Levan Tsamalaidze - Academia.edu (original) (raw)
Papers by Levan Tsamalaidze
Hpb, Sep 1, 2018
complex operations with high morbidity and considerable mortality. These lesions are known as "Kl... more complex operations with high morbidity and considerable mortality. These lesions are known as "Klatskin-mimicking lesions". Methods: We analyzed our prospectively established bile duct tumor database. The last 20 years we treated 73 patients who were referred to our tertiary center with a primary diagnosis of perihilar cholangiocarcinoma. All of the patients underwent thorough evaluation before the decision of treatment was made. Results: Seventy three patients were managed as having a perihilar cholangiocarcinoma but in only 59 of them the final histopathological examination confirmed the preoperative diagnosis. In 14 patients the final diagnosis differed from the primary cause of referral and the lesions were regarded as "Klatskin-mimicking lesions". Five patients had intrahepatic lithiasis, 4 patients had Mirizzi syndrome, one patient had portal lymphadenopathy secondary to rectal cancer, one patient had non functioning neuroendocrine tumor, 1 intrahepatic gastrinoma , and two patients had IgG4 cholangiopathy. Conclusion: Clinicians should always have a high suspicion of "Klatskin-mimicking lesions" when they evaluate a patient for the possibility of a perihilar cholangiocarcinoma so that they can avoid misdiagnosis and propose a proper treatment. Based in our experience we propose an algorithm for the management of these patients
Annals of Surgery, May 11, 2020
Background Bile duct injury (BDI) is the most common serious complication of laparoscopic cholecy... more Background Bile duct injury (BDI) is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI. Methods Literature reviews were conducted for 18 key questions across six broad topics around cholecystectomy directed by a steering group and subject experts from five surgical societies (SAGES, AHPBA IHPBA, SSAT, and EAES). Evidencebased recommendations were formulated using the GRADE methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus. Results Consensus was reached on 17 of 18 questions by the Guideline Development Group (GDG) and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team. Conclusion These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.
HPB, 2018
vs. 61.9% if absent, HR=2.924, p=0.044].CD3+ values stratified prognosis in T1 patients (5-year O... more vs. 61.9% if absent, HR=2.924, p=0.044].CD3+ values stratified prognosis in T1 patients (5-year OS 73.9%/ 14.3%, p< 0.001; 3-year RFS 60.8%/14.3%, p< 0.001), in N+ patients (OS 71.4%/0%, p=0.028; RFS 42.9%/0%, p=0.011) and in patients without lymph-node metastases (RFS 49.7%/20.0%, p=0.062). Conclusions: The lymphoid infiltrate impacts prognosis of MFCCC after complete surgery. CD3+ infiltrate is associated with higher survival and lower recurrence risk, while Foxp3+ is associated with worse prognosis. CD3+ infiltrate allows to refine prognosis in early tumors and across different N stages.
Khirurgiia, 2010
Basing on the largest experience in the country, authors characterize the dynamics of growth, loc... more Basing on the largest experience in the country, authors characterize the dynamics of growth, localizaton and severity of wounds from traumatic (nonlethal) weapon. Every third victim with neck wound had deep neck structures damage. Open wounds of thorax and abdomen, though performed from traumatic weapon, pose a certain life threat.
HPB, 2018
advantage over major hepatectomies, specifically in colorectal liver metastases (CRLM). PSH can b... more advantage over major hepatectomies, specifically in colorectal liver metastases (CRLM). PSH can be performed laparoscopically, but access to the cranial segments is difficult. The objective of this systematic review is to analyze feasibility, safety, and oncologic outcomes of laparoscopic PSH (LPSH). Methods: A systematic review of the literature was performed by searching Medline/PubMed, Scopus, and Cochrane databases. Resections were categorized by segment(s) and data regarding operative time, blood loss, length of hospital stay, complications, and R0 resection were analyzed. Results: Of 351 studies screened for relevance, 48 studies were selected. Because interventions or endpoints were noncontributory, 38 were excluded. Ten publications remained, reporting data from 579 patients undergoing LPSH. The most common indication was CRLM (58%) followed by hepatocellular carcinoma (16%). Of the resections, 132 (21.5%) were in the cranial segments which previously would have required laparoscopic hemi-hepatectomies or sectionectomies. Median operating time was 190 minutes (range: 125e 369 min), median estimated blood loss was 200 cc (range: 100e450 cc), median length of hospital stay was 6 days (range: 2e7 days). Conversion rate was 7%, and complications occurred in 17% of cases. No perioperative mortality was reported. No standardized reporting format for complications was used across studies. R0 resections were achieved in 91% of cases. Conclusion: Laparoscopic PSH of difficult to reach liver tumors is feasible with acceptable operating times, blood loss, conversion and complication rates. In future studies, data on long term survival and specific tumor type recurrence should be reported.
HPB, 2018
Background: Adjuvant chemotherapy with cholangiocarcinoma (CCA) has been recently proven benefici... more Background: Adjuvant chemotherapy with cholangiocarcinoma (CCA) has been recently proven beneficial but little is known regarding neoadjuvant therapy for CCA. There has been recent emphasis on neoadjuvant strategies for GI malignancies. The aim of the study was to analyze the NSQIP database and current use of neoadjuvant therapy for CCA. Methods: An analysis of the ACS-NSQIP HPB database from 2014 to 2015 was performed for CCA. Resections included pancreatectomy (48150, 48153) and hepatectomy (47120, 47125, 47130, and 47122). Patients undergoing neoadjuvant systemic therapy were identified and compared. Differences in specific morbidity and mortality were reviewed in detail and multivariate analysis was performed. Results: A total of 773 patients with CCA were identified including 475, 175, and 123 with intrahepatic, extrahepatic, and hilar CCA respectively. Of those patients, 82 underwent neoadjuvant therapy including 65, 11, and 6 with intrahepatic, extrahepatic, and hilar CCA respectively. We performed multivariate analysis to examine the association between risk factors and postoperative outcomes. The risk factors significantly associated with morbidity include right hepatectomy, trisegmentectomy as well as tumors with stage T3 and T4. The risk factors related with mortality were found to be obesity, preoperative weight loss and right hepatectomy. Neoadjuvant therapy did not increase morbidity or mortality for patients undergoing surgical resection of CCA. Table 1 demonstrates postoperative outcomes. Conclusion: The appropriate use of a neoadjuvant strategy for patients with CCA remains unclear but it appears that this approach does not significantly affect surgical outcomes. Further studies are needed to assess efficacy of neoadjuvant therapy for CCA.
The American surgeon, 2018
Mirizzi syndrome (MS), first described in 1948 by Argentinian surgeon Pablo Luis Mirizzi, is the ... more Mirizzi syndrome (MS), first described in 1948 by Argentinian surgeon Pablo Luis Mirizzi, is the impaction of a gallstone in the cystic duct or in the neck of the gallbladder that may result in the obstruction of the common hepatic duct with intermittent or constant jaundice.14 On occasion, significant inflammation of the gallbladder may contribute to the development of a cholecystocholedochal fistula.1, 4 A classification of MS exists that categorizes patients according to the degree of involvement of the bile duct in the inflammation and presence or absence of a cholecystocholedochal or cholecystohepatic fistula (Type I represents patients without fistula, types II, III, and IV include patients with cholecystobiliary fistulas according to the grade of circumferential involvement of the bile duct, and type V categorizes patients with a cholecystoenteric fistula).14 Patients with MS usually have symptoms associated with gallstone disease: intermittent right upper quadrant pain, fever, jaundice, nausea, vomiting, anorexia, and rarely weight loss.1, 2 Surgery is considered to be the only curative treatment option for MS, and open cholecystectomy remains the standard surgical approach because of the possible intraoperative difficulties related with the identification and safe dissection of the structures in the area of Calot’s triangle.14 Challenging dissection due to edema and significant inflammation can cause bleeding, iatrogenic bile duct injury, sepsis, or delayed biliary stricture.1, 2 It is established that open cholecystectomy has the advantage over laparoscopic cholecystectomy because of the involvement of the surgeon’s hands in the dissection within Calot’s triangle and, therefore, reducing the odds of possible complications mentioned previously.1 Moreover, a review by Valderrama-Treviño et al.1 reported that laparoscopic cholecystectomy is a technically difficult and dangerous procedure for patients with MS. In addition, laparoscopic cholecystectomy in MS has demonstrated 16 per cent of iatrogenic bile duct injuries and was delineated as the most common complication for this procedure.4 In these cases, if a laparoscopic approach was attempted, retrograde cholecystectomy facilitating the identification of the structures within Calot’s triangle was recommended by several authors.13 A 70-year-old female was referred to our institution after undergoing an evaluation for incidentally discovered elevated liver enzymes. The patient did not complain of any symptoms except for 15 pounds weight loss in the last three years which she attributed to dietary changes. Outside radiologic investigations including CT revealed the presence of a 2.1-cm calcified mass at the level of the confluence of the right and left hepatic ducts with mass effect on the common hepatic duct. Magnetic resonance cholangiopancreatography (MRCP) demonstrated dilatation of the intrahepatic biliary duct from a large gallstone. With these findings, she was referred to our center for differentiating the large stone from a calcified tumor in the biliary tract. In our center, physical examination was unremarkable and laboratory results showed elevated alkaline phosphatase (ALP): 698 units/L, alanine aminotransferase: 98 units/L, aspartate aminotransferase 126 units/L, total bilirubin 0.9 mg/dL, direct bilirubin 0.5 mg/dL, CA-19-9 111 units/mL, ANA 0.1 units, and antimitochondrial antibodies <0.1 units. A multidisciplinary team comprising radiologists, gastroenterologists, and hepatobiliary surgeons established the diagnosis of MS with a large gallstone as the cause of the obstruction of the common hepatic duct. Therefore, laparoscopic intervention was scheduled. Under general anesthesia, four 5-mm trocars were inserted in the right subcostal area. Significant adhesions were noted in the right upper quadrant involving the gallbladder, stomach, duodenum, and colon. After careful adhesiolysis avoiding iatrogenic injuries with blunt dissection, a markedly edematous and infiltrated gallbladder neck was identified. It was felt that the dissection of this area could Address correspondence and reprint requests to John Andrew Stauffer, M.D., 4500 San Pablo Road, Mayo Clinic Florida, Jacksonville, FL 32224. E-mail: stauffer.john@mayo.edu.
Obesity increases the risk for metabolic syndrome, diabetes, chronic kidney disease, cardiomyopat... more Obesity increases the risk for metabolic syndrome, diabetes, chronic kidney disease, cardiomyopathy, heart failure, fatty liver disease, and certain types of cancer while also causing increased health-care costs. Diabetes, often correlated with obesity, can result in chronic kidney disease and end-stage renal failure, while obesity itself can aggravate end-stage liver disease or cause nonalcoholic steatohepatitis (NASH). Bariatric surgery has demonstrated its safety and efficacy and may be beneficial for both pre- and posttransplant patients. Due to insufficient information in the literature about bariatric surgery in transplant patients, no definitive, ideal procedure exists. In this chapter, we evaluate features and outcomes of bariatric procedures (pre-, during, and posttransplant) in obese patients with solid organ (kidney, liver, and heart) transplantation. According to literature review and analysis, pure restrictive laparoscopic sleeve gastrectomy has demonstrated its superio...
The American surgeon, 2018
Colorectal cancer (CRC) is one of the most frequent oncologic diagnoses in the United States toda... more Colorectal cancer (CRC) is one of the most frequent oncologic diagnoses in the United States today with 40,000 patients diagnosed with CRC yearly. Almost a quarter will present with liver metastases at the time of diagnosis and others will have isolated liver recurrence during surveillance.1 To date, the only curable treatment option for CRC patients with liver metastasis remains resection of the primary site and metastatic lesions, achieving five-year survival rate up to 40 per cent.1 Patients usually require a sequential treatment strategy because of the complexity of the disease. There are several different treatment strategies for patients at different presentation and stages of metastatic colorectal cancer (mCRC) to the liver. Patients may undergo resection of the primary tumor with staged hepatectomy, combined surgical resection of CRC and synchronous mCRC, or a “liver-first” strategy.1, 2 For patients with bilobar mCRC isolated to the liver, advanced techniques are required to spare and hypertrophy noninvolved parenchyma while performing complete resection of all involved areas. Portal vein embolization (PVE) or ligation followed by hepatectomy is a well-established technique indicated for patients requiring hypertrophy of the functional liver remnant (FLR) to avoid posthepatectomy liver failure.2, 3 Alternatively, “associating liver partition and portal vein ligation for staged hepatectomy” has also been recently introduced as a strategy to deal with small functional remnant liver and can be used for patients with bilobar disease.3 The use of “selective internal radiation therapy” with yttrium-90 (Y-90) radioembolization has been providing radiological response for locally advanced liver tumor and metastases.2, 4 Furthermore, selective internal radiation therapy with Y-90 can cause significant hypertrophy of the contralateral liver lobe, becoming an interesting option to achieve hypertrophy of the FLR in addition to local tumor control.2 These specific features make this a novel treatment option advantageous over previous therapies. Herein, we present a case of a CRC patient with diffuse bilateral metachronous liver metastasis with sparing of only the caudate lobe. Transarterial radiation lobectomy with Y-90 to the right lobe followed by left lateral hepatectomy and nonanatomic segment IV resection was carried out in the first stage. The second stage consisted of PVE with subsequent right hepatectomy after allowing hypertrophy of a viable FLR. To our knowledge, this is the first case in the literature where Y-90 radioembolization was used in combination with PVE and staged hepatectomy for diffuse bilateral metastatic colorectal liver lesions. A 60-year-old man presented to our center with the diagnosis of diffuse metachronous biopsy–proven mCRC (KRAS wild type) nine months after the resection of a primary CRC tumor. MRI confirmed the existence of multiple liver metastases involving both lobes of the liver. Segment IV contained one superficial small lesion and the caudate lobe was free of disease. The total liver volume was 1435 cc with segment IV and caudate lobe measuring 230 cc (16% of total liver volume) (Fig. 1A). The case was discussed at multidisciplinary tumor board and a treatment strategy was devised. The patient underwent five months of systemic chemotherapies (FOLFOX, Avastin) showing positive radiologic response. At this point, he underwent visceral angiogram with treatment of the right hepatic lobe with Y-90 microspheres (Fig. 1B). Ten days after transarterial radiation lobectomy with Y-90, he underwent a successful left lateral hepatectomy and nonanatomic segment IV resection achieving clearance of the metastatic lesions in the FLR. Pathologic study of the surgical specimen identified mCRC lesions ranging from 0.2 to 3.2 cm. The procedure was well tolerated and the patient was discharged on postoperative day 3 with close follow-up. Address correspondence and reprint requests to John Andrew Stauffer, M.D., Department of Surgery, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224. E-mail: stauffer.john@ mayo.edu.
The American surgeon, 2017
Postcholecystectomy syndrome continues to be a longstanding diagnostic and clinical challenge for... more Postcholecystectomy syndrome continues to be a longstanding diagnostic and clinical challenge for surgeons. One of the possible causes of this syndrome is incomplete gallbladder removal at the initial operation, resulting in a remnant gallbladder. This may occur after either an open or laparoscopic procedure where a “subtotal cholecystectomy” is performed. Herein, we report a case of remnant cholecystitis requiring surgical reintervention and discuss the surgical management of the disease with pertinent literature review. A 27-year-old woman presented to the emergency room with epigastric abdominal pain radiating to her back associated with nausea and vomiting. Her past surgical history included undergoing a complicated laparoscopic cholecystectomy for acute cholecystitis one year prior. According to the operative note, there was significant acute inflammation in the area of Calot’s triangle and it was felt unsafe to persist in dissection toward the hilum. Therefore, the infundibulum of the gallbladder was transected with a linear stapler and a subtotal cholecystectomy was performed. Despite this operation, her postprandial right upper quadrant abdominal pain persisted into the postoperative period, worsening mostly at night. Gastroenterology workup over the next several months did not reveal any other abnormalities. Ultimately, crosssectional abdominal MRI with magnetic resonance cholangiopancreatography (MRCP) was performed and the patient was noted to have remnant gallbladder with impacted gallstone (Fig 1A and B). Laparoscopic remnant cholecystectomy was recommended and the patient was taken to the operating room. Lysis of adhesions was performed and the remnant gallbladder was clearly identified with a large impacted stone (Fig. 1C). After circumferential dissection, single cystic artery and cystic duct were exposed and a window was made around the structures away from the hepatoduodenal ligament (Fig. 1D). These were clipped twice distally and once proximally and transected. The remnant gallbladder was removed off the inferior cystic plate with monopolar electrocautery. The operative time was under 30 minutes and the anatomy was easily defined due to the lack of inflammatory changes that were encountered by the initial operative team. The patient was discharged home several hours later and experienced a full and rapid recovery with complete resolution of her symptoms. Reasons for incomplete gallbladder resection include poor visualization of gallbladder fossa during surgery due to adhesions, concurrent inflammation, excessive bleeding, or confounding gallbladder morphology such as a congenital duplication or an hourglass configuration due to adenomyomatosis.1 Elshaer et al.2 reported meta-analysis of 30 studies with a total of 1231 patients undergoing subtotal
OBJECTIVE The Superior Mesenteric Artery Syndrome (SMAS) was first described by Rokitansky in 184... more OBJECTIVE The Superior Mesenteric Artery Syndrome (SMAS) was first described by Rokitansky in 1842. Clinical symptoms include postprandial pain, nausea, vomiting and weight loss. Duodenojejunostomy is the treatment of choice for patients with SMAS. We now present a case of a young female with SMAS who successfully underwent laparoscopic duodenojejunostomy. INDICATIONS The first line treatment for SMAS is medical management, which includes infusion therapy, bowel rest, parenteral nutrition and a nasojejunal feeding tube inserted into the jejunum past the obstruction. If medical therapy fails, surgery is recommended. PROCEDURE A symptomatic patient with body mass index (BMI) of 19.4 kg/m2 underwent laparoscopic duodenojejunostomy. The patient tolerated the procedure well. The post-operative period was uneventful and the patient was discharged after three days. On six month follow up, the patient had gained weight and her symptoms were completely resolved. CONCLUSION SMAS is still a po...
IntroductionObesity is frequently encountered in patients with orthotopic liver transplant (OLT).... more IntroductionObesity is frequently encountered in patients with orthotopic liver transplant (OLT). The role of bariatric surgery is still unclear for this specific population. The aim of this study was to review our experience with laparoscopic sleeve gastrectomy (LSG) after OLT.Material and MethodsWe performed a retrospective case-control study of patients undergoing LSG after OLT from 2010 to 2016. OLT-LSG patients were matched by age, sex, body mass index (BMI), and year to non-OLT patients undergoing LSG. Demographics, operative variables, postoperative events, and long-term weight loss with comorbidity resolution were collected and compared between cases and controls.ResultsOf 303 patients undergoing LSG, 12 (4%) had previous OLT. They were matched to 36 non-OLT patients. No difference was found between groups in the American Society of Anesthesiologists class, mean operative time, or postoperative morbidity. The non-OLT group, however, had a significantly shorter mean hospital ...
Journal of the American College of Surgeons, Oct 1, 2017
63.5%), followed by left hepatectomy (30.8% vs 23.1%) and extended right hepatectomy (7.7% vs. 13... more 63.5%), followed by left hepatectomy (30.8% vs 23.1%) and extended right hepatectomy (7.7% vs. 13.5%). Operating time for LH and OH was 402.5 and 373.5 minutes, blood loss was 350 ml and 560 ml, and length of stay was 6 days and 7 days respectively. No difference in postoperative outcome was observed. The 5-year survival rate for LH and OH for hepatocellular carcinoma was 71.6% and 63.9% (p¼0.959) and for colorectal liver metastasis was 100% and 57.8% (p¼0.183). CONCLUSIONS: LH was associated with less blood loss and shorter hospital stay than OH with similar oncological outcome.
Postgraduate medicine, 1961
Acute perforations of the gastrointestinal tract (GI) with subsequent release of gastric or intes... more Acute perforations of the gastrointestinal tract (GI) with subsequent release of gastric or intestinal contents into the peritoneal space have multiple causes and portend a high mortality depending on the cause. The key symptom is a sudden appearance of abdominal pain followed by signs of peritoneal irritation, severe sepsis, or shock. A proper imaging evaluation should lead to surgical intervention and aggressive supportive management.
Journal of Laparoendoscopic & Advanced Surgical Techniques
Hpb, Sep 1, 2018
complex operations with high morbidity and considerable mortality. These lesions are known as "Kl... more complex operations with high morbidity and considerable mortality. These lesions are known as "Klatskin-mimicking lesions". Methods: We analyzed our prospectively established bile duct tumor database. The last 20 years we treated 73 patients who were referred to our tertiary center with a primary diagnosis of perihilar cholangiocarcinoma. All of the patients underwent thorough evaluation before the decision of treatment was made. Results: Seventy three patients were managed as having a perihilar cholangiocarcinoma but in only 59 of them the final histopathological examination confirmed the preoperative diagnosis. In 14 patients the final diagnosis differed from the primary cause of referral and the lesions were regarded as "Klatskin-mimicking lesions". Five patients had intrahepatic lithiasis, 4 patients had Mirizzi syndrome, one patient had portal lymphadenopathy secondary to rectal cancer, one patient had non functioning neuroendocrine tumor, 1 intrahepatic gastrinoma , and two patients had IgG4 cholangiopathy. Conclusion: Clinicians should always have a high suspicion of "Klatskin-mimicking lesions" when they evaluate a patient for the possibility of a perihilar cholangiocarcinoma so that they can avoid misdiagnosis and propose a proper treatment. Based in our experience we propose an algorithm for the management of these patients
Annals of Surgery, May 11, 2020
Background Bile duct injury (BDI) is the most common serious complication of laparoscopic cholecy... more Background Bile duct injury (BDI) is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI. Methods Literature reviews were conducted for 18 key questions across six broad topics around cholecystectomy directed by a steering group and subject experts from five surgical societies (SAGES, AHPBA IHPBA, SSAT, and EAES). Evidencebased recommendations were formulated using the GRADE methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus. Results Consensus was reached on 17 of 18 questions by the Guideline Development Group (GDG) and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team. Conclusion These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.
HPB, 2018
vs. 61.9% if absent, HR=2.924, p=0.044].CD3+ values stratified prognosis in T1 patients (5-year O... more vs. 61.9% if absent, HR=2.924, p=0.044].CD3+ values stratified prognosis in T1 patients (5-year OS 73.9%/ 14.3%, p< 0.001; 3-year RFS 60.8%/14.3%, p< 0.001), in N+ patients (OS 71.4%/0%, p=0.028; RFS 42.9%/0%, p=0.011) and in patients without lymph-node metastases (RFS 49.7%/20.0%, p=0.062). Conclusions: The lymphoid infiltrate impacts prognosis of MFCCC after complete surgery. CD3+ infiltrate is associated with higher survival and lower recurrence risk, while Foxp3+ is associated with worse prognosis. CD3+ infiltrate allows to refine prognosis in early tumors and across different N stages.
Khirurgiia, 2010
Basing on the largest experience in the country, authors characterize the dynamics of growth, loc... more Basing on the largest experience in the country, authors characterize the dynamics of growth, localizaton and severity of wounds from traumatic (nonlethal) weapon. Every third victim with neck wound had deep neck structures damage. Open wounds of thorax and abdomen, though performed from traumatic weapon, pose a certain life threat.
HPB, 2018
advantage over major hepatectomies, specifically in colorectal liver metastases (CRLM). PSH can b... more advantage over major hepatectomies, specifically in colorectal liver metastases (CRLM). PSH can be performed laparoscopically, but access to the cranial segments is difficult. The objective of this systematic review is to analyze feasibility, safety, and oncologic outcomes of laparoscopic PSH (LPSH). Methods: A systematic review of the literature was performed by searching Medline/PubMed, Scopus, and Cochrane databases. Resections were categorized by segment(s) and data regarding operative time, blood loss, length of hospital stay, complications, and R0 resection were analyzed. Results: Of 351 studies screened for relevance, 48 studies were selected. Because interventions or endpoints were noncontributory, 38 were excluded. Ten publications remained, reporting data from 579 patients undergoing LPSH. The most common indication was CRLM (58%) followed by hepatocellular carcinoma (16%). Of the resections, 132 (21.5%) were in the cranial segments which previously would have required laparoscopic hemi-hepatectomies or sectionectomies. Median operating time was 190 minutes (range: 125e 369 min), median estimated blood loss was 200 cc (range: 100e450 cc), median length of hospital stay was 6 days (range: 2e7 days). Conversion rate was 7%, and complications occurred in 17% of cases. No perioperative mortality was reported. No standardized reporting format for complications was used across studies. R0 resections were achieved in 91% of cases. Conclusion: Laparoscopic PSH of difficult to reach liver tumors is feasible with acceptable operating times, blood loss, conversion and complication rates. In future studies, data on long term survival and specific tumor type recurrence should be reported.
HPB, 2018
Background: Adjuvant chemotherapy with cholangiocarcinoma (CCA) has been recently proven benefici... more Background: Adjuvant chemotherapy with cholangiocarcinoma (CCA) has been recently proven beneficial but little is known regarding neoadjuvant therapy for CCA. There has been recent emphasis on neoadjuvant strategies for GI malignancies. The aim of the study was to analyze the NSQIP database and current use of neoadjuvant therapy for CCA. Methods: An analysis of the ACS-NSQIP HPB database from 2014 to 2015 was performed for CCA. Resections included pancreatectomy (48150, 48153) and hepatectomy (47120, 47125, 47130, and 47122). Patients undergoing neoadjuvant systemic therapy were identified and compared. Differences in specific morbidity and mortality were reviewed in detail and multivariate analysis was performed. Results: A total of 773 patients with CCA were identified including 475, 175, and 123 with intrahepatic, extrahepatic, and hilar CCA respectively. Of those patients, 82 underwent neoadjuvant therapy including 65, 11, and 6 with intrahepatic, extrahepatic, and hilar CCA respectively. We performed multivariate analysis to examine the association between risk factors and postoperative outcomes. The risk factors significantly associated with morbidity include right hepatectomy, trisegmentectomy as well as tumors with stage T3 and T4. The risk factors related with mortality were found to be obesity, preoperative weight loss and right hepatectomy. Neoadjuvant therapy did not increase morbidity or mortality for patients undergoing surgical resection of CCA. Table 1 demonstrates postoperative outcomes. Conclusion: The appropriate use of a neoadjuvant strategy for patients with CCA remains unclear but it appears that this approach does not significantly affect surgical outcomes. Further studies are needed to assess efficacy of neoadjuvant therapy for CCA.
The American surgeon, 2018
Mirizzi syndrome (MS), first described in 1948 by Argentinian surgeon Pablo Luis Mirizzi, is the ... more Mirizzi syndrome (MS), first described in 1948 by Argentinian surgeon Pablo Luis Mirizzi, is the impaction of a gallstone in the cystic duct or in the neck of the gallbladder that may result in the obstruction of the common hepatic duct with intermittent or constant jaundice.14 On occasion, significant inflammation of the gallbladder may contribute to the development of a cholecystocholedochal fistula.1, 4 A classification of MS exists that categorizes patients according to the degree of involvement of the bile duct in the inflammation and presence or absence of a cholecystocholedochal or cholecystohepatic fistula (Type I represents patients without fistula, types II, III, and IV include patients with cholecystobiliary fistulas according to the grade of circumferential involvement of the bile duct, and type V categorizes patients with a cholecystoenteric fistula).14 Patients with MS usually have symptoms associated with gallstone disease: intermittent right upper quadrant pain, fever, jaundice, nausea, vomiting, anorexia, and rarely weight loss.1, 2 Surgery is considered to be the only curative treatment option for MS, and open cholecystectomy remains the standard surgical approach because of the possible intraoperative difficulties related with the identification and safe dissection of the structures in the area of Calot’s triangle.14 Challenging dissection due to edema and significant inflammation can cause bleeding, iatrogenic bile duct injury, sepsis, or delayed biliary stricture.1, 2 It is established that open cholecystectomy has the advantage over laparoscopic cholecystectomy because of the involvement of the surgeon’s hands in the dissection within Calot’s triangle and, therefore, reducing the odds of possible complications mentioned previously.1 Moreover, a review by Valderrama-Treviño et al.1 reported that laparoscopic cholecystectomy is a technically difficult and dangerous procedure for patients with MS. In addition, laparoscopic cholecystectomy in MS has demonstrated 16 per cent of iatrogenic bile duct injuries and was delineated as the most common complication for this procedure.4 In these cases, if a laparoscopic approach was attempted, retrograde cholecystectomy facilitating the identification of the structures within Calot’s triangle was recommended by several authors.13 A 70-year-old female was referred to our institution after undergoing an evaluation for incidentally discovered elevated liver enzymes. The patient did not complain of any symptoms except for 15 pounds weight loss in the last three years which she attributed to dietary changes. Outside radiologic investigations including CT revealed the presence of a 2.1-cm calcified mass at the level of the confluence of the right and left hepatic ducts with mass effect on the common hepatic duct. Magnetic resonance cholangiopancreatography (MRCP) demonstrated dilatation of the intrahepatic biliary duct from a large gallstone. With these findings, she was referred to our center for differentiating the large stone from a calcified tumor in the biliary tract. In our center, physical examination was unremarkable and laboratory results showed elevated alkaline phosphatase (ALP): 698 units/L, alanine aminotransferase: 98 units/L, aspartate aminotransferase 126 units/L, total bilirubin 0.9 mg/dL, direct bilirubin 0.5 mg/dL, CA-19-9 111 units/mL, ANA 0.1 units, and antimitochondrial antibodies <0.1 units. A multidisciplinary team comprising radiologists, gastroenterologists, and hepatobiliary surgeons established the diagnosis of MS with a large gallstone as the cause of the obstruction of the common hepatic duct. Therefore, laparoscopic intervention was scheduled. Under general anesthesia, four 5-mm trocars were inserted in the right subcostal area. Significant adhesions were noted in the right upper quadrant involving the gallbladder, stomach, duodenum, and colon. After careful adhesiolysis avoiding iatrogenic injuries with blunt dissection, a markedly edematous and infiltrated gallbladder neck was identified. It was felt that the dissection of this area could Address correspondence and reprint requests to John Andrew Stauffer, M.D., 4500 San Pablo Road, Mayo Clinic Florida, Jacksonville, FL 32224. E-mail: stauffer.john@mayo.edu.
Obesity increases the risk for metabolic syndrome, diabetes, chronic kidney disease, cardiomyopat... more Obesity increases the risk for metabolic syndrome, diabetes, chronic kidney disease, cardiomyopathy, heart failure, fatty liver disease, and certain types of cancer while also causing increased health-care costs. Diabetes, often correlated with obesity, can result in chronic kidney disease and end-stage renal failure, while obesity itself can aggravate end-stage liver disease or cause nonalcoholic steatohepatitis (NASH). Bariatric surgery has demonstrated its safety and efficacy and may be beneficial for both pre- and posttransplant patients. Due to insufficient information in the literature about bariatric surgery in transplant patients, no definitive, ideal procedure exists. In this chapter, we evaluate features and outcomes of bariatric procedures (pre-, during, and posttransplant) in obese patients with solid organ (kidney, liver, and heart) transplantation. According to literature review and analysis, pure restrictive laparoscopic sleeve gastrectomy has demonstrated its superio...
The American surgeon, 2018
Colorectal cancer (CRC) is one of the most frequent oncologic diagnoses in the United States toda... more Colorectal cancer (CRC) is one of the most frequent oncologic diagnoses in the United States today with 40,000 patients diagnosed with CRC yearly. Almost a quarter will present with liver metastases at the time of diagnosis and others will have isolated liver recurrence during surveillance.1 To date, the only curable treatment option for CRC patients with liver metastasis remains resection of the primary site and metastatic lesions, achieving five-year survival rate up to 40 per cent.1 Patients usually require a sequential treatment strategy because of the complexity of the disease. There are several different treatment strategies for patients at different presentation and stages of metastatic colorectal cancer (mCRC) to the liver. Patients may undergo resection of the primary tumor with staged hepatectomy, combined surgical resection of CRC and synchronous mCRC, or a “liver-first” strategy.1, 2 For patients with bilobar mCRC isolated to the liver, advanced techniques are required to spare and hypertrophy noninvolved parenchyma while performing complete resection of all involved areas. Portal vein embolization (PVE) or ligation followed by hepatectomy is a well-established technique indicated for patients requiring hypertrophy of the functional liver remnant (FLR) to avoid posthepatectomy liver failure.2, 3 Alternatively, “associating liver partition and portal vein ligation for staged hepatectomy” has also been recently introduced as a strategy to deal with small functional remnant liver and can be used for patients with bilobar disease.3 The use of “selective internal radiation therapy” with yttrium-90 (Y-90) radioembolization has been providing radiological response for locally advanced liver tumor and metastases.2, 4 Furthermore, selective internal radiation therapy with Y-90 can cause significant hypertrophy of the contralateral liver lobe, becoming an interesting option to achieve hypertrophy of the FLR in addition to local tumor control.2 These specific features make this a novel treatment option advantageous over previous therapies. Herein, we present a case of a CRC patient with diffuse bilateral metachronous liver metastasis with sparing of only the caudate lobe. Transarterial radiation lobectomy with Y-90 to the right lobe followed by left lateral hepatectomy and nonanatomic segment IV resection was carried out in the first stage. The second stage consisted of PVE with subsequent right hepatectomy after allowing hypertrophy of a viable FLR. To our knowledge, this is the first case in the literature where Y-90 radioembolization was used in combination with PVE and staged hepatectomy for diffuse bilateral metastatic colorectal liver lesions. A 60-year-old man presented to our center with the diagnosis of diffuse metachronous biopsy–proven mCRC (KRAS wild type) nine months after the resection of a primary CRC tumor. MRI confirmed the existence of multiple liver metastases involving both lobes of the liver. Segment IV contained one superficial small lesion and the caudate lobe was free of disease. The total liver volume was 1435 cc with segment IV and caudate lobe measuring 230 cc (16% of total liver volume) (Fig. 1A). The case was discussed at multidisciplinary tumor board and a treatment strategy was devised. The patient underwent five months of systemic chemotherapies (FOLFOX, Avastin) showing positive radiologic response. At this point, he underwent visceral angiogram with treatment of the right hepatic lobe with Y-90 microspheres (Fig. 1B). Ten days after transarterial radiation lobectomy with Y-90, he underwent a successful left lateral hepatectomy and nonanatomic segment IV resection achieving clearance of the metastatic lesions in the FLR. Pathologic study of the surgical specimen identified mCRC lesions ranging from 0.2 to 3.2 cm. The procedure was well tolerated and the patient was discharged on postoperative day 3 with close follow-up. Address correspondence and reprint requests to John Andrew Stauffer, M.D., Department of Surgery, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224. E-mail: stauffer.john@ mayo.edu.
The American surgeon, 2017
Postcholecystectomy syndrome continues to be a longstanding diagnostic and clinical challenge for... more Postcholecystectomy syndrome continues to be a longstanding diagnostic and clinical challenge for surgeons. One of the possible causes of this syndrome is incomplete gallbladder removal at the initial operation, resulting in a remnant gallbladder. This may occur after either an open or laparoscopic procedure where a “subtotal cholecystectomy” is performed. Herein, we report a case of remnant cholecystitis requiring surgical reintervention and discuss the surgical management of the disease with pertinent literature review. A 27-year-old woman presented to the emergency room with epigastric abdominal pain radiating to her back associated with nausea and vomiting. Her past surgical history included undergoing a complicated laparoscopic cholecystectomy for acute cholecystitis one year prior. According to the operative note, there was significant acute inflammation in the area of Calot’s triangle and it was felt unsafe to persist in dissection toward the hilum. Therefore, the infundibulum of the gallbladder was transected with a linear stapler and a subtotal cholecystectomy was performed. Despite this operation, her postprandial right upper quadrant abdominal pain persisted into the postoperative period, worsening mostly at night. Gastroenterology workup over the next several months did not reveal any other abnormalities. Ultimately, crosssectional abdominal MRI with magnetic resonance cholangiopancreatography (MRCP) was performed and the patient was noted to have remnant gallbladder with impacted gallstone (Fig 1A and B). Laparoscopic remnant cholecystectomy was recommended and the patient was taken to the operating room. Lysis of adhesions was performed and the remnant gallbladder was clearly identified with a large impacted stone (Fig. 1C). After circumferential dissection, single cystic artery and cystic duct were exposed and a window was made around the structures away from the hepatoduodenal ligament (Fig. 1D). These were clipped twice distally and once proximally and transected. The remnant gallbladder was removed off the inferior cystic plate with monopolar electrocautery. The operative time was under 30 minutes and the anatomy was easily defined due to the lack of inflammatory changes that were encountered by the initial operative team. The patient was discharged home several hours later and experienced a full and rapid recovery with complete resolution of her symptoms. Reasons for incomplete gallbladder resection include poor visualization of gallbladder fossa during surgery due to adhesions, concurrent inflammation, excessive bleeding, or confounding gallbladder morphology such as a congenital duplication or an hourglass configuration due to adenomyomatosis.1 Elshaer et al.2 reported meta-analysis of 30 studies with a total of 1231 patients undergoing subtotal
OBJECTIVE The Superior Mesenteric Artery Syndrome (SMAS) was first described by Rokitansky in 184... more OBJECTIVE The Superior Mesenteric Artery Syndrome (SMAS) was first described by Rokitansky in 1842. Clinical symptoms include postprandial pain, nausea, vomiting and weight loss. Duodenojejunostomy is the treatment of choice for patients with SMAS. We now present a case of a young female with SMAS who successfully underwent laparoscopic duodenojejunostomy. INDICATIONS The first line treatment for SMAS is medical management, which includes infusion therapy, bowel rest, parenteral nutrition and a nasojejunal feeding tube inserted into the jejunum past the obstruction. If medical therapy fails, surgery is recommended. PROCEDURE A symptomatic patient with body mass index (BMI) of 19.4 kg/m2 underwent laparoscopic duodenojejunostomy. The patient tolerated the procedure well. The post-operative period was uneventful and the patient was discharged after three days. On six month follow up, the patient had gained weight and her symptoms were completely resolved. CONCLUSION SMAS is still a po...
IntroductionObesity is frequently encountered in patients with orthotopic liver transplant (OLT).... more IntroductionObesity is frequently encountered in patients with orthotopic liver transplant (OLT). The role of bariatric surgery is still unclear for this specific population. The aim of this study was to review our experience with laparoscopic sleeve gastrectomy (LSG) after OLT.Material and MethodsWe performed a retrospective case-control study of patients undergoing LSG after OLT from 2010 to 2016. OLT-LSG patients were matched by age, sex, body mass index (BMI), and year to non-OLT patients undergoing LSG. Demographics, operative variables, postoperative events, and long-term weight loss with comorbidity resolution were collected and compared between cases and controls.ResultsOf 303 patients undergoing LSG, 12 (4%) had previous OLT. They were matched to 36 non-OLT patients. No difference was found between groups in the American Society of Anesthesiologists class, mean operative time, or postoperative morbidity. The non-OLT group, however, had a significantly shorter mean hospital ...
Journal of the American College of Surgeons, Oct 1, 2017
63.5%), followed by left hepatectomy (30.8% vs 23.1%) and extended right hepatectomy (7.7% vs. 13... more 63.5%), followed by left hepatectomy (30.8% vs 23.1%) and extended right hepatectomy (7.7% vs. 13.5%). Operating time for LH and OH was 402.5 and 373.5 minutes, blood loss was 350 ml and 560 ml, and length of stay was 6 days and 7 days respectively. No difference in postoperative outcome was observed. The 5-year survival rate for LH and OH for hepatocellular carcinoma was 71.6% and 63.9% (p¼0.959) and for colorectal liver metastasis was 100% and 57.8% (p¼0.183). CONCLUSIONS: LH was associated with less blood loss and shorter hospital stay than OH with similar oncological outcome.
Postgraduate medicine, 1961
Acute perforations of the gastrointestinal tract (GI) with subsequent release of gastric or intes... more Acute perforations of the gastrointestinal tract (GI) with subsequent release of gastric or intestinal contents into the peritoneal space have multiple causes and portend a high mortality depending on the cause. The key symptom is a sudden appearance of abdominal pain followed by signs of peritoneal irritation, severe sepsis, or shock. A proper imaging evaluation should lead to surgical intervention and aggressive supportive management.
Journal of Laparoendoscopic & Advanced Surgical Techniques