Iatrogenic perforation of the gallbladder during laparoscopic cholecystectomy is a well-known occurrence; however, the consequences of spillage of gallstones in the peritoneum and particularly intrathoracic complications are less defined. We describe the delayed development of a perihepatic abscess and empyema in a patient five years following laparoscopic cholecystectomy secondary to dropped gallstones. A 53-year-old man with medical history significant for a laparoscopic cholecystectomy five years prior to acute cholecystitis presented with purulent cough, hemoptysis, night sweats, and right-upper quadrant (RUQ) pain. Computed tomography (CT) scan revealed 5.4 cm right-sided subpulmonic and 5.9 cm perihepatic fluid collections with an 8mm focal radiopaque density within the perihepatic fluid collection. Open intra-abdominal exploration resulted in retrieval of a 1 cm intraperitoneal gallstone. Laparoscopic cholecystectomy is a common surgical operation during which gallstone spillage can occur, causing both intra-abdominal and intrathoracic complications, presenting even years after surgery. This necessitates an attempt to retrieve all free intra-abdominal gallstones during the initial operation.

Background: Laparoscopic Roux-en-Y gastric bypass surgery (RYGB) was introduced at the authors' institution 5 years ago. The authors analyzed the short- and long-term results of this procedure compared with those for the same procedure using the laparotomy approach over the same period.Methods: Retrospective analysis of a prospectively collected bariatric database used the outcome end points used by the American Society of Bariatric Surgery (ASBS) and the American College of Surgeons (ACS) in their center of excellence programs.Results: From January 2001 to July 2005, 568 laparoscopic and 399 open gastric bypasses were performed at Vanderbilt University. The patients were from the same bariatric surgery program and therefore received the same pre- and postoperative care. The hospital length of stay in the laparoscopic group was significantly shorter (2.5 +/- 2.4 days) than in the open group (3.7 +/- 3.7 days; p = 0.001). The procedure time was significantly shorter in the laparoscopic group (164 +/- 50 min) than in the open group (195 +/- 50 min; p = 0.0001). The follow-up assessment response at 2 years was 76.6%. At 2 years, the excess weight loss (EWL) was significantly greater in the laparoscopic group (71.3% +/- 18.4%) than in the open group (67.3% +/- 15.3%; p = 0.03). The wound infection rate was significantly higher in open group (9.2%) than in the laparoscopic group (1.7%; p = 0.001). There was no significant difference in 30day mortality: open (0.50%) versus laparoscopic (0.17%; p = 0.371). There was no significant difference in the 30-day reoperation rate between the open (2.4%) and laparoscopic (2.6%; p = 0.705) groups. The 30-day readmission rate was similar in the open (5.0%) and laparoscopic (5.2%; p = 0.852) groups, as was the rate of leakage from the gastrojejunostomy in the open (0.50%) and laparoscopic (0.35%; p = 0.127) groups. The conversion rate from laparoscopic procedure to laparotomy was 1.7%.Conclusion: In the authors' institution, a laparoscopic bariatric surgery program with a very low rate of morbidity and mortality has been introduced. Operative time, hospital stay, and wound complications are reduced with the laparoscopic approach. The laparoscopic and open procedures are equally safe, with equivalent 30-day mortality, readmission, reoperation, and gastrojejunostomy leakage rates.

Background. Appropriate patient selection is crucial to the success of bariatric surgery (BaS). The objective of this study was to identify risk factors for increased post-operative mortality in patients undergoing BaS using a nationally representative sample.Materials and methods. BaS patients >= 18 years old in the United States were identified from the 2001 Nationwide Inpatient Sample (NIS). The effect of gender, age, insurance status, and need for re-operation on post-operative mortality was examined using a multivariate logistic regression model.Results. A national cohort of 54,878 patients was identified with age 41 +/- 0.2 years (mean +/- SE), 84 % women, length of stay (LOS) 3.9 +/- 0.2 days, and overall mortality of 4 per 1,000 BaS patients. Mean LOS of those who died was 17.6 +/- 3.7 days. Adjusting for comorbidities and demographics, men had increased likelihood of death [odds ratio (OR) 2.1, 95 % confidence interval (CI) 1.1-4.3, P < 0.05]. Compared to younger patients, those aged above 39 years had over two-fold risk of death [ages 40-49: OR 2.6, 95 % CI 1.1-6.5, P < 0.05; ages 50-59: OR 4.3, 95 % CI 1.7-11, P < 0.05]. Medicaid patients [OR 4.7, 95 % CI 1.2-13, P < 0.05 compared to privately insured] and those requiring re-operation [OR 22, 95 % CI 5.4-88, P < 0.05] had higher odds of dying.Conclusion. Based on national data, risk factors for increased post-operative mortality in BaS patients include male gender, age > 39 years, Medicaid insure, and need for re-operation. These data can assist in optimizing BaS patient outcomes. (c) 2005 Elsevier Inc. All rights reserved.

Poulose, Benjamin K. MD; Griffin, Marie R. MD, MPH; Speroff, Theodore PhD; Walter, Walter MD, MPH; So, Stephanie PhD; Moore, Derek E. MD, MPH; Wright, Kelly J. MD; Richards, William O. MD; Melvin, Willie MD; Grogan, Eric L. MD, MPH; Holzman, Michael D. MD, MPH Author Information

Introduction: Exploring bariatric surgery (BaS) utilization provides initial data in effective treatment allocation. This study analyzes regional and age differences in BaS utilization on a national level.

BACKGROUND:Elevated CA 19-9 may be found in both cystadenomas and cystadenocarcinomas of the liver.CASE OUTLINE:A 59-year-old woman presented with right upper quadrant abdominal pain, malaise and weight loss. Physical examination and laboratory evaluation revealed a mass in the right upper quadrant and a CA 19-9 level of 68 661 U/ml. CT scan demonstrated a cystic liver mass. She underwent a right hepatectomy, and her CA 19-9 returned to normal. Pathologic analysis revealed no malignancy.DISCUSSION:In hepatic cystic neoplasms, an elevated CA 19-9 should not be used to establish the diagnosis of malignancy nor should it preclude resection.

HYPOTHESIS Long-term quality of life (QOL) in patients undergoing laparoscopic cholecystectomy (LC) incurring bile duct injury (BDI) and repair is comparable to that of patients undergoing uncomplicated LC. DESIGN Case comparison study. SETTING Secondary and tertiary care centers. PATIENTS Eighty-six patients incurring BDI during LC between January 1, 1991, and July 31, 2003, were surveyed. Comparison subjects underwent uncomplicated LC during the same period. MAIN OUTCOME MEASURES Health-related QOL as assessed by the Karnofsky Performance Scale, Medical Outcomes Study 36-Item Short Form Health Survey (SF-36), and Psychosocial Adjustment to Illness Scale. RESULTS Fifty patients with BDI (39 [78%] female; mean +/- SEM age, 55 +/- 2 years) and 74 patients with uncomplicated LC (51 [69%] female, mean +/- SEM age, 52 +/- 2 years) responded. Of the 50 BDI patients, 48 (96%) had no stricture and normal liver function at QOL assessment. The mean +/- SEM follow-up period to QOL assessment for the BDI and uncomplicated LC groups was 62 +/- 6 and 47 +/- 3 months, respectively. The mean +/- SD Karnofsky Performance Scale scores were 77 +/- 9 vs 93 +/- 8 for the 2 groups, respectively (P <.001). The mean +/- SD SF-36 physical component scale scores after BDI vs uncomplicated LC were 36 +/- 11 vs 47 +/- 12, respectively (P <.001), compared with 50 +/- 10 for the normal population (P <.001). The mean +/- SD SF-36 mental component scale scores were 43 +/- 14 vs 49 +/- 11 for the 2 groups, respectively (P =.02), compared with 50 +/- 10 for the normal population (P =.01). Patients with BDI scored poorer on the Psychosocial Adjustment to Illness Scale health care orientation and domestic environment scales (P=.01). CONCLUSION After BDI and repair, there are long-term detrimental effects of BDI on health-related QOL.

Introduction: Utilization of grafts from donors greater than 60 years old (older donors [OD]) presumably decreases wait time and improves overall survival; however, OD recipients have shortened survival, increased rejection and retransplantation. We examined the cost-effectiveness of using OD compared to donors less than 60 (younger donors [YD]) in liver transplantation.

BACKGROUND:. The effects of dopamine (DA) on systemic hemodynamics are better understood than its effects on hepatic hemodynamics, especially after liver denervation occurring during liver transplantation. Therefore, a porcine model was used to study DA's effects on hemodynamics after hepatic denervation.MATERIALS AND METHODS:Fifteen pigs underwent laparotomy for catheter and flow probe placement. The experimental group (n = 7) also underwent hepatic denervation. After 1 week, all pigs underwent DA infusion at increasing doses (3-30 mcg/kg/min) while measuring hepatic parameters [portal vein flow (PVF), hepatic artery flow (HAF), total hepatic blood flow (THBF = HAF + PVF), portal and hepatic vein pressures] and systemic parameters [heart rate (HR), mean arterial pressure (MAP)].RESULTS:There was a significant increase in HAF from baseline to the 30 mcg/kg/min DA infusion rate (within-subjects P < 0.01), but the differences between the two groups were not significant. PVF and THBF showed large effects (increases) with denervation, but the increase in flow with DA infusion was not present after denervation. Perihepatic pressures were unchanged by denervation or DA. Heart rate differed significantly between the control and denervated animals at baseline, 3, 6, 12 (all P < 0.05), and 30 mcg/kg/min DA (P = 0.10). Control vs denervation MAP at baseline was 100 +/- 4 vs 98 +/- 4 Torr and at 30 mcg/kg/min it was 110 +/- 3 vs 101 +/- 5 mm Hg.CONCLUSIONS:Hepatic flows tended to be higher after denervation. HAF showed similar increases with DA in both control and denervation groups. Increases in PVF and THBF with DA infusion were not present after denervation. HR was significantly decreased and MAP tended to be lower after denervation. The HR and MAP response to DA was similar in both groups. Therefore, both denervation and DA infusion have an effect on systemic and hepatic hemodynamics.

Combined multivisceral transplantation has emerged as a therapeutic option for a select patient cohort; however, clinical decision-making remains complex and controversial. The aim of this study was to examine patient characteristics, operative complications, and long-term outcomes of all patients who have undergone combined heart-lung-liver transplantation (HLLTx) in Australia.In this study, we performed a retrospective analysis of all adult patients who have undergone combined HLLTx in Australia to date. Recipient clinical characteristics, waitlist, and transplant outcomes are described.Eight adult patients have received HLLTx at a single Australian transplant center. Recipients of HLLTx have typically been young (median age, 30.1 years; range, 24-37), underweight (median body mass index, 19.8 kg/m2; range, 16.2-30.4) patients with cystic fibrosis (n = 8, 100%) with severe airflow obstruction (median forced expiratory volume in the first second of expiration, 24% predicted; range, 17%-48%) accompanied by liver cirrhosis confirmed on histopathology (n = 8, 100%). Despite relative preservation of synthetic function and low model for end-stage liver disease scores (median, 8; range, 6-17), all recipients had complications of portal hypertension prior to transplantation, with many patients having suffered life-threatening variceal hemorrhage. In this cohort, HLLTx was associated with overall posttransplant survival of 87.5% at 30 days, 71.4% at 1 year, and 42.9% at 5 years. Listing for combined HLLTx was associated with prolonged waitlist times relative to bilateral sequential single-lung transplantation (median 556 vs 56 days, respectively), however waitlist mortality and/or delisting was comparable between groups.Taken together, these findings highlight the opportunities and challenges facing combined (heart-) lung and liver transplantation in patients with multiorgan failure.

THE most commonly reported cause of sudden, devastating postoperative visual loss is anterior ischemic optic neuropathy (ION), resulting from decreased oxygen delivery to the optic nerves. 1Postoperative blindness has been previously reported in association with pressure-induced eye-injury, arterial hypotension, low hematocrit concentration, and obstruction of venous outflow. One cause of venous obstruction, superior vena cava syndrome (SVCS), is a reported but uncommon complication of liver transplantation in patients with a history of central venous thrombosis, indwelling catheters, or peritoneovenous shunts. 2–7A 43-yr-old man with hepatitis C cirrhosis had intractable ascites and a history of repeated placement of peritoneojugular shunts and placement of a transjugular intrahepatic portosystemic shunt. At the time of liver transplantation, induction of anesthesia with thiopental, fentanyl, and succinylcholine was achieved, and femoral and radial arterial catheters were placed. Because of poor peripheral venous access, insertion of peripheral, larger bore catheters was not successful. Several attempts were necessary to place central lines. Ultimately, large-bore intravenous catheters (8.5 French) were inserted into both internal jugular veins and the subclavian veins. An oximetric pulmonary artery catheter was inserted through the right internal jugular catheter. Anesthesia was maintained with isoflurane, fentanyl, and pancuronium.The transplant operation was uneventful until the third hour, when it was aborted (just before recipient hepatectomy) because malignancy within the donor organ was revealed by postmortem examination. Stable hemodynamic parameters recorded throughout the procedure included central venous pressure (8 to 9 mmHg), pulmonary artery pressure (22–25/10–15 mmHg), and cardiac index (3.2–4.0 l/m2). The administered fluids included 4 l of crystalloids, 1 l of 5% albumin, 4 units packed erythrocytes, and 4 units fresh frozen plasma. No antifibrinolytic agents were administered to the patient during the operation.During the closure of the aborted transplantation, the previously placed, nonfunctional peritoneojugular shunt was removed by sliding the venous end from the subcostal incision. Swelling and cyanosis of the patient’s face and neck were noted thereafter. The positions of all intravenous catheters were reconfirmed by the ability to draw back blood easily. Intravenous fluid maintenance was limited, and the patient was placed in the 30° reverse Trendelenburg position. Postoperatively in the intensive care unit, the head, face, and upper extremities became markedly edematous and cyanotic. A diagnosis of acute SVCS was determined, and three of four larger bore catheters were removed; the right internal jugular pulmonary artery indwelling catheter was left in place. Doppler study revealed total occlusion of both subclavian veins and the left and right internal jugular veins and a clot in the superior vena cava (SVC). Because of the facial edema, the patient remained intubated in the surgical intensive care unit, and maintenance fluid was continued through a freshly inserted femoral catheter. The patient required intermittent use of vasopressors and β-blockers to control tachycardia. By the second postoperative day, the patient had become hemodynamically stable, but there was little improvement in the signs of SVCS.A second liver allograft was identified, and liver transplantation was performed successfully 48 h later using the piggyback technique. Intravenous access for this procedure was secured through large-bore femoral vein catheters. The procedure proceeded routinely except for a 2-min extreme hypotensive episode (systolic blood pressure, 50–60 mmHg) because of acute blood loss, which was rapidly corrected with massive-volume resuscitation. Total blood loss was estimated to be approximately 6 l and during the procedure the patient received 12 l of crystalloids, 1 l albumin, 5%, 13 units packed erythrocytes, 10 units fresh frozen plasma, and 20 units platelets. The postoperative course initially was uneventful, and the patient was extubated on the third postoperative day. On the fourth postoperative day, the patient verbalized that he was unable to see, and examination showed for the first time that his pupils were fixed and dilated, with no reaction to light. Fundoscopic examination performed by the ophthalmology consultant showed bilaterally elevated, pale, and blurred optic disks. The retina in both disks was flat, and the macula and vessels seemed to be normal. Computed tomography of the head showed no evidence of acute intracranial hemorrhage or infarction. The ophthalmology consultant diagnosed the patient with bilateral anterior ION. Facial and upper extremity congestion and edema resolved as the patient recovered from the transplant procedure. Subsequent eye examinations showed no significant changes and that the patient was unable to see. The patient was discharged from the hospital on postoperative day 21, with complete bilateral blindness and resolving SVCS.In patients with recurrent ascites after peritoneovenous shunt placement, total and partial occlusion of the SVC is seen in 53 and 17% of patients, respectively. 6,7Patients with partial SVC obstruction may be asymptomatic preoperatively, but overt SVCS may develop after transplantation and placement of large-bore lines into the subclavian or jugular vein. Several cases of acute SVCS associated with peritoneovenous shunt have been reported in patients undergoing liver transplantation; however, without any alteration in vision in the postoperative period. 2–5The most commonly reported cause of postoperative visual loss is acute optic nerve ischemia. 1Visual loss as a result of ischemic injury to the optic nerve are labeled as anterior and posterior ION because these parts of the optic nerve have different blood supplies, different predisposing factors for injury, and varying clinical pictures. 1Anterior ION is characterized by sudden, progressive and painless visual-field deficit and defect in a pupillary light reaction, from a slight decrease in visual acuity to no light perception (as in the presented case). Ophtalmoscopic examination initially shows optic disk edema, which usually resolves in several weeks and is replaced by optic atropy. There are vascular causes of postoperative loss of vision other than ION. Cortical blindness, retinal occlusion, and ophthalmic venous obstruction therefore should be excluded. Cortical blindness is characterized by loss of visual sensation with retention of papillary reaction to light and normal fundoscopic examination results. Computerized tomography or magnetic resonance imaging abnormalities in the parietal or occipital lobe confirm the diagnosis. Central retinal artery occlusion presents as painless, monocular blindness. Ophthalmoscopic examination of eyes with retinal artery occlusion shows a pale edematous retina, a cherry-red spot at the fovea, and platelet–fibrin or cholesterol emboli in the narrowed retinal arterioles. Obstruction of venous drainage from the eye may occur intraoperatively when patient positioning results in external pressure on the eyes. In severe cases, ophthalmoscopic examination shows normal or dilated retinal arterioles, engorgement of the veins, and edema of the macula and the retina surrounding the optic disk. Another rare causes of postoperative blindness in liver transplantation is cyclosporine-induced neurotoxicity, which results in usually reversible cortical blindness. 8Postoperative anterior ION is the result of multiple causes of decreased oxygen delivery. It is usually associated with hypotension and blood loss. However, often there are other contributing variables, such as venous obstruction or vascular abnormalities. In a recent retrospective study of 350 patients who experienced massive trauma, anterior ION developed in 2.6%, and there was a significant association among ION, massive fluid resuscitation, and prolonged ventilatory support. 9Importantly, most of the patients in this study and those in our study were placed in the supine position.Increased venous pressure was cited previously as a contributor to postoperative anterior ION after head and neck surgery as a result of local obstruction of venous outflow. 1It is speculated that changes in central venous pressure concomitant with changes in body position result in venous stasis in the drainage of the optical nerve. Patients with SVCS or predisposition to SVCS perhaps should be positioned in the reverse Trendelenburg position. The potential for SVC thrombosis and ION should be considered in patients with a history of peritoneovenous shunt placement.

These data show that dopamine infused at dosages of 3-30 microg/kg/min augments HAF, PVF, and THBF and that this effect is linear. These results suggest high-dose dopamine infusion does not disqualify a potential donor liver for transplantation.

Background. While dopamine produces well-characterized dose-dependent effects on systemic hemodynamics, there is a paucity of information regarding its effects on hepatic hemodynamics, Infusion rates above 10 mu g/kg/min are reported to produce significant vasoconstriction and impair organ perfusion. Therefore, donors are sometimes considered unsuitable when higher doses of dopamine are in use. The aim of this study was to determine the effect of increasing doses of dopamine on hepatic hemodynamics in a nonanesthetized swine model.Materials and methods. Sixteen pigs were instrumented with indwelling catheters in a peripheral artery, peripheral vein, portal vein, and hepatic vein and flow probes around the portal vein and hepatic artery. After recovery, the following variables were measured 10 +/- 1 days postinstrumentation: hepatic arterial flow (HAF), portal venous flow (PVF), mean systemic arterial pressure (MAP), central venous pressure (CVP), portal venous pressure (PVP), hepatic venous pressure (HVP), heart rate (HR). Recordings were obtained at baseline and subsequently when dopamine was infused at rates of 3, 6, 12, 15, 21, and 30 mu g/kg/min increasing at l-h intervals.Results. HAF and PVF increased linearly over the entire infusion range, to 69 and 13% over baseline, respectively (P < 0.001, P < 0.05). Total hepatic blood flow rose 23% over baseline at the 30 mu g/kg/min dosage (P < 0.01). MAP increased linearly 13% over the range 12 to 30 mu g/kg/min (P < 0.001). CVP, HVP, and PVP did not change significantly. HR decreased from 12 to 15 mu g/kg/min (P < 0.01), then increased from 15 to 30 mu g/kg/min (P < 0.05).Conclusion. These data show that dopamine infused at dosages of 3-30 mu g/kg/min augments HAF, PVF, and THBF and that this effect is linear. These results suggest high-dose dopamine infusion does not disqualify a potential donor liver for transplantation. (C) 2000 Academic Press.

Bilioenteric reconstruction using a Roux limb of jejunum is a well-established surgical option for the reconstruction of the proximal bile duct. Previous studies discussing short- and long-term complications of biliary-enteric anastomosis have focused on technical aspects, such as the use of anastomotic stenting or the level of the biliary tree used. We report two cases of previously unreported complications after hepaticojejunostomy that resulted from a technical error in constructing the Roux limb. Within a 3-month period, two patients were referred to our institution with recurrent cholangitis after biliary reconstruction for injuries sustained during laparoscopic cholecystectomy. Reexploration disclosed major technical flaws in the construction of the Roux limb used for biliary drainage. Antiperistaltic limbs had been constructed in both patients: one from the distal ileum and one from the conventional location in the jejunum. In both cases, isoperistaltic reconstruction of the Roux limbs resolved the recurrent cholangitis. Cholangitis after biliary-enteric bypass can arise from a variety of etiologies and lead to anastomotic narrowing or ineffective drainage of the biliary tree. Review of the literature failed to disclose reports of technically flawed Roux limb construction as a cause of cholangitis. We present these cases to highlight the devastating consequences of antiperistaltic construction of the Roux limb. We hope that by publishing the role of this avoidable error in recurrent cholangitis after biliary-enteric bypass we may help prevent its future occurrence.

Attempts at improving anastomoses have included the development of stapling techniques. Our purpose was to evaluate arcuate-legged clipped versus standard sutured anastomoses of the hepatic artery (HA), portal vein (PV), and bile duct in a porcine liver transplantation model. Two groups of pigs were studied intraoperatively and 1 day after liver transplantation. A control group underwent sutured anastomosis of PV and HA with polypropylene and of bile duct with polydioxanone (n = 8). An experimental group underwent anastomoses with arcuate-legged clips (n = 8). We analyzed the time to perform anastomosis and flows before and at various time points after anastomosis. In addition, patency and histology of the anastomoses were evaluated 1 day after operation, including a fibrin-thrombosis score, medial injury, and inflammation score. Times to complete HA and PV anastomoses were not different between clipped and sutured groups. However, the time was shorter to complete bile duct anastomosis with clips than with sutures (6.3 +/- 1.1 minutes and 13.3 +/- 2.0 minutes, respectively). Flows through HA anastomoses were not different between groups, but flow through the PV was higher in clipped compared with sutured anastomosis (P = 0.06). Patency was 100 per cent with no leaks for all three anastomoses in both groups. Histologic data were similar between vascular anastomotic groups. Sutured bile duct anastomoses revealed mild smooth muscle injury in 75 per cent whereas clipped bile duct anastomoses displayed no smooth muscle injury. We conclude that arcuate-legged clipped anastomosis represents a viable option to sutured anastomoses of the PV, HA, and bile duct anastomoses. Bile duct anastomoses were completed in less than half the time and with less tissue damage documented histologically.