Cirrhotic liver disease is an important cause of peri-operative morbidity and mortality in general surgical patients. Early recog-nition and optimization of liver dysfunction is imperative before any elective surgery. Patients with MELD <12 or classified asChild A have a higher morbidity and mortality than matched controls without liver dysfunction, but are generally safe for electiveprocedures with appropriate patient education.
“Choledocholithiasis occurs in 3.4% of patients undergoing laparoscopic cholecystectomy but more than one third of these pass the calculi spontaneously within 6 weeks of operation and may be spared endoscopic retrograde cholangiopancreatography.” (Collins)
“Between January 1995 and April 2003, 1595 patients underwent PD for periampullary disease (392 benign, 1203 malignant). A retrospective analysis of a prospectively collected database was performed to determine the incidence of biliary stricture after PD.”
Results: “Forty-two of the 1595 patients (2.6%) who underwent PD developed postoperative jaundice secondary to a stricture of the biliary-enteric anastomosis. There was no difference in the incidence of biliary strictures after resection for benign (n = 10, 2.6%) or malignant disease (n = 32, 2.6%). The median time to stricture formation resulting in jaundice was 13 months (range, 1–106 months) and was similar for patients with benign and malignant disease. Preoperative jaundice did not protect against biliary stricture formation. By univariate analysis, biliary strictures were associated with preoperative percutaneous biliary drainage (odds ratio [OR] = 2.11, P = 0.02) and postoperative biliary stenting (OR = 2.11, P = 0.013). Postoperative chemoradiotherapy in patients with malignant disease was not associated with stricture formation. All strictures were initially managed with percutaneous biliary balloon dilatation and stenting, and only 2 patients required redo hepaticojejunostomy. Recurrent neoplastic disease was discovered in only 3 of the 32 patients (9%) with malignant disease. All 3 of these patients had cholangiocarcinoma as their initial diagnosis.”
Continue reading“Pneumobilia should be differentiated from portal venous gas. Portal venous gas is peripherally distributed to within 2 cm of the liver margin, whereas pneumobilia is centrally distributed.” (Gupta, P, et al. “PLAIN FILMS: BASICS.” Acute Care Surgery: Imaging Essentials for Rapid Diagnosis Eds. Kathryn L. Butler, et al. McGraw Hill, 2015.)
Continue readingPaolino J, Steinhagen RM. Colorectal surgery in cirrhotic patients. ScientificWorldJournal. 2014 Jan 15;2014:239293. Free full-text.
Patients with cirrhosis have a greater risk of morbidity and mortality following colorectal surgery. Therefore, preoperative medical optimization and risk assessment using criteria such as the MELD score are vital in preventing complications. Some risk factors include age, urgency of surgery, and ASA score. Postoperative morbidity and mortality are related to portal hypertension, ascites, infection, and anastomotic and stomal complications. This review highlights the assessment of risk and perioperative management of cirrhotic patients undergoing colorectal surgery.
Here are recent publications on the management of necrotizing pancreatitis.
BACKGROUND: The 2010 randomized PANTER trial in (infected) necrotizing pancreatitis found a minimally invasive step-up approach to be superior to primary open necrosectomy for the primary combined endpoint of mortality and major complications, but long-term results are unknown.
NEW FINDINGS: With extended follow-up, in the step-up group, patients had fewer incisional hernias, less exocrine insufficiency and a trend towards less endocrine insufficiency. No differences between groups were seen for recurrent or chronic pancreatitis, pancreatic endoscopic or surgical interventions, quality of life or costs.
IMPACT: Considering both short and long-term results, the step-up approach is superior to open necrosectomy for the treatment of infected necrotizing pancreatitis.
Continue readingHo VP, Patel NJ, Bokhari F, et al. Management of adult pancreatic injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2017 Jan;82(1):185-199. Free-full text.
In summary, we propose the following recommendations:
Surgical Focus 