Utility of fluorescent cholangiography during laparoscopic cholecystectomy: A systematic review

AIM: To verify the utility of fluorescent cholangiography for more rigorous identification of the extrahepatic biliary system.METHODS: MEDLINE and Pub Med searches were performed using the key words "fluorescent cholangiography", "fluorescent angiography", "intraoperative fluorescent imaging", and "laparoscopic cholecystectomy" in order to identify relevant articles published in English, French, German, and Italian during the years of 2009 to 2014. Reference lists from the articles were reviewed to identify additional pertinent articles. For studies published in languages other than those mentioned above, all available information was collected from their English abstracts. Retrieved manuscripts(case reports, reviews, and abstracts) concerning the application of fluorescent cholangiography were reviewed by the authors, and the data were extracted using a standardized collection tool. Data were subsequently analyzed with descriptive statistics. In contrast to classic meta-analyses, statistical analysis was performed where the outcome was calculated as the percentages of an event(without comparison) in pseudo-cohorts of observed patients.RESULTS: A total of 16 studies were found that involved fluorescent cholangiography during standard laparoscopic cholecystectomies(n = 11), singleincision robotic cholecystectomies(n = 3), multiport robotic cholecystectomy(n = 1), and single-incision laparoscopic cholecystectomy(n = 1). Overall, these preliminary studies indicated that this novel technique was highly sensitive for the detection of important biliary anatomy and could facilitate the prevention of bile duct injuries. The structures effectively identified before dissection of Calot's triangle included the cystic duct(CD), the common hepatic duct(CHD), the common bile duct(CBD), and the CD-CHD junction. A review of the literature revealed that the frequenciesof detection of the extrahepatic biliary system ranged from 71.4% to 100% for the CD, 33.3% to 100% for the CHD, 50% to 100% for the CBD, and 25% to 100% for the CD-CHD junction. However, the frequency of visualization of the CD and the CBD were reduced in patients with a body mass index > 35 kg/m2 relative to those with a body mass index < 35 kg/m2(91.0% and 64.0% vs 92.3% and 71.8%, respectively).CONCLUSION: Fluorescent cholangiography is a safe procedure enabling real-time visualization of bile duct anatomy and may become standard practice to prevent bile duct injury during laparoscopic cholecystectomy.

Adjusting CA19-9 values to predict malignancy in obstructive jaundice:Influence of bilirubin and C-reactive protein

AIM:To find a possible relationship between inflammation and CA19-9 tumor marker by analyzing data from patients with benign jaundice(BJ) and malignant jaundice(MJ).METHODS:All patients admitted for obstructive jaundice,in the period 2005-2009,were prospectively enrolled in the study,obtaining a total of 102 patients.On admission,all patients underwent complete standard blood test examinations including C-reactive protein(CRP),bilirubin,CA19-9.Patients were considered eligible for the study when they presented obstructive jaundice confirmed by instrumental examinations and increased serum bilirubin levels(total bilirubin > 2.0 mg/dL).The standard cut-off level for CA19-9 was 32 U/mL,whereas for CRP this was 1.5 mg/L.The CA19-9 level was adjusted by dividing it by the value of serum bilirubin or by the CRP value.The patients were divided into 2 groups,MJ and BJ,and after the adjustment a comparison between the 2 groups of patients was performed.Sensitivity,specificity and positive predictive values were calculated before and after the adjustment.RESULTS:Of the 102 patients,51 were affected by BJ and 51 by MJ.Pathologic CA19-9 levels were found in 71.7% of the patients.In the group of 51 BJ patients there were 29(56.9%) males and 22(43.1%) females with a median age of 66 years(range 24-96 years),whereas in the MJ group there were 24(47%) males and 27(53%) females,with a mean age of 70 years(range 30-92 years).Pathologic CA19-9 serum level was found in 82.3% of MJ.CRP levels were pathologic in 66.6% of the patients with BJ and in 49% with MJ.Bilirubin and CA19-9 average levels were significantly higher in MJ compared with BJ(P = 0.000 and P = 0.02),while the CRP level was significantly higher in BJ(P = 0.000).Considering a CA19-9 cut-off level of 32 U/mL,82.3% in the MJ group and 54.9% in the BJ group were positive for CA19-9(P = 0.002).A CA19-9 cut-off of 100 U/mL increases the difference between the two groups:35.3% in BJ and 68.6% in MJ(P = 0.0007).Adjusting the CA19-9 value by dividing it by serum bilirubin level meant that 21.5% in the BJ and 49% in the MJ group remained with a positive CA19-9 value(P = 0.003),while adjusting the CA19-9 value by dividing it by serum CRP value meant that 31.4% in the BJ group and 76.5% in the MJ group still had a positive CA19-9 value(P = 0.000004).Sensitivity,specificity,positive predictive values of CA19-9 > 32 U/mL were 82.3%,45% and 59.1%;when the cutoff was CA19-9 > 100 U/mL they were,respectively,68.6%,64.7% and 66%.When the CA19-9 value was adjusted by dividing it by the bilirubin or CRP values,these became 49%,78.4%,69.4% and 76.5%,68.6%,70.9%,respectively.CONCLUSION:The present study proposes CRP as a new and useful correction factor to improve the diag-nostic value of the CA19-9 tumor marker in patients with cholestatic jaundice.

Colorectal cancer and lymph nodes:The obsession with the number 12

Lymphadenectomy of colorectal cancer is a decisive factor for the prognostic and therapeutic staging of the patient.For over 15 years,we have asked ourselves if the minimum number of 12 examined lymph nodes(LNs)was sufficient for the prevention of understaging.The debate is certainly still open if we consider that a limit of 12 LNs is still not the gold standard mainly because the research methodology of the first studies has been criticized.Moreover many authors report that to date both in the United States and Europe the number"12"target is uncommon,not adequate,or accessible only in highly specialised centres.It should however be noted that both the pressing nature of the debate and the dissemination of guidelines have been responsible for a trend that has allowed for a general increase in the number of LNs examined.There are different variables that can affect the retrieval of LNs.Some,like the surgeon,the surgery,and the pathology exam,are without question modifiable;however,other both patient and disease-related variables are non-modifiable and pose the question of whether the minimum number of examined LNs must be individually assigned.The lymph nodal ratio,the sentinel LNs and the study of the biological aspects of the tumor could find valid application in this field in the near future.