Association between biliary complications and technique of hilar division (extrahepatic vs. intrahepatic) in major liver resections

BACKGROUND: Division of major vascular and biliary structures during major hepatectomies can be carried out either extrahepatically at the porta hepatic or intrahepatically during the parenchymal transection. In this retrospective study we test the hypothesis that the intrahepatic technique is associated with less early biliary complications. METHODS: 150 patients who underwent major hepatectomies were retrospectively allocated into an intrahepatic group (n = 100) and an extrahepatic group (n = 50) based on the technique of hilar division. The two groups were operated by two different surgical teams, each one favoring one of the two approaches for hilar dissection. Operative data (warm ischemic time, operative time, blood loss), biliary complications, morbidity and mortality rates were analyzed. RESULTS: In extrahepatic patients, operative time was longer (245 ± 50 vs 214 ± 38 min, p < 0.05) while the overall complication rate (55% vs 52%), hospital stay (13 ± 7 vs 12 ± 4 days), bile leak rate (22% vs 20%) and mortality (2% vs 2%) were similar compared to intrahepatic patients. However, most (57%) bile leaks in extrahepatic patients were grade II (leaks that required non-operative interventional treatment, while most (70%) leaks in the intrahepatic group were grade I (leaks that resolved and presented two injuries (4%) of the remaining bile ducts (p < 0.05). CONCLUSION: Intrahepatic hilar division is as safe as extrahepatic hilar division in terms of intraoperative blood requirements, morbidity and mortality. The extrahepatic technique is associated with more severe bile leaks and biliary injuries

Conservative treatment of acute appendicitis: heresy or an effective and acceptable alternative to surgery?

For more than a century, emergency appendectomy has been a ‘surgical dogma’ in the management of acute appendicitis (AA). During recent decades, however, there is an increasing body of evidence suggesting that selected patients with AA could be treated conservatively. This approach has many advantages, including high success and low recurrence rates, reduced morbidity and mortality, less pain, shorter hospitalization and sick leave, and reduced costs. Despite that conservative management of AA cannot be used for all patients with AA (for example, in the presence of peritonitis), it could be preferred in a large percentage of patients with mild infection (as evidenced by clinical, laboratory, and imaging findings). Eur J Gastroenterol Hepatol 23:121-127 (C) 2011 Wolters Kluwer Health vertical bar Lippincott Williams &amp; Wilkins