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Surgical indication for gallbladder cancer
588
Journal of Gastrointestinal Surgery
Abstracts
8 mm balloon angioplasty catheters with an excellent cholangiographic result. A brush biopsy was obtained at the end of the procedure and it showed no evidence of malignancy. There were no complications. The patient was discharged home the next day. The technique described combines laparoscopic cholecystectomy with laparoscopic balloon dilatation and brush biopsy using a transcystic approach. This allowed us to manage simultaneously the cholelithiasis and the benign CBD stricture without the morbidity of additional procedures. We are not aware of any description of this technique in surgical literature.
217 SURGICAL INDICATION FOR GALLBLADDER CANCER Hiroyuki Baba, MD, PhD, Gaku Matsumoto, MD, PhD, Koji Tsuruta, MD, PhD, Atsutake Okamoto, MD, PhD, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan There are still controversies for adequate lymph node dissection for advanced gallbladder cancer. The aim of this study is to evaluate the long-term results in patients who had undergone various surgical procedures against gallbladder cancer from the standpoint of lymph node metastases. 144 patients who were diagnosed as gallbladder cancer from July 1975 to May 2001 at Tokyo Metropolitan Komagome Hospital were briefly reviewed. Lymph node dissection was carried out in every surgical procedure. Extended cholecystectomy was defined as cholecystectomy with liver resection of any volume. Modified extended cholecytectomy was defined as cholecystectomy without liver resection. 81 patients underwent surgery and the total number of extended cholecystectomy was 65. Dissected lymph nodes were examined according to the TNM classification (sixth edition, 2002) and number of positive nodes was counted. There were 22 males and 59 females, with the average age of 68. Extended cholecystectomy group included 8 cases of hepatopancreatoduodenectomies. Modified extended cholecystectomy group consist of 12 cholecystectomies and 4 pancreaticoduodenectomies. Average number of dissected lymph nodes were 15.1 ⫾ 11.4. There were 36 node positive cases and the average positive nodes were 2.9 ⫾ 2.5. Significant prognostic factors according to the Coxhazard model were number of involved nodes (node negative group vs. 4 or more node positive group; HR 0.059, P ⬍ 0.0001, 95% CI: 0.024-0.143, 1 to 3 node positive group vs. 4 or more node positive group; HR 0.189, P ⫽ 0.0001, 95% CI: 0.080-0.445) and operative procedure (extended cholecystectomy group vs. modified extended cholecystectomy group; HR 0.507, P ⫽ 0.0366, 95% CI: 0.268-0.959). When the involved lymph nodes were within the regional nodes (pN1), survival curve was significantly better than cases with extensive node involvement (M1: LYM) (P ⫽ 0.0001). However, even in pN1 group, when the number of involved nodes was 4 or more, the survival did not differ from M1: LYM group. Liver resection included 25 partial resections, 26 segmentectomies, and 14 lobectomies. Liver resection method did not influence the survival (P ⫽ 0.1216); 79% of pathologically liver invasion positive cases showed node involvement (P ⫽ 0.0005). Survival ratio did not differ among none, one or two involved organs, which may encourage radical resection. Regional lymph node dissection and liver resection can be concluded as a standard procedure for gallbladder cancer. Regional lymph node dissection is indispensable but sufficient, although the number of involved nodes is a prognostic factor.
218 BILE DUCT INJURIES: RESULTS OF 44 CASES IN A SINGLE UNIT Andre De Moricz, MD, Fabricio Pereira Andrade, MD, Tercio De Campos, MD, Alexandre Schinit Sassatani, MD, Fernando Leal Pereira, MD, Fernando Torres Vasquez, MD, Adhemar Monteiro
Pacheco, Jr., MD, PhD, Santa Casa School of Medicine, Sao Paulo, Brazil The aim of this study was to evaluate how the moment of diagnosis, the severity of injury (classification), and the different kinds of repair affect outcome of the patients treated with iatrogenic bile duct injuries. There were 4077 elective cholecystectomies (2497 open and 1580 laparoscopic) performed in our service between March 1984 and August 2004. Forty-four patients sustained biliary tract injury, and 21 among them were referred from other hospitals. There were 39 women (88.6%) and 5 men (11.4%) with a mean age of 46.7 years. They were evaluated for the moment of the injury: during-operation, precocious (until 30th day after surgery), and later. The injuries were separated under Strasberg and Bismuth classification, and their surgical repair results were evaluated as well. The data of cholangiography results during operation time were collected. The injury rates in open and laparoscopic cholecystectomies were 0.6% and 0.5%, respectively (P ⫽ 0.861). The injury diagnosis was established during operation in 28 patients, precocious in 7 and later in 9. There were 19 (43.2%) cholangiographic studies performed with 10.5% of missed injuries during operation (P ⫽ 0.290). The rates of success of bile duct injury treatment were 67.9%, 14.3%, and 88.9% for the three different moments evaluated. The patients treated in the precocious period of time had worse outcome compared with those treated during and later after surgery (P ⫽ 0.027 and 0.01). When the modalities of surgical repair were analyzed, the results about success rates showed single suture, 69.2%; suture with T-tube, 83.3%; duct-to-duct anastomosis, 33.3%; and biliary bypass, 63.2% (P ⫽ 0.686). There were no statistical differences between outcomes of patients submitted to one- or two-layer biliary bypass and the severity of injury did not influence outcome. The mean follow-up period of time was 26.9 months (1-192 months). For patients with bile duct injuries treated in our institution: the moment of treatment had influenced the outcome; the modality of repair and the severity of injury did not change the outcome, and the cholangiography had no significance in the final results.
219 MANAGEMENT OF COMPLEX BILE DUCT INJURIES Eduardo de Santiban˜es, Juan Pekolj, Rodrigo Sa´nchez Claria´, Martı´n Palavecino, Christian Bertona, Emilio Quin˜onez, Hospital Italiano, Buenos Aires, Argentina Laparoscopic cholecystectomy (LC) is the treatment of choice for gallbladder stones. This approach was associated with a higher incidence of biliary injuries (BDI). These injuries seem to be more complex. We considered complex injuries those 1) that involve the confluence; 2) with a previous failed repair; 3) associated with a vascular injury; or 4) with portal hypertension or secondary biliary cirrhosis. Between 1989 and 2003, 166 patients with BCI were treated in our Unit. 91 patients were female. The mean age of the patients was 46.2 years (range: 6-74). 21 BDIs were inflicted in our institution and 133 were referred from other institutions. Injuries were diagnosed during the surgical procedure in 39 cases (25.3%). In our own series of 5084 LCs, the incidence of BDI was 0.15% (8 patients) whereas in the open procedure it was 0.18%. 115 were produced during the open procedure and 51 occurred during LC. 107 patients (64.4%) were complex BDIs, 10 of which met more than one criterium. 54 involved the hepatic confluence, 38 were high stenoses with unsuccessful repair attempts, 7 had associated vascular injuries, and 18 had associated portal hypertension or secondary biliary cirrhosis. Percutaneous transhepatic biliary drainage (PTBD) was employed in 30 patients. Balloon dilatation was used in 12 patients and auto-expandable metallic prosthesis in 1 patient. Hepaticojejunostomy (HJ) as initial treatment was performed in 87 cases. HJ was also carried out for biliary stenosis
Journal of Gastrointestinal Surgery
Abstracts
8 mm balloon angioplasty catheters with an excellent cholangiographic result. A brush biopsy was obtained at the end of the procedure and it showed no evidence of malignancy. There were no complications. The patient was discharged home the next day. The technique described combines laparoscopic cholecystectomy with laparoscopic balloon dilatation and brush biopsy using a transcystic approach. This allowed us to manage simultaneously the cholelithiasis and the benign CBD stricture without the morbidity of additional procedures. We are not aware of any description of this technique in surgical literature.
217 SURGICAL INDICATION FOR GALLBLADDER CANCER Hiroyuki Baba, MD, PhD, Gaku Matsumoto, MD, PhD, Koji Tsuruta, MD, PhD, Atsutake Okamoto, MD, PhD, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan There are still controversies for adequate lymph node dissection for advanced gallbladder cancer. The aim of this study is to evaluate the long-term results in patients who had undergone various surgical procedures against gallbladder cancer from the standpoint of lymph node metastases. 144 patients who were diagnosed as gallbladder cancer from July 1975 to May 2001 at Tokyo Metropolitan Komagome Hospital were briefly reviewed. Lymph node dissection was carried out in every surgical procedure. Extended cholecystectomy was defined as cholecystectomy with liver resection of any volume. Modified extended cholecytectomy was defined as cholecystectomy without liver resection. 81 patients underwent surgery and the total number of extended cholecystectomy was 65. Dissected lymph nodes were examined according to the TNM classification (sixth edition, 2002) and number of positive nodes was counted. There were 22 males and 59 females, with the average age of 68. Extended cholecystectomy group included 8 cases of hepatopancreatoduodenectomies. Modified extended cholecystectomy group consist of 12 cholecystectomies and 4 pancreaticoduodenectomies. Average number of dissected lymph nodes were 15.1 ⫾ 11.4. There were 36 node positive cases and the average positive nodes were 2.9 ⫾ 2.5. Significant prognostic factors according to the Coxhazard model were number of involved nodes (node negative group vs. 4 or more node positive group; HR 0.059, P ⬍ 0.0001, 95% CI: 0.024-0.143, 1 to 3 node positive group vs. 4 or more node positive group; HR 0.189, P ⫽ 0.0001, 95% CI: 0.080-0.445) and operative procedure (extended cholecystectomy group vs. modified extended cholecystectomy group; HR 0.507, P ⫽ 0.0366, 95% CI: 0.268-0.959). When the involved lymph nodes were within the regional nodes (pN1), survival curve was significantly better than cases with extensive node involvement (M1: LYM) (P ⫽ 0.0001). However, even in pN1 group, when the number of involved nodes was 4 or more, the survival did not differ from M1: LYM group. Liver resection included 25 partial resections, 26 segmentectomies, and 14 lobectomies. Liver resection method did not influence the survival (P ⫽ 0.1216); 79% of pathologically liver invasion positive cases showed node involvement (P ⫽ 0.0005). Survival ratio did not differ among none, one or two involved organs, which may encourage radical resection. Regional lymph node dissection and liver resection can be concluded as a standard procedure for gallbladder cancer. Regional lymph node dissection is indispensable but sufficient, although the number of involved nodes is a prognostic factor.
218 BILE DUCT INJURIES: RESULTS OF 44 CASES IN A SINGLE UNIT Andre De Moricz, MD, Fabricio Pereira Andrade, MD, Tercio De Campos, MD, Alexandre Schinit Sassatani, MD, Fernando Leal Pereira, MD, Fernando Torres Vasquez, MD, Adhemar Monteiro
Pacheco, Jr., MD, PhD, Santa Casa School of Medicine, Sao Paulo, Brazil The aim of this study was to evaluate how the moment of diagnosis, the severity of injury (classification), and the different kinds of repair affect outcome of the patients treated with iatrogenic bile duct injuries. There were 4077 elective cholecystectomies (2497 open and 1580 laparoscopic) performed in our service between March 1984 and August 2004. Forty-four patients sustained biliary tract injury, and 21 among them were referred from other hospitals. There were 39 women (88.6%) and 5 men (11.4%) with a mean age of 46.7 years. They were evaluated for the moment of the injury: during-operation, precocious (until 30th day after surgery), and later. The injuries were separated under Strasberg and Bismuth classification, and their surgical repair results were evaluated as well. The data of cholangiography results during operation time were collected. The injury rates in open and laparoscopic cholecystectomies were 0.6% and 0.5%, respectively (P ⫽ 0.861). The injury diagnosis was established during operation in 28 patients, precocious in 7 and later in 9. There were 19 (43.2%) cholangiographic studies performed with 10.5% of missed injuries during operation (P ⫽ 0.290). The rates of success of bile duct injury treatment were 67.9%, 14.3%, and 88.9% for the three different moments evaluated. The patients treated in the precocious period of time had worse outcome compared with those treated during and later after surgery (P ⫽ 0.027 and 0.01). When the modalities of surgical repair were analyzed, the results about success rates showed single suture, 69.2%; suture with T-tube, 83.3%; duct-to-duct anastomosis, 33.3%; and biliary bypass, 63.2% (P ⫽ 0.686). There were no statistical differences between outcomes of patients submitted to one- or two-layer biliary bypass and the severity of injury did not influence outcome. The mean follow-up period of time was 26.9 months (1-192 months). For patients with bile duct injuries treated in our institution: the moment of treatment had influenced the outcome; the modality of repair and the severity of injury did not change the outcome, and the cholangiography had no significance in the final results.
219 MANAGEMENT OF COMPLEX BILE DUCT INJURIES Eduardo de Santiban˜es, Juan Pekolj, Rodrigo Sa´nchez Claria´, Martı´n Palavecino, Christian Bertona, Emilio Quin˜onez, Hospital Italiano, Buenos Aires, Argentina Laparoscopic cholecystectomy (LC) is the treatment of choice for gallbladder stones. This approach was associated with a higher incidence of biliary injuries (BDI). These injuries seem to be more complex. We considered complex injuries those 1) that involve the confluence; 2) with a previous failed repair; 3) associated with a vascular injury; or 4) with portal hypertension or secondary biliary cirrhosis. Between 1989 and 2003, 166 patients with BCI were treated in our Unit. 91 patients were female. The mean age of the patients was 46.2 years (range: 6-74). 21 BDIs were inflicted in our institution and 133 were referred from other institutions. Injuries were diagnosed during the surgical procedure in 39 cases (25.3%). In our own series of 5084 LCs, the incidence of BDI was 0.15% (8 patients) whereas in the open procedure it was 0.18%. 115 were produced during the open procedure and 51 occurred during LC. 107 patients (64.4%) were complex BDIs, 10 of which met more than one criterium. 54 involved the hepatic confluence, 38 were high stenoses with unsuccessful repair attempts, 7 had associated vascular injuries, and 18 had associated portal hypertension or secondary biliary cirrhosis. Percutaneous transhepatic biliary drainage (PTBD) was employed in 30 patients. Balloon dilatation was used in 12 patients and auto-expandable metallic prosthesis in 1 patient. Hepaticojejunostomy (HJ) as initial treatment was performed in 87 cases. HJ was also carried out for biliary stenosis