Cirrhosis is not a contraindication to laparoscopic cholecystectomy: results and practical recommendations

Background

Gallstones appear more frequently in patients with cirrhosis and open cholecystectomy in this patient population is associated with higher morbidity and mortality. The aim of the present study was to evaluate experience with laparoscopic cholecystectomy in patients with cirrhosis and to provide recommendations for management.

Methods

Retrospective review of laparoscopic cholecystectomy in patients with cirrhosis from March 1999 to May 2008 was performed. Peri-operative characteristics and subgroup analysis were performed in patients with Child–Pugh''s classes A, B and C cirrhosis.

Results

A total of 68 patients were reviewed in this study. In all, 69% of the patients were Child''s class A. The most common indication for cholecystectomy was chronic/symptomatic cholelithiasis (68%). Compared with patients with Child''s class B and C, laparoscopic cholecystectomy in patients with Child''s class A was associated with significantly decreased operative time (P= 0.01), blood loss (P= 0.001), conversion to open cholecystectomy (P= 0.001) and length of hospital stay (P= 0.001).

Conclusions

Laparoscopic cholecystectomy in patients with cirrhosis is feasible with no mortality and low morbidity, especially in patients with Child''s class A cirrhosis.     

Management of choledocholithiasis in an emergency cohort undergoing laparoscopic cholecystectomy: a single-centre experience

Introduction

Minimally-invasive options for the management of choledocholithiasis in patients undergoing laparoscopic cholecystectomy include laparoscopic and endoscopic approaches. This study reviews the effectiveness of both approaches in an emergency setting.

Methods

A retrospective chart review was performed for a cohort of patients who underwent laparoscopic cholecystectomy. Outcomes assessed were duct clearance, the number of procedures performed (NPP), length of stay (LOS) and complication rate.

Results

A total of 182 patients who underwent emergency laparoscopic cholecystectomies received intervention for choledocholithiasis. The duct clearance rate was lower in the laparoscopic group, 63% versus 86% (P = 0.001). However, the median NPP was also lesser in the laparoscopic group, 1 (interquartile range (IQR) 1–2) versus 2 (IQR 2–2) (P < 0.001), as was the median LOS, 5 days (IQR 3–8) versus 7 days (IQR 6–10) (P = 0.009). Forty-eight laparoscopic endobiliary stents were attempted; stent deployment was successful in 37 patients. A larger proportion of patients with laparoscopic endobiliary stents had duct clearance by endoscopic retrograde cholangiopancreatography (ERCP) compared with those without, although this was not statistically significant (P = 0.208).

Conclusion

Laparoscopic clearance is not as effective as post-operative ERCP in an emergency cohort, but is associated with fewer procedures required and a shorter inpatient stay. Thus, laparoscopic clearance may still be an attractive option for surgeons especially where conditions are favourable during an emergency laparoscopic cholecystectomy.     

Clinical outcomes of a percutaneous cholecystostomy for acute cholecystitis: a multicentre analysis

Background

The aim of this study was to review a series of consecutive percutaneous cholecystostomies (PC) to analyse the clinical outcomes.

Methods

All patients who underwent a PC between 2000 and 2010 were reviewed retrospectively for indications, complications, and short- and long-term outcomes.

Results

Fifty-three patients underwent a PC with a median age was 74 years (range 14–93). 92.4% (n = 49) of patients were American Society of Anesthesiologists (ASA) III and IV. 82% (43/53) had ultrasound-guided drainage whereas 18% (10/53) had computed tomography (CT)-guided drainage. 71.6% (n = 38) of PC''s employed a transhepatic route and 28.4% (n = 15) transabdominal route. 13% (7/53) of patients developed complications including bile leaks (n = 5), haemorrhage (n = 1) and a duodenal fistula (n = 1). All bile leaks were noted with transabdominal access (5 versus 0, P = 0.001). 18/53 of patients underwent a cholecystectomy of 4/18 was done on the index admission. 6/18 cholecystectomies (33%) underwent a laparoscopic cholecystectomy and the remaining required conversion to an open cholecystectomy (67%). 13/53 (22%) patients were readmitted with recurrent cholecystitis during follow-up of which 7 (54%) had a repeated PC. 12/53 patients died on the index admission. The overall 1-year mortality was 37.7% (20/53).

Conclusions

Only a small fraction of patients undergoing a PC proceed to a cholecystectomy with a high risk of conversion to an open procedure. A quarter of patients presented with recurrent cholecystitis during follow-up. The mortality rate is high during the index admission from sepsis and within the 1 year of follow-up from other causes.     

Open and laparoscopic resection of hepatocellular adenoma: trends over 23 years at a specialist hepatobiliary unit

Background

Hepatocellular adenoma (HCA) is a rare benign liver epithelial tumour that can require surgery. This retrospective study reports a 23-year experience of open and laparoscopic resections for HCA.

Methods

Patients with a histological diagnosis of HCA were included in this analysis. Surgical resection was performed in all symptomatic patients and in those with lesions measuring > 5 cm.

Results

Between 1989 and 2012, 62 patients, 59 of whom were female, underwent surgery for HCA (26 by open surgery and 36 by laparoscopic surgery). Overall, 96.6% of female patients had a history of contraceptive use; 54.8% of patients presented with abdominal pain and 11.2% with haemorrhage; the remaining patients were asymptomatic. Patients who underwent laparoscopy had smaller lesions (mean ± standard deviation diameter: 68.3 ± 35.2 mm versus 91.9 ± 42.5 mm; P = 0.022). Operatively, laparoscopic and open liver resection did not differ except in the number of pedicle clamps, which was significantly lower in the laparoscopic group (27.8% versus 57.7% of patients; P = 0.008). Postoperative variables did not differ between the groups. Mortality was nil. Two surgical specimens were classified as HCA/borderline hepatocellular carcinoma. At the 3-year follow-up, all patients were alive with no recurrence of HCA.

Conclusions

Open and laparoscopic liver resections are both safe and feasible approaches for the surgical management of HCA. However, laparoscopic liver resections may be limited by lesion size and location and require advanced surgical skills.     

Bile Duct Injuries Following Laparoscopic Cholecystectomy: A Clinical Study

Background/Aim:

This study aimed at assessing the outcome of laparoscopic cholecystectomy (LC) by determining the frequency of complications, especially of bile duct injuries.

Materials and Methods:

The case files of all patients undergoing laparoscopic cholecystectomy between 2002 and 2006 (inclusive) at King Hussein Medical Center (KHMC) were retrospectively analyzed. We evaluated the data according to outcome measures, such as bile duct injury, morbidity, mortality and numbers of patients whose resections had to be converted from laparoscopic to open.

Results:

During the four years (January 2002 and December 2006), 336 patients underwent LC for chronic cholecystitis (CC), of whom 22 (6.5%) developed complications. Among those who developed complications, two patients had major bile duct injuries (0.4%); 43 other patients (12.8%) had planned laparoscopic operations converted to open cholecystectomy intra-operatively. None of the patients in this study died as a result of LC.

Conclusion:

Bile duct injury is a major complication of LC. Anatomical anomalies, local pathology, and poor surgical techniques are the main factors responsible. The two patients who had severe common bile duct injury in this study had major anatomical anomalies that were only recognized during surgery.     

The long-term effect of bile duct injuries on health-related quality of life: a meta-analysis

Background

The reported effects of biliary injury on health-related quality of life (HRQOL) have varied widely. Meta-analysis methodology was applied to examine the collective findings of the long-term effect of bile duct injury (BDI) on HRQOL.

Methods

A comprehensive literature search was conducted in March, 2012. Because the HRQOL surveys differed among reports, BDI and uncomplicated laparoscopic cholecystectomy (LC) groups'' HRQOL scores were expressed as effect sizes (ES) in relation to a common, general population, standard. A negative ES indicated a reduced HRQOL, with a substantive reduction defined as an ES ≤ −0.50. Weighted logistic regression tested the effects of BDI (versus LC) and follow-up time on whether physical and mental HRQOL were substantively reduced.

Results

Data were abstracted from six publications, which encompass all reports of HRQOL after BDI in the current, peer-reviewed literature. The analytic database comprised 90 ES computations representing 831 patients and 11 unique study groups (six BDI and five LC). After controlling for follow-up time (P ≤ 0.001), BDI patients were more likely to have reduced long-term mental [odds ratio (OR) = 38.42, 95% confidence interval (CI) = 19.14–77.10; P < 0.001] but not physical (P = 0.993) HRQOL compared with LC patients.

Discussion

This meta-analysis of findings from six peer-review reports indicates that, in comparison to LC, there is a long-term detrimental effect of BDI on mental HRQOL.     

Laparoscopic cholecystectomy is more difficult after a previous endoscopic retrograde cholangiography

Background

Endoscopic retrograde cholangiography (ERCP) with endoscopic sphincterotomy (ES) followed by a laparoscopic cholecystectomy (LC) is generally accepted as the treatment of choice for patients with choledochocystolithiasis who are eligible for surgery. Previous studies have shown that LC after ES is associated with a high conversion rate. The aim of the present study was to assess the complexity of LC after ES compared with standard LC for symptomatic uncomplicated cholecystolithiasis.

Methods

The study population consisted of two patient cohorts: patients who had undergone a previous ERCP with ES for choledocholithiasis (PES) and patients with cholecystolithiasis who had no previous intervention prior to LC (NPES).

Results

The PES group consisted of 93 patients and the NPES group consisted of 83 consecutive patients. Patients in the PES group had higher risks for longer [more than 65 min, odds ratio (OR) = 4.21 (95% confidence interval (CI) 1.79–9.91)] and more complex [higher than 6 points, on a 0–10 scale, OR 3.12 (95% CI 1.43–6.81)] surgery. The conversion rate in the PES and NPES group (6.5% versus 2.4%, respectively) and the complication rate (12.9% versus 9.6%, respectively) were not significantly different.

Discussion

A laparoscopic cholecystectomy after ES is lengthier and more difficult than in uncomplicated cholelithiasis and should therefore be performed by an experienced surgeon.     

Index admission laparoscopic cholecystectomy for patients with acute biliary symptoms: results from a specialist centre

Background:

Index admission laparoscopic cholecystectomy (ALC) is the treatment of choice for patients admitted with biliary symptoms but is performed in less than 15% of these admissions. We analysed our results for ALC within a tertiary hepatobiliary centre.

Methods:

Data from all cholecystectomies carried out under the care of the two senior authors from 1998 to 2008 were prospectively collected and interrogated.

Results:

1710 patients underwent cholecystectomy of which 439 (26%) were ALC. Pateints operated on acutely did not have a significantly different complication rate (P= 0.279; 4% vs.3%). Factors predicting complications were abnormal alkaline phosphatase (ALP) (P= 0.037), dilated common bile duct (CBD) (P= 0.026), cholangitis (P= 0.040) and absence of on table cholangiography (OTC) (P= 0.011). There were no bile duct injuries. Patients undergoing ALC had a higher rate of conversion to an open procedure (P < 0.001:10% vs.3%). The proportion of complicated disease was higher in the ALC group (P < 0.001; 70% vs.31%). Only complicated disease (P= 0.006), absence of OTC (P < 0.001) and age greater than 65 years (P < 0.001) were predictive of conversion on multivariate analysis.

Conclusions:

Laparoscopic cholecystectomy can be performed safely in patients with acute biliary symptoms and should be considered the gold standard for management of these patients thus avoiding avoidable readmissions and life-threatening complications. A higher conversion rate to an open procedure must be accepted when treating more complicated disease. It is the severity of disease rather than timing of surgery which most probably predicts complications and conversions.     

The feasibility and safety of the endoscopic submucosal dissection of superficial gastric neoplastic lesions in patients with compensated liver cirrhosis: a retrospective study

Background/Aims

When undergoing endoscopic submucosal dissection (ESD), patients with liver cirrhosis (LC) may suffer from a high risk of bleeding, bacteremia and tissue vulnerability. There have been few reports evaluating the efficacy and safety of ESD in patients with LC.

Methods

From January 2004 to March 2010, 23 patients with LC (cirrhosis group) underwent ESD for superficial gastric neoplastic lesions. The number of patients with a liver function in the Child-Pugh classes A and B were 20 and 3, respectively. The clinical outcomes and complications were compared with 69 patients without LC (control group) that were matched for age and sex.

Results

The en bloc resection, R0 resection and en bloc plus R0 resection rates of the cirrhosis group were 82.6%, 91.3%, and 82.6%, respectively, and did not show significant differences from the rates of the control group. No local recurrence was found in either group during the follow-up period. The procedure length of time (41.0 vs 39.0 minutes), rate of bleeding (4.3% vs 7.2%) and rate of perforation (0.0% vs 1.4%) in the cirrhosis group were also comparable to the results from the control group.

Conclusions

ESD was safely performed in patients with LC, and satisfactory outcomes were achieved with high en bloc and R0 resection rates for superficial gastric neoplastic lesions.     

Evaluation of laparoscopic versus open colorectal surgery in elderly patients more than 70?years old: an evaluation of 727 patients

Background

With longer life expectancy, surgeons can expect to operate on older patients. Laparoscopic colorectal (LC) surgery has been demonstrated to be superior to open surgery. Controversy persists, however, regarding benefits of LC in the elderly due to increase in operative time. The aim of our study was to compare short-term outcomes of LC versus open colorectal (OC) surgery in elderly patients.

Materials and methods

Patients ≥70?years old that underwent elective LC between 2005 and 2008 were compared with controls who underwent OC. Data was extracted from a prospectively collected database.

Results

Seven hundred and twenty-seven patients underwent colorectal resection in this study period (LC n?=?225, OC n?=?502). The laparoscopic arm was characterised by shorter incisions (LC 6.0?cm vs. OC 12.0?cm, p?p?p?p?p?=?0.14) and post-operative morbidity (p?=?0.725). Thirty-day mortality was significantly lower in the laparoscopic arm (LC 1.3% vs. OC 4.6%, p?=?0.03)

Conclusion

This is the largest series from a single institution comparing LC and OC in elderly patients. In our series, LC in elderly patients was safe and not associated with a higher morbidity. LC was also associated with less narcotic use and shorter length of stay.     

Minimally invasive versus the conventional open surgical approach of a radical cholecystectomy for gallbladder cancer: a retrospective comparative study

Background

Laparoscopic surgery has traditionally been contraindicated for the management of gall bladder cancer (GBC). This study was undertaken to determine the safety and feasibility of a laparoscopic radical cholecystectomy (LRC) for GBC and compare it with an open radical cholecystectomy (ORC).

Methods

Retrospective analysis of primary GBC patients (with limited liver infiltration) and incidental GBC (IGBC) patients (detected after a laparoscopic cholecystectomy) who underwent LRC between June 2011 and October 2013. Patients who fulfilled the study criteria and underwent ORC during the same period formed the control group.

Results

During the study period, 147 patients with GBC underwent a radical cholecystectomy. Of these, 24 patients (primary GBC– 20, IGBC – 4) who underwent a LRC formed the study group (Group A). Of the remaining 123 patients who underwent ORC, 46 matched patients formed the control group (Group B). The median operating time was higher in Group A (270 versus 240 mins, P = 0.021) and the median blood loss (ml) was lower (200 versus 275 ml, P = 0.034). The post-operative morbidity and mortality were similar (P = 1.0). The pathological stage of the tumour in Group A was T_1b (n = 1), T₂ (n = 11) and T₃ (n = 8), respectively. The median lymph node yield was 10 (4–31) and was comparable between the two groups (P = 0.642). During a median follow-up of 18 (6–34) months, 1 patient in Group A and 3 in Group B developed recurrence. No patient developed a recurrence at a port site.

Conclusion

LRC is safe and feasible in selected patients with GBC, and the results were comparable to ORC in this retrospective comparison.     

Medicolegal costs of bile duct injuries incurred during laparoscopic cholecystectomy

Background:

When laparoscopic cholecystectomy (LC) is performed successfully, recovery is faster than after open cholecystectomy. However, LC results in higher incidences of biliary, bowel and vascular injury.

Methods:

We performed a retrospective review of LC-related claims reported to the National Health Service Litigation Authority (NHSLA) during 2000–2005. The data were analysed from a medicolegal perspective to assess the effects of type of injury and delay in recognition on litigation costs.

Results:

A total of 208 claims following laparoscopic procedures in general surgery were reported to NHSLA during 2000–2005, of which 133 (64%) were related to LC. Bile duct injury (BDI) accounted for the majority of claims (72%); bowel injury and ‘others’ accounted for 9% and 19%, respectively. Only 20% of BDIs were recognized during surgery; the majority were missed and diagnosed later. Claims related to LC resulted in payments totalling £6 m, of which £4.3 m was paid out for BDIs. The average cost was higher for patients who suffered a delay in diagnosis, as was the chance of a successful claim.

Conclusions:

Bile duct injury incurred during LC remains a serious hazard for patients. The resulting complications have led to litigation that has caused a huge financial drain on the health care system. Delayed recognition appears to correlate with more costly litigation.     

Laparoscopic or open cholecystectomy in cirrhosis: a systematic review of outcomes and meta-analysis of randomized trials

BackgroundCholecystectomy is associated with increased risks in patients with cirrhosis. The well-established advantages of laparoscopic surgery may be offset by the increased risk for complications relating particularly to portal hypertension and coagulopathy.MethodsA systematic search was undertaken to identify studies comparing open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) in patients with cirrhosis. A meta-analysis was performed of the available randomized controlled trials (RCTs).ResultsForty-four studies were analysed. These included a total of 2005 patients with cirrhosis who underwent laparoscopic (n= 1756) or open (n= 249) cholecystectomy, with mortality rates of 0.74% and 2.00%, respectively. A meta-analysis of three RCTs involving a total of 220 patients was conducted. There was a reduction in the overall incidences of postoperative complications and infectious complications and a shorter length of hospital stay in LC. However, frequencies of postoperative hepatic insufficiency did not differ significantly.ConclusionsThere are few RCTs comparing OC and LC in patients with cirrhosis. These studies are small, heterogeneous in design and include almost exclusively patients with Child–Pugh class A and B disease. However, LC appears to be associated with shorter operative time, reduced complication rates and reduced length of hospital stay.     

Survival analysis of high-intensity focused ultrasound ablation in patients with small hepatocellular carcinoma

Background

High-intensity focused ultrasound (HIFU) ablation is a non-invasive treatment for hepatocellular carcinoma (HCC). At present, data on the treatment''s long-term outcome are limited. This study analysed the survival outcome of HIFU ablation for HCCs smaller than 3 cm.

Patients and methods

Forty-seven patients with HCCs smaller than 3 cm received HIFU treatment between October 2006 and September 2010. Fifty-nine patients who received percutaneous radiofrequency ablation (RFA) were selected for comparison. The two groups of patients were compared in terms of pre-operative variables and survival.

Results

More patients in the HIFU group patients had Child–Pugh B cirrhosis (34% versus 8.5%; P = 0.001). The 1- and 3-year overall survival rates of patients whose tumours were completely ablated in the HIFU group compared with the RFA group were 97.4% versus 94.6% and 81.2% versus 79.8%, respectively (P = 0.530). The corresponding 1- and 3-year disease-free survival rates were 63.6% versus 62.4% and 25.9% versus 34.1% (P = 0.683).

Conclusions

HIFU ablation is a safe and effective method for small HCCs. It can achieve survival outcomes comparable to those of percutaneous RFA and thus serves as a good alternative ablation treatment for patients with cirrhosis.     

Comorbidity Burden and Perioperative Complications for Living Kidney Donors in the United States

Background and objectives

Since 1998, 35% of kidney transplants in the United States have been derived from living donors. Research suggests minimal long-term health consequences after donation, but comprehensive studies are limited. The primary objective was to evaluate trends in comorbidity burden and complications among living donors.

Design, setting, participants, & measurements

The National Inpatient Sample (NIS) was used to identify donors from 1998 to 2010 (n=69,117). Comorbid conditions, complications, and length of stay during hospitalization were evaluated. Outcomes among cohorts undergoing appendectomies, cholecystectomies and nephrectomy for nonmetastatic carcinoma were compared, and sample characteristics were validated with the Scientific Registry of Transplant Recipients (SRTR). Survey regression models were used to identify risk factors for outcomes.

Results

The NIS captured 89% (69,117 of 77,702) of living donors in the United States. Donor characteristics were relatively concordant with those noted in SRTR (mean age, 40.1 versus 40.3 years [P=0.18]; female donors, 59.0% versus 59.1% [P=0.13]; white donors, 68.4% versus 69.8% [P<0.001] for NIS versus SRTR). Incidence of perioperative complications was 7.9% and decreased from 1998 to 2010 (from 10.1% to 7.6%). Men (adjusted odds ratio [AOR], 1.37; 95% confidence interval [CI], 1.20 to 1.56) and donors with hypertension (AOR, 3.35; 95% CI, 2.24 to 5.01) were more likely to have perioperative complications. Median length of stay declined over time (from 3.7 days to 2.5 days), with longer length of stay associated with obesity, depression, hypertension, and pulmonary disorders. Presence of depression (AOR, 1.08; 95% CI, 1.04 to 1.12), hypothyroidism (AOR, 1.07; 95% CI, 1.04 to 1.11), hypertension (AOR, 1.38; 95% CI, 1.27 to 1.49), and obesity (AOR, 1.07; 95% CI, 1.03 to 1.11) increased over time. Complication rates and length of stay were similar for patients undergoing appendectomies and cholecystectomies but were less than those with nephrectomies for carcinoma.

Conclusions

The NIS is a representative sample of living donors. Complications and length of stay after donation have declined over time, while presence of documented comorbid conditions has increased. Patients undergoing appendectomy and cholecystectomy have similar outcomes during hospitalization. Monitoring the health of living donors remains critically important.     

Outcome of Laparoscopic Cholecystectomy at a Secondary Level of Care in Saudi Arabia

Background/Aim:

The first option for gallbladder surgery is laparoscopic cholecystectomy. The aim of this study is to analyze the outcomes for all patients who underwent laparoscopic cholecystectomy at a secondary level of care.

Patients and Methods:

Between 2005 and 2008, 968 consecutive laparoscopic cholecystectomies were performed at King Fahad Hospital. We collected and analyzed data including age, gender, body mass index (kg/m²), the American Society of Anesthesiologists (ASA) class, mode of admission (elective or emergency), indication for LC (chronic or acute cholecystitis [AC]), co-morbid disease, previous abdominal surgery, conversion to open cholecystectomy, complications, operation time, and length of postoperative hospital stay.

Results:

Nine hundred and sixty-eight patients had laparoscopic cholecystectomy at the center. There were 824 females and 144 males; the age range was 15-64 (mean 32.9± 12.7 years). The operating time was 45 to 180 min (median 85 min); the complication rate was 4.03% (39 patients).

Conclusion:

Laparoscopic cholecystectomy could be performed safely in the majority of patients with cholelithiasis, by an experienced surgical team at a secondary level of care.     

Focused open necrosectomy in necrotizing pancreatitis

Background

The control of sepsis is the primary goal of surgical intervention in patients with infected necrosis. Simple surgical approaches that are easy to reproduce may improve outcomes when specialists in endoscopy are not available. The aim of the present study was to describe the experience with a focused open necrosectomy (FON) in patients with infected necrosis.

Method

A prospective pilot study conducted to compare a semi-open/closed drainage laparotomy and FON with the assistance of peri-operative ultrasound. The incidence of sepsis, dynamics of C-reactive protein (CRP), intensive care unit (ICU)/hospital stay, complication rate and mortality were compared and analysed.

Results

From a total of 58 patients, 36 patients underwent a conventional open necrosectomy and 22 patients underwent FON. The latter method resulted in a faster resolution of sepsis and a significant decrease in mean CRP on Day 3 after FON, P = 0.001. Post-operative bleeding was in 1 versus 7 patients and the incidence of intestinal and pancreatic fistula was 2 versus 8 patients when comparing FON to the conventional approach. The median ICU stay was 11.6 versus 23 days and the hospital stay was significantly shorter, 57 versus 72 days, P = 0.024 when comparing FON versus the conventional group. One patient died in the FON group and seven patients died in the laparotomy group, P = 0.139.

Discussion

FON can be an alternative method to conventional open necrosectomy in patients with infected necrosis and unresolved sepsis.     

Does pre‐operative chemoradiation for initially unresectable or borderline resectable pancreatic adenocarcinoma increase post‐operative morbidity? A case‐matched analysis

Background

Neoadjuvant chemoradiation therapy for locally unresectable and borderline resectable pancreatic cancer may allow some patients to a undergo a resection, but whether or not this increases post-operative morbidity remains unclear.

Methods

The post-operative morbidity of 29 patients with initially locally unresectable/borderline pancreatic cancer who underwent a resection were compared with 29 patients with initially resectable tumours matched for age, gender, the presence of comorbidities (yes/no), American Society of Anesthesiology (ASA) score, tumour location (head/body-tail), procedure (pancreaticoduodenectomy/distal pancreatectomy) and vascular resection (yes /no). Wilcoxon''s signed ranks test was used for continuous variables and McNemar''s chi-square test for categorical variables.

Results

Compared with patients with initially resectable tumours, patients who underwent a resection after pre-operative chemoradiation therapy had similar rates of overall post-operative complications (55% versus 41%, P = 0.42), major complications (21% versus 21%, P = 1), pancreatic leaks and fistulae (7% versus 10%, P = 1) and mortality (0% versus 1.7%, P = 1).

Conclusion

Although some previous studies have suggested differences in post-operative morbidity after chemoradiation, our case-matched analysis did not find statistical differences in surgical morbidity and mortality associated with pre-operative chemoradiation therapy.     

Incidental pT2-T3 gallbladder cancer after a cholecystectomy: outcome of staging at 3 months prior to a radical resection

Introduction

Patients with incidental pT2-T3 gallbladder cancer (IGC) after a cholecystectomy may benefit from a radical re-resection although their optimal treatment strategy is not well defined. In this Unit, such patients undergo delayed staging at 3 months after a cholecystectomy to assess the evidence of a residual tumour, extra hepatic spread and the biological behaviour of the tumour. The aim of this study was to evaluate the outcome of patients who had delayed staging at 3 months after a cholecystectomy.

Methods

From July 2003 to July 2011, 56 patients with T2-T3 gallbladder cancer were referred to this Unit of which 49 were diagnosed incidentally on histology after a cholecystectomy. All 49 patients underwent delayed pre-operative staging using multi-detector computed tomography (MDCT) followed selectively by laparoscopy at 3 months after a cholecystectomy. Data were collected from a prospectively held database. The peri-operative and long-term outcomes of patients were analysed. SPSS software was used for statistical analysis.

Results

There were 38 pT2 and 11 pT3 tumours. After delayed staging, 24/49 (49%) patients underwent a radical resection, 24/49 (49%) were found to be inoperable on pre-operative assessment and 1/49 (2%) patient underwent an exploratory laparotomy and were found to be unresectable. The overall median survival from referral was 20.7 months (54.8 months for the group who had a radical re-resection versus 9.7 months for the group who had unresectable disease, P < 0.001). These results compare favourably with the reported outcome of fast-track management for incidental pT2-T3 gallbladder cancer from other major series in the literature.

Conclusion

Delayed staging in patients with incidental T2-T3 gallbladder cancer after a cholecystectomy is a useful strategy to select patients who will benefit from a resection and avoid unnecessary major surgery.     

Evaluation of stapler hepatectomy during a laparoscopic liver resection

Methods

An international database of 1499 laparoscopic liver resections was analysed using multivariate and Kaplan–Meier analysis.

Results

In total, 764 stapler hepatectomies (SH) were compared with 735 electrosurgical resections (ER). SH was employed in larger tumours (4.5 versus 3.8 cm; P < 0.003) with decreased operative times (2.6 versus 3.1 h; P < 0.001), blood loss (100 versus 200 cc; P < 0.001) and length of stay (3.0 versus 7.0 days; P < 0.001). SH incurred a trend towards higher complications (16% versus 13%; P = 0.057) including bile leaks (26/764, 3.4% versus 16/735, 2.2%: P = 0.091). To address group homogeneity, a subset analysis of lobar resections confirmed the benefits of SH. Kaplan–Meier analysis in non-cirrhotic and cirrhotic patients confirmed equivalent patient (P = 0.290 and 0.118) and disease-free survival (P = 0.120 and 0.268). Multivariate analysis confirmed the parenchymal transection technique did not increase the risk of cancer recurrence, whereas tumour size, the presence of cirrhosis and concomitant operations did.

Conclusions

A SH provides several advantages including: diminished blood loss, transfusion requirements and shorter operative times. In spite of the smaller surgical margins in the SH group, equivalent recurrence and survival rates were observed when matched for parenchyma and extent of resection.