Large periampullary villous tumor of the duodenum

A 67-year-old woman, who had symptoms of epigastric pain and abdominal distension, was found, on endoscopy, to have a large sessile villous adenoma of the periampullary duodenum. Despite the lack of evidence of malignancy, a pancreaticoduodenectomy procedure was performed, mainly because of the tumor size and site, involving the ampulla of Vater. The presence of the carcinoma was diagnosed only in the resected specimen by definitive histology. Because there is no general consensus on the optimal surgical procedure for the treatment of villous tumors of the duodenum, especially for the early stages, the indications for the operative procedure are discussed, based on a review of the literature

CAUSES, PREDICTIVE FACTORS AND MANAGEMENT OF CONVERSIONS IN 223 CONSECUTIVE LAPAROSCOPIC LIVER RESECTIONS

Background. As a consequence of continuous technical developments in liver surgery, laparoscopic liver resection (LLR) is increasingly performed worldwide, especially for malignancies. We report herein a single institution 7-year experience in LLR, focusing on causes of conversion, technical issues and outcomes. Method: Between January 2004 and December 2010, 223 LLR were performed in 200 patients for benign, live donation, primary and metastatic liver disease. Repeat LLR and two-stage hepatectomy were performed in 19 (8.5%) and 3 (1.3%) cases, respectively. Simultaneous resection of colo-rectal primary cancer and synchronous liver metastases was done in 6 (2.7%) patients. Results: Overall conversion rate was 17/223 (7.6%), mainly due to bleeding episodes (52.9%). Conversions were equally distributed over time and statistically significant factors for conversion were found to be LLR of P-S segments in the converted vs. the non-converted group (14.5% vs. 4.1%, p=0.012 respectively) and major vs. minor hepatectomy (17.5% vs. 5.5%, p=0.017). In malignancy, R0 resection was obtained in 91% of cases. Complication rates were scored as: n=15 grade I; n=9 grade II; n=7 grade III and n=1 grade IV. Multivariate analysis revealed resections involving P-S segments as an independent risk factor for conversion (p=0.036, OR=3.2, CI=1.1-9.4). Conclusion: LLR can be safely performed accounting for low overall morbidity and a favourable outcome. LLR in P-S segments most likely lead to conversion to open approach irrespective from the learning curve, needing careful intraoperative management

Risk factors and management of conversions to an open approach in laparoscopic liver resection: analysis of 265 consecutive cases

Background: As a consequence of continuous technical developments in liver surgery, laparoscopic liver resection (LLR) is increasingly performed worldwide. Methods: Between January 2004 and December 2011, 265 LLR were performed in 242 patients for various diseases. The experience of LLR is reported focusing on risk factors of conversion and their management. Results: The overall conversion rate was 17/265 (6.4%), equally distributed over the period of the study. Statistically significant factors for conversion were found to be LLR of the postero-superior (P-S) segments (SI, SIVa; SVII; SVIII) (12.7% converted versus 2.5% non-converted groups, P = 0.01) and a major compared with a minor hepatectomy (15.2% vs. 4.6%, P = 0.02 respectively). A R0 resection was achieved in 93.2% of cases. According to Dindo's classification, complications were recorded as grade I (n = 20); grade II (6); grade III (11) and grade IV(1) events (total morbidity rate of 14%). Univariate analysis identified a major hepatectomy and resection involving P-S segments as prognostic factors for conversion whereas multivariate analysis identified the latter as an independent risk factor [P = 0.003, odds ratio (OR) = 5.9, 95% confidence interval (CI) = 1.8-18.8]. Conclusions: LLR can be safely performed with low overall morbidity. According to this experience and irrespective of the learning curve, resections of P-S segments were identified as an independent risk factor for conversion in LLR