We evaluated the capacity to predict severe respiratory complications (SRCs) following upper abdominal surgery (UAS) by using the results of a respiratory questionnaire and preoperative pulmonary function tests.Lung volumes, flows and transfer factor of the lung for carbon monoxide (TL,CO,sb) were assessed in 361 consecutive adult patients (248 males and 113 females). SRCs were diagnosed 24 h after UAS by clinical examination and chest radiography. Univariate and stepwise multiple logistic regression analyses were performed to estimate the odds ratio (OR) and 95% confidence interval (95% CI) of each single input variable, and to determine which indices best predicted outcome.These patients had a 1% mortality rate and 14% incidence of SRCs, with a male:female ratio of 0.86. The best predictors for SRCs by multiple analysis were: preoperative current hypersecretion of mucus (OR=133; p<0.0001); an increase in residual volume (RV) (OR=3.11; p=0.01); and, to a lesser extent, low percentage of predicted values both of forced expiratory volume in one second (FEV1 % pred) and TL,CO,sb. The algorithm thus obtained (logit θ) was extremely sensitive (84%), specific (99%), and accurate (95%) for preoperative prediction of SRCs.We have found that preoperative current hypersecretion of mucus and pulmonary hyperinflation, and to a lesser extent percentage predicted values both of forced expiratory volume in one second and transfer factor of the lung for carbon monoxide, have a significant predictive capacity for severe respiratory complications following upper abdominal surgery. Eur Respir J 1997; 10: 1301-1308 Since 1910, it has been well-known that patients undergoing upper abdominal surgery (UAS) generally develop a severe pulmonary restrictive pattern [1], and carry a high risk of postoperative respiratory complications [2][3][4]. The most important factors determining the degree of postoperative impairment of ventilation and gas exchange are the site of operation, the age, and clinical status of the patient [5]. Forced vital capacity (FVC) and peak flows are often reduced to half, and the functional residual capacity (FRC) to below 70% of the preoperative values [5]. These effects may not be restored even by the fifth postoperative day [5]. The reduced FVC and the reduction of FRC are mainly a consequence of an impaired diaphragmatic function [6]. Furthermore, the risk for postoperative respiratory complications decreases with the distance of the surgical incision from the diaphragm [7,8].Several studies have tried to determine the incidence of postoperative respiratory complications of UAS, and the estimates vary widely. The majority of investigations have focused on subclinical complications, i.e. radiographic evidence of atelectasis, with or without pleural fluid. With this broader definition of complication, the incidence of postoperative complications of UAS is approximately 25-75% [9,10].In this paper, we examine the relationship between preoperative respiratory symptoms and physiology, and postoperative r...

From January 1980 to June 1997 we treated 159 patients with carcinoma of the hepatic duct confluence. Seventy-five patients underwent surgical resection (overall resectability rate: 47.2%), and radical resection was attempted in 46 patients (radical resectability rate: 28.9%) classified in the first three stages of our staging system. Perioperative mortality was 10% (16 patients). The 5-year survival rate for 46 patients with curative resection was 17.5% with a median survival of 19 months. The 5-year survival rate for those patients who underwent combined caudate lobectomy (n = 17) was 25%, whereas the survival rate for those who did not was zero. The difference between these two groups' results was statistically significant. The importance of careful preoperative staging is stressed. Preoperative tests should be limited to investigations (ultrasound with Doppler scan, spiral computed tomography, percutaneous transhepatic cholangiography) supplying most information about intra- and extrabiliary diffusion of the tumoral mass. We conclude by highlighting the importance of resection as the only treatment potentially improving long-term survival. On the basis of these results, caudate lobectomy is always recommended in association with resectional treatment of the neoplasm.

Between January 1979 and September 1999 a series of 96 patients were operated on at our institution for iatrogenic biliary injuries, and among them 62 involved the proximal biliary tract. Injuries, according to the Strasberg classification, were type E2 in 18 patients, type E3 in 29 patients, and type E4 in 15 patients. The most frequent primary surgical procedures were laparoscopic cholecystectomy in 27 of the 62 patients (43.6%) and open cholecystectomy in 30 patients (48.3%). Previous repair had been attempted in 25 patients (40.3%). A total of 58 cholangiojejunostomies were performed. Repair had been performed directly, and a T-tube had been left in the main bile duct in four patients with E2 Strasberg lesions. Postoperative death occurred in four patients (6.4%). Outcome was graded as excellent, good, or poor depending on clinical symptoms, liver function tests, and the need for reintervention due to anastomotic stricture. The final outcome was evaluated in 54 patients. The mean follow-up was 5.9 +/- 0.3 years, with the longest follow-up 10.2 years. Following our first repair 49 of the 54 patients (90.7%) had excellent results, 1 (1.9%) had good results, and 4 (7.4%) had poor results. None of the patients who underwent immediate or early repair had complications. Diagnostic and therapeutic courses are given on the basis of the type of lesion and the timing of repair. We emphasize the importance of timing (i.e., carrying out surgical repair as soon as possible) and of cholangiojejunostomy reconstruction in respect to defined technical principles. Moreover, we believe that repair treatment at a hepatobiliary center with multidisciplinary competence greatly influences the final long-term outcome.

Despite the careful selection of cirrhotic patients with hepatic neoplasms, liver resection for these patients remains associated with greater risk than in patients without underlying liver disease. The most rational indications for resective surgery in patients with hepatic neoplasms and cirrhosis are nonprogressive cirrhosis and good functional reserve. Therefore, evaluation of hepatic reserve is mandatory for hepatectomy candidates. Because of the complexity of hepatic function, a single, reliable liver function test is not yet available. However, a good multifactorial system that combines several elements (clinical, laboratory, functional, and volumetric evaluation) does provide sufficient data for determining the safe limits of hepatectomy.

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