complete mobilization of the lesion with an adequate margin, without any unexpected capsular tear. Left-hand-assisted laparoscopic procedures would be feasible for the easy and safe resection of localized hepatocellular carcinoma developing in an accessory liver. Received: November 13, 2000 / Accepted: March 7, 2001     

Intraoperative fluoroscopy vs. intraoperative laparoscopic ultrasonography for early colorectal cancer localization in laparoscopic surgery

Background In colorectal cancer (CRC) surgery, precise tumor localization is important for oncologically correct surgery and adequate tumor and lymph node resection margins. During laparoscopic surgery it is difficult to localize early CRC. The aim of this study was to compare the usefulness of two tumor localization techniques; intraoperative fluoroscopy and intraoperative laparoscopic ultrasonography. Methods Seventeen patients with CRC necessitating preoperative marking were alternately allocated to either the fluoroscopy (F) group (n = 8) or the laparoscopic ultrasonography (LU) group (n = 9). A three-step technique was used. At first lesions were localized preoperatively by metallic clips that were colonoscopically applied proximally and distally to the tumor site. Second, computed tomography (CT) colonography was taken to obtain preoperative staging. The location of the metallic clips was confirmed by CT colonography, preoperatively. Third, in the F group, intraoperative fluoroscopy was performed to localize the applied clips. In the LU group, the applied clips were detected from the serosal aspect of the colon using intraoperative laparoscopic ultrasonography. Results In all patients, colonoscopic metallic clips were successfully applied and preoperative CT colonography correctly detected the location of the tumor. Marking sites were detected precisely using intraoperative fluoroscopy or intraoperative laparoscopic ultrasonography in all cases, without complications. The mean detection time was 15.8 minutes in the F group and 7.0 minutes in the LU group (p = 0.005). In the LU group, two cases were technically difficult because of interruption of the ultrasound by intestinal air. Conclusions Both intraoperative fluoroscopy and intraoperative laparoscopic ultrasonography are safe and accurate techniques for intraoperative localization of early CRC. With regard to detection time, intraoperative laparoscopic ultrasonography is superior to intraoperative fluoroscopy. However, when there is a massive amount of intestinal air, intraoperative laparoscopic ultrasonography is cumbersome in localizing the lesion. Computed tomography colonography is useful for preoperative tumor localization and might be effective for shortening detection time during surgery. Presented in part at the 20th World Congress of International Society for Digestive Surgery (ISDS), Rome, Italy, December 2, 2006     

Outcomes of bariatric surgery in patients with obesity and compensated liver cirrhosis

BackgroundObesity is a major health burden worldwide and is associated with nonalcoholic fatty liver disease, which can lead to cirrhosis. Bariatric surgery is increasingly being used to treat obesity, and the number of patients with obesity and cirrhosis undergoing bariatric surgery is also rising. However, the safety and feasibility of bariatric surgery in patients with obesity and cirrhosis are controversial.ObjectivesIn this meta-analysis, we compared postoperative complications, mortality, and weight loss between patients with and without cirrhosis undergoing bariatric surgery.SettingAn electronic search of Medline, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL).MethodsPatient morbidity and mortality odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were assessed. Intraoperative and overall complications, length of hospital stay, in-hospital mortality, long-term mortality, and total weight loss were recorded.ResultsThe literature search yielded 2977 articles. Eight studies were included in the analysis. Meta-analysis showed that the overall complications (OR: 2.1; 95% CI: 1.47–3.00; P < .0001), postoperative bleeding (OR: 2.22; 95% CI: 1.95–2.54; P < .00001), length of hospital stay (MD: .68; 95% CI: .14–1.19; P = .01), and in-hospital/90-day mortality (OR: 3.59; 95% CI: 2.84–4.54; P < .00001) were significantly higher in patients with compensated cirrhosis than in patients without cirrhosis. Intraoperative complications, operation time, major complications, and long-term mortality were similar between the groups. Total weight loss was also not significantly different between the groups.ConclusionBariatric surgery can be considered only in highly selected patients with obesity and compensated cirrhosis.     

Prediction of portal pressure from intraoperative ultrasonography

Background

Portal hypertension is a major risk factor for hepatic failure or bleeding in patients who have undergone hepatectomy, but it cannot be measured indirectly. We attempted to evaluate the intraoperative ultrasonography parameters that correlate with portal pressure (PP) in patients undergoing hepatectomy.

Methods

We examined 30 patients in whom PP was directly measured during surgery. The background liver conditions included chronic viral liver disease in seven patients, chemotherapy-associated steatohepatitis in four patients, fatty liver in one patient, hepatolithiasis in one patient, obstructive jaundice in one patient, and a normal liver in 16 patients. A multivariate logistic analysis and linear regression analysis were conducted to develop a predictive formula for PP.

Results

The mean PP was 10.4 ± 4.1 mm Hg. The PP tended to be increased in patients with chronic viral hepatitis. A univariate analysis identified the association of the six following parameters with PP: the platelet count and the maximum (max), minimum (min), endo-diastolic, peak-systolic, and mean velocity in the portal vein (PV) flow. Using multiple linear regression analysis, the predictive formula using the PV max and min was as follows: Y (estimated PP) = 18.235−0.120 × (PV max.[m/s])−0.364 × (PV min). The calculated PP (10.44 ± 2.61 mm Hg) was nearly the same as the actual PP (10.43 ± 4.07 mm Hg). However, there was no significant relationship between the calculated PP and the intraoperative blood loss and post hepatectomy morbidity.

Conclusions

This formula, which uses ultrasonographic Doppler flow parameters, appears to be useful for predicting PP.     

三维可视化技术结合术中超声在可切除肝癌腹腔镜手术的应用

目的探讨术前应用三维可视化技术结合术中超声实时引导在可切除原发性肝癌腹腔镜手术中应用的近期效果及价值。 方法回顾性分析蚌埠医学院第一附属医院2021年1月至2022年3月行腹腔镜肝切除术的68例原发性肝癌患者资料,根据术前是否行肝脏三维重建及术中超声引导,将患者分为对照组和观察组,各34例。对照组术前增强CT检查后行手术规划,观察组术前在增强CT的基础上采用三维可视化技术进行肝脏三维重建,拟定手术方案,术中行超声实时引导。对比两组患者的手术方式、术中出血量、术中输血比例、肝门阻断时间、手术时间、术后并发症发生率及术后住院时间。 结果与对照组相比,观察组患者术中出血量更少,术中输血比例更低,术中肝门阻断时间、手术时间及术后住院时间更短（均P<0.05）。对照组6例患者中转开腹,两组手术方式比较差异有统计学意义（χ²=4.570,P=0.033）。观察组术后总并发症发生率显著低于对照组（11.8% vs 35.3%,χ²=5.231,P=0.022）。 结论术前三维可视化技术结合术中超声引导在可切除原发性肝癌腹腔镜手术中的应用,有助于制定个体化手术策略,提升临床治疗效果,减少术中出血和肝门阻断时间,降低术后并发症的发生率,对腹腔镜肝切除手术的发展有重要指导意义。     

Ultrasound-guided finger compression in liver subsegmentectomy for hepatocellular carcinoma

Systematic subsegmentectomy is now accepted as the best option for the surgical management of hepatocellular carcinoma in patients with cirrhosis because it optimizes the balance between oncological requirements and the need to spare functioning liver parenchyma. However, this technique can be difficult because it requires a strong background in ultrasound-guided interventional procedures. We describe a new, simplified technique for the anatomical subsegmental hepatic resection of segment 2 or 3. It consists of IOUS-guided blunt portal branch compression to disclose the subsegmental area to be removed. This technique is a further evolution of so-called systematic subsegmentectomy for tumors located in segments 2 and 3. Its main advantages are that it is easy, fast, and reversible. We believe that it has the potential to lead to new opportunities in subsegmental anatomic liver resection.     

腹腔镜与开腹肝左叶部分切除治疗肝癌的临床疗效分析

【摘要】〓目的〓探讨腹腔镜肝左叶部分切除治疗肝癌的近期及远期临床疗效。方法〓回顾性分析2008年5月~2012年6月我科51例腹腔镜下肝左叶部分切除术(腹腔镜组)与50例开腹肝左叶部分切除术(开腹组)的临床资料,比较两组患者手术时间、术中出血量、住院时间、并发症、住院费用和生存率、复发率。结果〓腹腔镜组手术时间长于开腹组(128.6±29.7 min vs 106.3±26.5 min, P<0.05),术中出血量多于开腹组(180.5±53.6 mL vs 130.2±44.5 mL, P<0.05),住院时间短于开腹组(6.8±1.4 d vs 11.4±3.0 d,P<0.05),住院费用少于开腹组(3.1±0.5万元 vs 3.3±0.6万元, P<0.05),两组术后并发症发生率(3.9% vs 6.0%)无差异。腹腔镜组中位生存时间为40个月,1、2、3年生存率分别为90.2%、80.4%、68.6%;开腹组中位生存时间为41个月,1、2、 3年生存率分别为90.0%、82.0%、66.0%。腹腔镜组中位无瘤生存时间为29个月,l、2、3年复发率分别为19.6%、45.1%、54.9%;开腹组中位无瘤生存时间为31个月,1、2、3年复发率分别为22.0%、42.0%、50.0%。结论〓腹腔镜肝左叶部分切除安全可行,不影响肝癌患者的预后,与开腹手术相比,具有微创,术后恢复快,住院时间短,费用低的优势。