digestive surgery

Purpose: The authors want to determine the indications and complications of digestive stomas at Uvira General Reference Hospital (HGRU) / (South Kivu / DRC).
Patients and methods: This is a retrospective study of 33 patients who underwent digestive stoma in the HGRU Surgery Department, serving as a complementary site for the training of the finalist students of the Faculty of Medicine of the official University of Bukavu, during the period from 1 January 2010 to 31 December 2014, for a period of 5 years.
The data were taken from the patient's clinical records and the operating records.
Results: Our results show that the sex ratio was 2.66 in favor of the male sex. The average age was 28.34 years (Extremes of 0 and 60 years). The agro-pastoral population was the most concerned with 81.81% of cases. Peritonitis by ileal perforation was the most common indication of stomas with 27.27% of cases. Colostomies were performed in 17 cases (51.51%) compared to 16 ileostomies (48.48%). This was most often (87.87%) temporary stoma. Evolution was simple in 42.42% of cases and peristomal irritation was the most common complication with 15.15% of cases. The average time to restore continuity was 58.7 days with extremes of 9 and 112 days. The average hospital stay was 38.3 days with extremes of 15 and 120 days.
Conclusion: Ostomy indications in our context are dominated by peritonitis on intestinal perforation to which are added traumatic digestive fistulas by fire arm.
Keywords: Digestive ostomy, indications, complications

Parastomal hernia is one of the most common complications following stoma creation and its prevalence is only expected to increase. It often leads to a decrease in the quality of life for patients due to discomfort, pain, frequent ostomy appliance leakage, or peristomal skin irritation and can result in significantly increased healthcare costs. Surgical technique for parastomal hernia repair has evolved significantly over the past two decades with the introduction of new types of mesh and laparoscopic procedures. The use of prophylactic mesh in high-risk patients at the time of stoma creation has gained attention in lieu of several promising studies that have emerged in the recent days. This review will attempt to demonstrate the burden that parastomal hernias present to patients, surgeons, and the healthcare system and also provide an overview of the current management and surgical techniques at both preventing and treating parastomal hernias.

A 63-year-old female presented to our department complaining of epigastric pain, nausea and vomiting. Symptoms started after a significant loss of weight and persisted despite treatment, leading to hospitalization for dehydration and renal failure due to protracted vomiting. During hospitalization, no pathology could be identified and the patient was discharged. Symptoms persisted and she was eventually readmitted. Superior mesenteric artery syndrome was diagnosed based upon clinical suspicion and barium studies. She was subjected to duodenojejunostomy after failure of conservative treatment. Her immediate postoperative course was uneventful and the patient was well during her two-year follow-up. Clinicians should be suspicious of superior mesenteric artery syndrome, albeit rare, and be aware of its treatment, which is either conservative or surgical.

Adenocarcinomas are exceedingly rare in the cervical esophagus (26 reported cases), where squamous cell cancer (SCC) is the predominant tumor type. Esophageal heterotopic gastric mucosa (HGM)-a frequent remnant of incomplete replacement of the original ...

In selected patients, local excision of rectal cancer may be an alternative to radical surgery such as abdominoperineal excision of the rectum or anterior resection. Local excision carries lower mortality and morbidity, without the functional disturbance or alteration in body image that can be associated with radical surgery. There are several techniques of local therapy for rectal cancer, with most experience being available in transanal excision. Transanal endoscopic microsurgery is also used but experience with this newer technique is limited. Patient selection is the most important factor in successful local excision, however specific criteria for selecting patients have not been universally accepted. Review of the published literature is difficult because of the variation in adjuvant therapy regimes and follow-up strategies, as well as results reported in terms of local recurrence and survival rates. There is increasing evidence to suggest that local excision should be restricted to patients with T1 stage rectal cancer without high-risk factors. The place for local excision in patients with T2 or high-risk T1 tumours requires prospective, randomised multi-centre trials comparing radical surgery with local excision, with or without adjuvant therapy.

Laboratory data disclosed a normal white blood cell count without left shift (7410/L). An abdominal X-ray showed a calcic image in the lower right abdominal quadrant (fig. 1). Acute appendicitis was considered; a CT scan was done showing a foreign body, an enlarged segment of small bowel and free intraperitoneal fluid (fig. 2). An otherwise healthy 56-year-old woman was admitted for abdominal pain. Approximately 2 h before admission, the patient had begun to experience abdominal pain and vomiting. She had fever, and presented with abdominal pain and tenderness in the lower right abdominal quadrant on physical examination.

A case is reported in which focal lymphoid hyperplasia (pseudolymphoma) of the stomach preceded by 45 months the development of gastric diffuse lymphocytic lymphoma. Review of the literature discloses only two similar cases reported with satisfactory histopathologic documentation. Analogous cases, in other anatomic sites, of an apparent association between benign and malignant lympoid lesions are reviewed. The cases suggest that occasionally lymphoid hyperplasia of the stomach may precede lymphoma. Lymphoid hyperplasia is not yet considered a consistent precursor of lymphoma.

Background: Strangulation is the most serious complication of inguinal hernia. Diverticulitis, a common condition, is usually localized in the left colon. The association of complicated inguinal hernia and diverticulitis is rare. Methods: We report the case of a 73-yearold male patient who presented with a suspicion of strangulated inguinal hernia. Results: CT and operative findings showed transverse colon diverticulitis lodged in an incarcerated inguinal hernia without signs of strangulation. Surgical hernia repair was undertaken while the treatment of diverticulitis was conservative. Follow-up was uneventful. Conclusion: This is a first report of documented transverse colon diverticulitis simulating inguinal hernia strangulation.

comparison showed significant differences in the length of hospital stay, blood loss and operation time. Complications did not differ significantly between the two groups (26 vs. 21%). The 2011 survey showed that 21 centers in the Netherlands performed formal liver resections and that 49 (5% of total) laparoscopic liver resections were performed in 2010. Conclusion: The systematic review revealed that very few laparoscopic liver resections were performed in the Netherlands in the previous millennium. The matched case-control comparison of laparoscopic and open left lateral resection showed a reduction in hospital length of stay with comparable morbidity. The laparoscopic technique has been slowly adopted in the Netherlands, but its popularity seems to increase in recent years.

The management outcome of complicated CDCs was compared with that of uncomplicated CDCs. Results: Complicated CDCs were signifi cantly more common with type IV-A anatomy. Endoscopic, percutaneous or external surgical biliary drainage procedure was performed in 14 complicated CDCs prior to cyst excision. Desired defi nitive surgical procedure could be performed in 26/33 (79%) patients with complicated CDCs as compared to 107/111 (96%) patients with uncomplicated CDCs. Four (12%) patients with complicated CDCs had early postoperative complications as compared to 9/111 (8%) patients with uncomplicated CDCs. During a median follow-up of 13 months (2 months to 8 years), 2 patients with complicated CDCs died due to advanced secondary biliary cirrhosis and advanced gall bladder cancer, respectively. Six patients reported complications. Of the 6 patients, 3 required reoperation for a strictured hepaticojejunostomy (n = 2) and hepatolithiasis (n = 1). In contrast, there was no disease-related mortality and only 1 out of 111 patients with uncomplicated cysts had a complication during follow-up. Conclusion: Complicated CDCs merit a carefully planned management strategy including percutaneous, endoscopic and surgical procedures. The management may have to be staged. The outcome depends on the nature of complication and the management strategy adopted.

dominal surgery and the lack of well-designed randomized controlled trials are limiting factors for the application of ERAS. However, the present results indicate that the implementation of ERAS programs in pancreatic, hepatic, esophageal and gastric surgery patients contributes to a reduction in complications, length of hospital stay and costs without an increase in mortality or readmission rates.

Background: A hydatid cyst is still a serious health problem in endemic areas. Invasion of the spleen is rare in hydatid disease. In the medical literature, reports about isolated splenic hydatidoses are quite rare. Also there is not a consensus about the way of treatment. Methods: Between 1978 and 2000, in our clinic approximately 900 patients were operated on for an abdominal hydatidosis; 850 of these patients were treated for a hepatic hydatidosis and 14 patients for an isolated splenic hydatidosis. Six (42.8%) of the latter patients were male and 8 (57.1%) were female. The mean age of the patients was 47.14 B 4.9 (range 17-72) years. Ten patients (71.4%) presented with a painful mass in the left upper quadrant of the abdomen, and the other 4 patients (28.5%) were asymptomatic and were diagnosed incidentally. Results: All of the patients underwent elective splenectomy. There was no mortality, but complications occurred in 4 (28.5%) patients. The period of hospitalization ranged from 7 to 17 days with a mean of 9.8 days. 1 patient died from an acute myocardial infarction during the 2nd postoperative year, and 1 patient died as a consequence of a traffic accident during the 5th postoperative year. Nine patients, after follow-up periods of between 2 and 14 years, are living free from disease. No recurrence occurred in any of them. In the remaining 3 patients, long-term follow-up could not be maintained. Conclusions: A hydatid cyst must be included in the differential diagnosis of cystic lesions of the spleen. A splenic hydatid cyst should be treated surgically due to the high risk of a rupture, and the ideal procedure in adulthood is standard splenectomy.

Background: This study aims to evaluate the feasibility and safety of resection of sarcoma liver metastases, and to identify possible prognostic factors for long-term survival. Methods: All patients who underwent resection of liver metastases of sarcoma in the Netherlands from 1998 to 2014 were included. Study data was retrospectively collected from patient files. Survival rates were calculated using Kaplan-Meier survival analysis. Results: Some 38 patients treated in 16 hospitals were included (15 male, 23 female). The median age was 57 years (37-80 years). The most common histological subtype was leiomyosarcoma (63%). The predominant site of primary tumour was the abdomen (59%). R0 resection was achieved in 16 patients. Mortality was 3 and 16% of included patients had 1 or more complications. The median follow-up period was 18 months (range 1-161). After liver resection, 1-, 3-, and 5-year survival were 88, 54, and 42% respectively. Median overall survival was 46 months (1-161 months). One-and three-year progression-free survival (PFS) after liver resection were 54 and 19% respectively. Median PFS was 16 months (1-61 months). Conclusions: Liver surgery for sarcoma metastases is safe and leads to a relatively good survival. The choice for surgical treatment should always be discussed in a multidisciplinary sarcoma and liver team.

the aim of the work was the clinical characteristics and analysis of preliminary results for surgical treatment of pancreatic neuroendocrine tumors (PNETs), based on own material. material and methods. In the period from 2005 to 2009, in the Department of Gastrointestinal Surgery, Silesian Medical University in Katowice, there were 27 patients (15 males and 12 females) treated surgically for pancreatic neuroendocrine tumours, constituting 65.86% (27/41) of all gastroenteropancreatic neuroendocrine tumours. Prior to the surgery, the following diagnostic examinations were performed: laboratory tests and imaging examinations (abdominal ultrasound and CT scan). The following tumour localisation was established: head of the pancreas -14, body of the pancreas -4, tail of the pancreas -5, body and tail of the pancreas -1, retroperitoneal space -4. There were found 24 (88.89%) primary tumours and 3 (11.11%) recurrences. The following methods of surgical treatment were applied: pancreatoduodenectomy -11, distal pancreatic resection with splenectomy -6, middle segment resection with anastomosis between the pancreatic tail and jejunal loop: Roux-Y procedure -1, pancreatic resection by Beger procedure -1, pancreatic head and body resection with splenectomy -1, tumour enucleation or local excision -4, exploratory laparotomy with specimen collection -3. Results. The mean hospitalisation period was 25 days (4 -78 days). The mean procedure duration was 4.2 hours (1.15-9.15 hours). Early post-operative complications were observed in 10 patients (37.04%). The following early complications were observed: intra-abdominal abscess -2, wound suppuration -2, pancreatic fistula -1, acute pancreatitis -1, pancreaticojejunal anastomosis leak -1, peritoneal cavity haemorrhage -1, acute cholangitis -1, adhesion obstruction -1, subobstruction -1, portal vein thrombosis -1, sepsis -1, fluid in pleural cavity -1, acute heart failure -1. There were performed 2 (7.41%) repeat surgeries: one due to adhesion obstruction and one due to peritoneal cavity haemorrhage. Death of 1 patient (3.71%) was recorded in the post-operative period due to acute heart failure. conclusions. Pancreatic neuroendocrine tumours constituted the majority of gastroenteropancreatic neuroendocrine tumours in the analysed patient group. Most commonly, PNETs were localised in the head of the pancreas. In the presented material, the mortality rate does not exceed 4%, similarly as in other renowned centres.

Pancreatic cancer is the fourth leading cause of death from malignant disease in Western industrialized countries. It is a devastating disease with a very poor prognosis and has a death rate roughly equal to its incidence rate. As this tumor is resistant to all medical treatment options, such as radio-and chemotherapy, radical surgical resection is the only chance of cure so far. Significant advances have been made over the past decades in pancreaticoduodenectomy, which is the standard operation in patients with pancreatic head cancer or periampullary cancer. In specialized centers the operative mortality has fallen under 5%. However, the postoperative complication rates after this demanding procedure are still between 30 and 40%. Complications are mainly due to the technical difficulty of performing a safe and proper anastomosis between the stomach or small bowel and the soft pancreas. This article reviews the treatment of the complications most frequently occurring after pancreatic cancer surgery, such as leakage of pancreatic anastomosis, pancreatic fistula, abscess and hemorrhage. Furthermore, we discuss the management of these complications and how complications following pancreatic surgery can be prevented.

Despite improvements in anesthesiology and intensive care medicine, mortality for perforated gastroduodenal ulcer disease remains high. This study was designed to evaluate the results of surgery for perforated ulcer disease and to identify prognostic factors for mortality in order to optimize treatment.

An optimal management of gastric cancer should be stage-oriented with the main criterion of lymph node status. Nodal status can be assessed preoperatively with modern radiological imaging techniques, sentinel node biopsy, molecular or genetic markers of tumor and computer analysis. The aim of this study was to evaluate the feasibility and accuracy in preoperative prediction of lymph node status with the help of computer analysis. The computer model was constructed with data from patients with gastric cancer treated at the University Medical Centre Ljubljana between 1993 and 2003. Prediction of the computer model was then tested on 110 patients treated between 2004 and 2005 in the same manner as patients from the database. The goal of the study was to compare prediction for lymph node status in the control group by the computer program with real data collected after surgery. Accuracy of computerized preoperative predictions of N0/N1 status is 86% (sensitivity 91% and specificity 79%) and of N1/N2 status is 89% (sensitivity 87% and specificity 90%). Results of accuracy of preoperative predictions of nodal status are very high and allow in each individual case to guide stage-appropriate therapy. Best applicability is obtained with implementation of this new approach with standard diagnostic methods.

The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precau tions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. All rights reserved. No part of this publication may be translated into other languages, repro duced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the pub lisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center (see 'Information for Readers and Sub scribers').

The aim of this paper is to present our brief experience on laparoscopic hydatid cyst surgery; we estimated the reproducibility of used techniques in conventional surgery with this relatively recent and attractive method. Fifteen cysts in 12 selected hydatid disease patients were treated laparoscopically. Cystotomy, partial cystectomy and drainage were performed in 9 patients. Omentoplasty was added to the procedure in the remaining 3 cases. The mean postoperative hospital stay was 4.9 days. There was no mortality, and 1 patient developed bile leakage. Mean follow-up is 18 months. No recurrence was observed during this period. We suggest that laparoscopic treatment of hydatid disease is feasible in selected patients respecting the principles of open surgery and seems beneficial concerning postoperative comfort, hospital stay and return to daily activities.

An unusual case of obstructive jaundice caused by intussusception of a simple liver cyst into the left hepatic duct with partial obstruction of the common hepatic duct is presented. This interesting finding was discovered during surgery for a liver cyst with a suspected common hepatic duct lesion.Copyright © 1993 S. Karger AG, Basel

Bariatric surgery is the most effective treatment of obesity and its associated diseases like type 2 diabetes mellitus. Given the obesity epidemic and the efficacy of surgical treatment, the number of surgical weight loss procedures has grown in recent years. Nevertheless, there is little consensus regarding the extent of preoperative investigations required prior to patients undergoing surgery. This article aims to discuss the available evidence on which preoperative tests are useful for the detection and treatment of conditions such as venous thromboembolism, obstructive sleep apnea syndrome and Helicobacter pyloripositive gastritis prior to an operation. The present literature suggests that only a few preoperative investigations are essential, but that preoperative multidisciplinary care is beneficial.

A 55-year-old woman was admitted to the Verona University Hospital with jaundice. US and CT scans revealed an enlarged biliary tree but no evident mass. A duodenoscopy was performed and multiple biopsy samples were taken. Immediate clarification of the nature of the lesion was achieved by cryostatic examination of three biopsy specimens stained with hematoxylin and eosin. Within 24 h

Esophageal cancer is one of the most difficult malignancies to cure. The prognosis remains unsatisfactory despite significant advances in surgical techniques and perioperative management. The optimal treatment strategy for localized esophageal cancer has not yet been established. Surgical resection remains the mainstay of treatment for esophageal cancer, and curative resection is the most important surgery. Extended esophagectomy with three-field lymphadenectomy provides the highest quality of tumor clearance and prolongation of patient survival. There has been intense effort in developing novel strategies to treat patients with resectable esophageal cancer. Various combined-modality approaches have been attempted to improve treatment outcomes. Definitive chemoradiotherapy has an impact on long-term survival in patients with resectable esophageal cancer. Accordingly, there are three main combined-modality approaches: esophagectomy with adjuvant chemotherapy or chemoradiotherapy; pri...

Introduction: Endoscopic pneumatic pyloric balloon dilation is a treatment option for early postoperative delayed gastric tube emptying following esophageal resection. This study aimed to determine the safety and effectiveness of endoscopic balloon dilation. Methods: Between 2015 and 2018, patients with delayed gastric emptying 8–10 days after esophageal resection with gastric tube reconstruction due to esophageal carcinoma were considered for inclusion. Inclusion criteria were ≥1 of the following: nasogastric tube production ≥500 mL/24 h, ≥300 mL gastric retention, ≥50% gastric tube dilatation on X-ray, or nasogastric tube replacement. Patients were excluded on evidence of anastomotic leakage or reintervention. Success was defined as the ability to expand intake without needing to replace the nasogastric tube. Dilation was performed using a 30-mm Rigiflex balloon. Results: Fifteen patients underwent pyloric dilation, 12 according to the study protocol. Treatment was performed at a ...

Dear Editor, We have read the original article 'Pri-mary Splenic Hydatidosis' by Durgun et al. [1] with interest. The authors evaluated 14 patients with isolated splenic hydatid cyst. All their patients underwent elective sple-nectomy with a 28.5% complication rate and without ...

Hepatocellular carcinoma W Liver resection W Multicentric carcinogenesis W Acute exacerbation of hepatitis W Hepatitis B virus DNA W Hepatitis B envelope antigen W Hepatitis B virus surface antigen W Wild-type hepatitis B virus W Precore mutant-type hepatitis B virus Abstract Background/Aims: During the natural course of hepatitis B virus (HBV) infection, clearance of HB e antigen (HBeAg) and HB surface antigen (HBsAg) occurs with remission of liver disease. We investigated the effects of postoperative changes in virologic and biochemical parameters on the prognosis after liver resection for HBVrelated hepatocellular carcinoma (HCC). Methods: We investigated the relationship between postoperative changes in virologic and biochemical parameters and the incidence of intrahepatic recurrence and the outcome during a 3-year period following surgery in 30 HCC patients with HBsAg. Results: The incidence of intrahepatic recurrence of HCC was significantly higher in patients with acute postoperative exacerbation of hepatitis (p = 0.0084), a sustained high serum concentration of HBV DNA (65.0 mEq/ml, p = 0.001), and sustained expression of HBsAg after surgery (p = 0.0421). A high serum concentration of HBV DNA was significantly associated with a shorter survival time (p = 0.0447) and the cause of death was recurrence of HCC. Conclusion: Patients with acute postoperative exacerbation of hepatitis, sustained HBsAg expression, and sustained high serum concentrations of HBV DNA after surgery may require more intensive postoperative monitoring for HCC recurrence.

Background: The role of sentinel lymph nodes in colorectal cancer remains unclear. Methods: Cryosections from central para-aortic mesenterial lymph nodes were stained using mAb BER-Ep4. Overall survival and distant recurrence were calculated using Kaplan-Meier plots. Results: All patients (n = 48) were free of distant metastases and curatively resected (R0). 23 pN0, 13 pN1 and 12 pN2 stages were found. 21/48 patients (44%) showed BER-Ep4+ cells in their central lymph nodes (7/23 pN0, 8/13 pN1, 6/12 pN2). In 6/23 pN0 patients, BER-Ep4+ cells were also found in locoregional nodes (p = 0.03, Fisher's exact test). pN status predicted overall survival (p = 0.006, Kaplan-Meier curve, log-rank test). An impact was exerted by central mesenteric BER-Ep4+ cells on overall survival (p = 0.009 in pN0 patients, p = 0.07 for all pN) and distant recurrence-free survival (p = 0.001 in pN0 patients, p = 0.007 for all pN). Multivariate analysis showed an independent prognostic effect on overall survival in pN0 patients (p = 0.022). Conclusion: Central lymph nodes are sen

more reinterventions to treat postoperative complications compared to PA. Besides, HP resulted in a longer total hospital and intensive care unit stay. Specialist colorectal surgeons performed significantly more frequently a PA instead of a HP and had fewer postoperative complications than general surgeons. The time of operation did not influence the choice of surgical procedure. Conclusion: Selected patients with perforated diverticulitis can be managed well by PA, as it does not seem to be inferior to HP in terms of severe postoperative complications that need surgical or radiological reintervention and mortality. This decision should be made while taking into account the patient's concomitant diseases, response on preoperative resuscitation and the availability of a surgeon experienced in colorectal surgery.

This study aimed to evaluate the feasibility of laparoscopy-assisted distal gastrectomy (LADG) in early gastric cancer (EGC) with special interest in a learning curve effect. The clinical outcomes of EGC patients who underwent LADG (n = 100) and sex-, age- and body mass index- (BMI) matched EGC patients who underwent open distal gastrectomy (ODG; n = 100) were compared retrospectively. In addition, the outcomes between the early (n = 50) and late LADG group (n = 50) were compared. The mean number of retrieved lymph nodes was significantly smaller in the LADG group than in the ODG group (29.3 vs. 36.4, p < 0.001). The operative time of the LADG group was significantly longer than in the ODG group (249.1 vs. 152.9 min, p < 0.001). The complication rates were comparable between both groups (14 vs. 13%, p = 0.84). No cancer-related death was observed in either group. Between early and late LADG groups, the operative time was shorter (p < 0.001) and the number of retrieved lymph nodes was higher (p = 0.016) in the late group. LADG seems to be a safe and feasible procedure in treating EGC, as it shows comparable outcomes with ODG. The potential disadvantages of LADG, such as longer operation time and smaller number of retrieved lymph nodes, diminished after overcoming the learning curve.

External pancreatic fistula (EPF) is a common sequel to surgical or percutaneous intervention for infective complications of acute severe pancreatitis. The present study was aimed at studying the clinical profile, course and outcome of patients with EPF following surgical or percutaneous management of these infective complications. A retrospective analysis of clinical data of patients with EPF following intervention (surgical or percutaneous) for acute severe pancreatitis managed between January 1989 and April 2002 recorded on a prospective database was done. Univariate analysis of various factors (etiology, imaging findings prior to intervention, fistula characteristics and management) that could predict early closure of fistula was performed. Of 210 patients with acute severe pancreatitis, 43 (20%) patients developed EPF (mean age 38 (range 16-78) years, M:F ratio 5:1) following intervention for infected pancreatic necrosis (n=23) and pancreatic abscess (n=20) and constituted the study group. The fistula output was categorized as low (<200 ml), moderate (200-500 ml) and high (>500 ml) in 29 (67%), 11 (26%) and 3 (7%) patients, respectively. Fifteen patients (35%) had morbidity in the form of abscess (n=5), bleeding (n=1), pseudoaneurysm (n=2) and fever with no other focus of infection (n=7). Spontaneous closure of the fistula occurred in 38 (88%) patients. The average time to closure of fistula was 109+/- 26 (median 70) days. Fistula closed after intervention in 5 patients (2 after endoscopic papillotomy, 1 after fistulojejunostomy and 2 after downsizing the drains). Of the 38 patients with spontaneous closure, 9 (24%) patients developed a pseudocyst after a mean interval of 123 days of which 7 underwent surgical drainage of the cyst. Univariate analysis of various factors (etiology, imaging findings prior to intervention, fistula characteristics and management) failed to identify any factors that could predict early closure of fistula. EPF is a common sequel following intervention in acute severe pancreatitis. The majority of these are low output fistulae and close spontaneously with conservative management. One-fourth of patients with spontaneous closure develop a pseudocyst as a sequel, requiring surgical management.

particularly because of the hepatic sinusoidal structure, which does not have smooth muscle capable of contraction to induce vasoconstriction [2]. Consequently, traumatic damage, including parenchymal lacerations and fractures, and surgical cutting during elective operative procedures tend to expose wide, raw surfaces with multiple bleeding sites that are often not amenable to suturing and ligation [3]. Although there is almost total agreement on issues such as the need for bloodless dissection to achieve favorable results, several authors have still reported relatively high rates of patients receiving blood transfusions undergoing partial hepatectomy recently. On the contrary, there are also large series in which fewer than 10% of patients received transfusions [4-7]. In addition to the inherent difficulties in adequately replacing blood components in cases of severe bleeding, allogeneic blood transfusion constitutes a risk factor for intra-and postoperative morbidity, including transmission of viral disease, transfusion reactions and, in case of malignant disease, the controversial adverse effect of blood transfusion on tumor recurrence [8, 9]. Achieving and maintaining hemostasis is largely dependent on several key factors, including anesthetic and surgical techniques (table 1), the quality of the liver and intrinsic and extrinsic clotting components.

tomy. The 2 test analysis showed the presence of heterogeneity among studies (Tiffenau index 2 = 99.97, p = 0.03). The sensitivity analysis confirms the validity of our results. Conclusions: Postoperative pulmonary function is better preserved after laparoscopic cholecystectomy than open cholecystectomy.