Laparoscopic Drainage as First Line Treatment for Complex Pyogenic Liver Abscesses.

UNLABELLED: Background/aims: Pyogenic liver abscess (PLA) is a rare but potentially fatal condition if untreated. In available retrospective series successful rate of per- cutaneous drainage (PD) on large multiloculated PLA, that has been definited "complex". In this observation- al study, we report the experience of our Institution in performing laparoscopic drainage of complex liver ab- scess over a 5-years period as first line treatment for selected cases of PLA. Methodology: All cases of large multiloculated liver abscesses admitted to the General and Hepatobiliary Surgery of "Loreto Nuovo" Hospital Naples, Italy over the last 5-years period were treated by laparoscopic drainage and his clinicopathological variables were retrospectively reviewed. RESULTS: Ten patients with large multiloculated liver abscess has been admitted and treated by only laparoscopic drainage without need of other perioperative procedures. Mean age was 51.5 years (range 41-75y); average hospital stay was 4.6 days (range 2-6 days) and major postoperative morbidity or deaths were not registered. Successful rate was 100% with no recurrence at 2-years follow up (range 12/38 months). CONCLUSIONS: Laparoscopic drainage seems to be a safe and reproducible mini-invasive treatment of complex liver abscesses and to offer advantages over percutaneous and surgical open approach.

Minimally Invasive ALPPS Procedure: A Review of Feasibility and Short-Term Outcomes.

BACKGROUND: Associated liver partition with portal vein ligation for staged hepatectomy (ALPPS) represents a recent strategy to improve resectability of extensive hepatic malignancies. Recent surgical advances, such as the application of technical variants and use of a mini-invasive approach (MI-ALPPS), have been proposed to improve clinical outcomes in terms of morbidity and mortality. METHODS: A total of 119 MI-ALPPS cases from 6 series were identified and discussed to evaluate the feasibility of the procedure and short-term clinical outcomes. RESULTS: Hepatocellular carcinoma were widely the most common indication for MI-ALPPS. The median estimated blood loss was 260 mL during Stage 1 and 1625 mL in Stage 2. The median length of the procedures was 230 min in Stage 1 and 184 in Stage 2. The median increase ratio of future liver remnant volume was 87.8%. The median major morbidity was 8.14% in Stage 1 and 23.39 in Stage 2. The mortality rate was 0.6%. CONCLUSIONS: MI-ALPPS appears to be a feasible and safe procedure, with potentially better short-term outcomes in terms of blood loss, morbidity, and mortality rate if compared with those of open series.

[Use of screens, sedentary lifestyle, and physical activity in children under six years of age, during the period of preventive and compulsory social isolation in AMBA: online survey]. / Uso de pantallas, sedentarismo y actividad física en los niños menores de seis años, durante el periodo de aislamiento social preventivo y obligatorio en AMBA: encuesta en línea.

Introduction: Within the context of the COVID-19 pandemic, children were confined to their homes. The Buenos Aires Metropolitan Area (AMBA) region has the highest urban density in Argentina and has been the epicenter of COVID-19 infections and deaths. The objectives of this study are to characterize the habits of screen use, sedentary lifestyle and physical activity and describe their associations, in children under six years of age from AMBA, Argentina. Methods: analytical and cross-sectional study, in which data from the online survey (Google Forms®) were used. Through a non-probabilistic convenience sampling, fathers, mothers, legal guardians, and caregivers of children under six years of age were invited to participate. The survey was available during four months of the quarantine period and was made up of 31 questions about screen use, physical activity, and sedentary lifestyle of children. Results: 256 surveys were answered, the majority (79.6%) were female and 50.8% in the age range of 31-40 years. Conclusion: The television is the most used and children begin to use touch screens from one year. The play time of adults with children and the time that they usually carry out activities such as reading a book or drawing is one to two hours per day. There was an association between owning the screen and using it for more hours. The lower the income level, the more time adults play with their children.

Introducción: Dentro del contexto de la pandemia de COVID-19, los niños se quedaron confinados en sus hogares. La región del Área Metropolitana de Buenos Aires (AMBA) concentra la mayor densidad urbana de la Argentina y ha sido el epicentro de contagios y muertes por COVID-19. Los objetivos del presente estudio son caracterizar los hábitos del uso de pantalla, de sedentarismo y de la actividad física y describir sus asociaciones, en niños menores a seis años, del AMBA, Argentina. Métodos: estudio analítico y transversal, en que se utilizaron los datos de la encuesta en línea (Google Forms®). Mediante un muestreo no probabilístico por conveniencia, se invitaron a participar padres, madres, tutores legales y cuidadores de niños/as menores de seis años. La encuesta estuvo disponible durante cuatro meses del periodo de cuarentena y estuvo conformada por 31 preguntas sobre uso de pantalla, actividad física y sedentarismo de los niños. Resultados: fueron respondidas 256 encuestas, la mayoría (79,6%) era del género femenino y 50,8% en el rango etario de 31-40 años. Conclusión: La televisión es la más utilizada y los niños empiezan a usar pantallas táctiles a partir de un año. El tiempo de juego de los adultos con los niños y el tiempo que ellos suelen realizar actividades como leer un libro o dibujar es de una a dos horas por día. Hubo asociación entre ser dueño de la pantalla y usarla por más horas. Cuanto menor el nivel de ingreso, más tiempo los adultos juegan con sus niños.

Laparoscopic and open surgical treatment of left-sided pancreatic lesions: clinical outcomes and cost-effectiveness analysis.

BACKGROUND: Previous studies comparing open distal pancreatectomy (ODP) and laparoscopic distal pancreatectomy (LDP) have found advantages related to minimal-access surgery. Few studies have compared direct and associated costs after LDP versus ODP. The purpose of the current study was to compare perioperative outcomes of patients undergoing LDP and ODP and to assess whether LDP was a cost-effective procedure compared with the traditional ODP. METHODS: A retrospective analysis of a prospectively maintained database of 52 distal pancreatic resections that were performed during a 10-year period was performed. RESULTS: Patients included in the analysis were 16 in the LDP group and 29 in the ODP. Tumors operated laparoscopically were smaller than those removed at open operation, but the length of pancreatic resection was similar. The mean operating time for LDP was longer than ODP (204 ± 31 vs. 160 ± 35; P < 0.0001), whereas blood loss was higher in the open group (365 ± 215 vs. 160 ± 185, P < 0.0001). Morbidity (25 vs. 41; P = 0.373) and pancreatic fistula (18 vs. 20%; P = 0.6) rates were similar after LDP and ODP, as was 30-day mortality (0 vs. 2%; P = 0.565). LDP had a shorter mean length of hospital stay than ODP (6.4 (2.3) vs. 8.8 (1.7) days; P < 0.0001). Operative cost for LDP was higher than ODP (2889 vs. 1989; P < 0.0001). The entire cost of the associated hospital stay was higher in the ODP group (8955 vs. 6714; P < 0.043). The total cost was comparable in LDP and ODP groups (9603 vs. 10944; P = 0.204). CONCLUSIONS: Laparoscopic distal pancreatectomy for left-sided lesions can be performed safely and effectively in selected patients, with reduced hospital stay and operative blood loss. Major complications, including pancreatic leak, were not reduced, whereas total cost was comparable between LDP and ODP. A selective use of LDP seems to be an effective and cost-efficient alternative to ODP.

Single port laparoscopic cholecystectomy: a new evolving technique.

Although multiple groups have reported initial success with single port laparoscopy, no consensus exists concerning the technical aspect of this surgery. In this report, we describe in detail our technique to perform single port laparoscopic cholecystectomy. Twelve cases of single port laparoscopic cholecystectomy for gallbladder stones were performed in our surgical unit. There was only one conversion during the first operation of the series to standard laparoscopy, and never to open operation. No intraoperative adverse events or major perioperative complications were reported. All the patients have been discharged within 48 hours, with uneventful postoperative course, nearly painless, without any discomfort and no visible scar. Single port laparoscopic surgery is a promising option for the treatment of gallbladder stones providing that technical and oncological surgical principles are respected.

Quality of Life in Patients With Severe Skin Reactions in Course of First-Generation Epidermal Growth Factor Receptor Inhibitors Monoclonal Antibodies (Our Experience With Cetuximab).

BACKGROUND: Metastatic colorectal cancer (mCRC) with wild type expression of RAS and RAF genes can be treated with anti-epidermal growth factor receptor (EGFR) monoclonal antibodies, such as cetuximab, in combination with chemotherapy. Skin toxicity represents the most serious and frequent side effect in these patients. Skin manifestations occur in approximately 80% of patients. In this study, we investigated the consequences on body image and quality of life (QoL) of patients with severe skin toxicity. METHODS: One hundred patients were enrolled with mCRC. All patients signed informed consent and completed questionnaires to assess QoL and body discomfort. Toxicity was assessed on Common Terminology Criteria for Adverse Events (CTCAEs). RESULTS: The greatest impact on QoL was represented by difficulties in managing skin rash-related side effects. Data showed a significant impact in psychological sphere and social relationships. CONCLUSIONS: Skin side effects, particularly rash, influence QoL and social relationships, compromising therapeutic compliance.

Laparoscopic redo surgery for recurrent hepatocellular carcinoma in cirrhotic patients: feasibility, safety, and results.

BACKGROUND: Recurrence of cancer and the need for several surgical treatments are the Achilles' heel of the treatment for hepatocellular carcinoma (HCC) in cases of cirrhosis. The difficulty of reintervention is increased by the formation of adhesions after the previous hepatectomy that can make a new surgical procedure more difficult and less safe. With a minimally invasive approach, the formation of postoperative adhesions seems to be minimized, and the adhesiolysis procedure seems to be faster and safer in terms of blood loss and risk of visceral injuries. METHODS: This report describes a series of 15 patients submitted to a laparoscopic reintervention (hepatic resection or radiofrequency ablation) for a recurrence of HCC after a previous open (group 1) or laparoscopic (group 2) procedure for a primary tumor. It aims to explain the feasibility, safety, and results of repeated laparoscopic liver surgery. RESULTS: The rates for overall postoperative mortality and morbidity were respectively 0% and 26.6% (4/15). No patients had a severe postoperative complication. Only one patient in group 2 presented with moderate ascites postoperatively, whereas two patients in group 1 reported atelectasis requiring physiotherapy and one experienced pneumonia, which was treated with antibiotics. In this series, the findings indicated that patients submitted first to an open hepatic resection (group 1) experience more intraabdominal adhesions. Moreover, in group 1, hypervascularized adhesions typical of cirrhotic patients were several and thicker, with a major potential risk of bleeding and bowel injuries at the time of reintervention. Although for group 2 the length of the intervention was shorter, for group 1, the operating times and safety in terms of bowel injuries were acceptable, demonstrating the feasibility of iterative laparoscopic surgery also for cirrhotic patients previously treated by the open surgical approach. The operative time for the second surgical procedure was shorter and the adhesiolysis easier for the patients previously treated with the laparoscopic approach (group 2). This underscores the advantages of the minimally invasive approach for managing the long oncologic history of cirrhotic patients. CONCLUSION: Laparoscopic redo surgery for recurrent HCC in cirrhotic patients is a safe and feasible procedure with good short-term outcomes, but further prospective studies are needed to support these results.

Laparoscopic hand-assisted right hemihepatectomy by ultrasound-directed intrahepatic approach.

BACKGROUND/PURPOSE: Laparoscopic hepatectomy is a promising option for patients affected by a liver mass, and the procedure is gaining popularity. Minor laparoscopic resections have been widely reported. In contrast, major laparoscopic hepatectomy has been performed in only a limited number of cases. Hand-assisted laparoscopic liver surgery has been advocated in order to improve liver exposure and vascular control and increase the safety of the procedure. Transparenchymal en-bloc transection of the right portal triad has been reported to be safe and useful in open surgery. METHODS: We describe a personal technique for hand-assisted right hemihepatectomy. With ultrasound guidance, the right hepatic pedicle is isolated intrahepatically and transected en bloc with a single firing of an endostapler. Parenchymal transection is carried out with ultrasonically activated or vessel-sealing devices together with endostaplers. RESULTS: The procedure was successfully accomplished in three patients. The Pringle maneuver was never performed. No intraoperative or postoperative complications occurred. CONCLUSION: This study is the first to report a technique of right hemihepatectomy that combines hand-assisted laparoscopy and an ultrasound-guided intrahepatic approach. This technique may be a useful option to simplify the operation, reduce operative time, and increase the safety of the procedure.

Surgical treatment of giant liver hemangiomas by enucleation using an ultrasonically activated device (USAD).

Hemangioma is the most frequent focal liver lesion. It affects mainly women and may cause symptoms such as abdominal pain, mass, and early satiety, or complications such as heart failure or coagulopathy (Kasabach-Merrit syndrome). Although, surgical resection is the only curative treatment for symptomatic giant hemangiomas, the best surgical technique (formal liver resection or enucleation) is still debated. Between January 2000 and April 2006 we treated 12 giant symptomatic hemangioma. Of these, 4 anterior and superficially located in the liver were treated by enucleation and they are discussed in this paper. The operative technique is described. Detailed pathologic examination has demonstrated an interface between hemangiomas and the normal liver tissue that allowed the enucleation. The dissection in the plane between the tumor and the adjacent normal liver tissue has been facilitated by the use of an ultrasonically activated device (USAD). Median operative blood loss was 90 ml (range, 50 to 190 ml), and no transfusion were used. The procedure described allowed a safe enucleation of giant hemangiomas with a reduced blood loss and the preservation of virtually all normal hepatic parenchyma.

Laparoscopic radiofrequency ablation combined with laparoscopic liver resection for more than one HCC on cirrhosis.

The management of patients affected by more than one hepatocellular carcinoma (HCC) is still controversial but nowadays a multimodal approach to this pathology seems to be the most effective and versatile therapeutic option. When orthotopic liver transplantation is not indicated, survival-time and quality of life improvement is the goal for patients who will have a long metabolic and oncologic disease history. Combined use of minimally invasive nonsurgical treatments [percutaneous ethanol injection, radiofrequency ablation, transcutaneous arterial chemioembolization (TACE)] allows to offer to the patients the advantages of each therapeutic procedure reducing their individual side effects and complications. We consider laparoscopy as a minimally invasive procedure, which can offer the benefits of surgical treatment, by tumor removing, but with an improved postoperative course. If recurrence risk factors are present, the costs/benefits rapport can be decreased by the laparoscopic approach which offers, in addition to a radical resection, a decreased postoperative pain, reduced trauma to the abdominal wall, smaller incisions, reduced peritoneal adhesions and, in selected cases, an earlier beginning of chemiotherapy. We report the case of a patient affected by more than one HCC with a bigger lesion of 50 mm protruding from hepatic segment III, one subcapsular lesion located at segment V, and one deep lesion located at segment VII-VIII. The patient was submitted to a double laparoscopic liver resection in association with laparoscopic radiofrequency ablation. Five months later, the patient presented an early recurrence of malignancy that was treated by TACE. At 8 months from the treatment, the patient presented another multifocal recurrence and was submitted to another TACE. At 2 years from the laparoscopic procedure, the patient is in apparent good conditions with an acceptable quality of life. We think that laparoscopic resection could gain a considerable place in the multimodal treatment of cirrhotic liver with more than one HCC because, by tumor removing, it offers the benefits of surgical treatment with a lower complications rate.

Laparoscopic incisional and umbilical hernia repair in cirrhotic patients.

BACKGROUND: Traditional approach to incisional hernias (IHs) in cirrhotic patients is plagued by a significant recurrence rate and frequent wound infections. The laparoscopic repair of IHs was designed to offer a minimally invasive and tension-free technique that yields less morbidity and fewer recurrences than the standard open repair. In cirrhotic patients there are additional reasons for the benefits of laparoscopy. First, preservation of the abdominal wall avoids interruption of large collateral veins. Second, nonexposure of viscera restricts electrolytic and protein losses, and improves absorption of ascites. Finally, the laparoscopic approach is associated with a lower perioperative blood loss (smaller abdominal incision). METHODS: A retrospective review was performed for 14 consecutive patients with ventral hernias and affected by chronic hepatitis or cirrhosis related to hepatitis C-B virus, who underwent laparoscopic repair at our institution between September 2002 and October 2004. All patients were in class A of Child-Pugh classification. RESULTS: There was no conversion to open operation. The mean size of the defects was 87 cm (range 1 to 480); incarceration was present in 2 patients and multiple (Swiss-cheese) defects in 1. In all cases, the mesh (average, 287 cm) was secured with transabdominal sutures and metal tacks or staples leaving the sac in situ. Operative time and estimated blood loss averaged 88 min (range 18 to 270) and 30 mL (range 10 to 150). Length of hospital stay averaged 2.6 days (range 1 to 6). There were 11 minor complications: seroma lasting >4 weeks (5), postoperative ileus (2), suture site pain >2 weeks (2), urinary retention (1), and skin breakdown (1). We experienced no recurrences with an average follow-up of 8 months (range 3 to 24). CONCLUSIONS: Laparoscopic IH repair is technically feasible and safe even in cirrhotic patients with fascial defects. This operation decreases postoperative pain, shortens the recovery period, and seems to reduce postoperative morbidity and recurrence. To the best of our knowledge, this is the first report in which a series of cirrhotic patients affected by incisional and umbilical hernias is treated with a laparoscopic approach.

Laparoscopic surgical treatment of hepatic splenosis. A case report.

AIM: Isolated hepatic splenosis is a rare but possible condition in abdominal surgery. At radiological imaging liver splenosis mimics malignant or pathological condition of the liver; obtaining a certain diagnosis prior to surgery is difficult. For this reason, the patients undergo to unnecessary operation, with a laparotomy access. We report a case of suspicious liver mass removed laparoscopically and revealed as hepatic splenosis. CASE REPORT: A 31 years old man patient was admitted to our Institution because of upper chronic abdominal pain. Thirteen years before the recovery the patient was operated of splenectomy with laparotomic incision. Computerized Tomography and Magnetic Resonance demonstrated the presence of suspicious hepatic mass in the III segment. RESULTS: The mass has been radically excised with laparoscopic approach. Postoperative stay was good and patient was discharged seven day after the operation. At histological examination ectopic splenic tissue on liver surface was found (socalled splenosis). DISCUSSION AND CONCLUSION: Hepatic splenosis is not a rare condition and should be considered with the differential diagnosis especially in patients who had previous splenectomy and absence of liver cirrhosis. Laparoscopic exploration should always be preferred for the diagnosis of uncertain liver mass. Few works report laparoscopic excision for liver splenosis. For experience at our Institution laparoscopic procedure has an important role to get the diagnosis and it is also a feasible approach for minimally invasive resection. KEY WORDS: Laparoscopy, Liver, Splenosis.

[Laparoscopic liver resection without a Pringle maneuver for HCC in cirrhotic patients]. / Resezioni epatiche laparoscopiche per HCC su cirrosi senza manovra di Pringle.

In the belief that the advantages stemming from a minimally invasive approach are significant, particularly in cirrhosis patients, we decided to apply this technique in the treatment of a group of patients suffering from HCC associated with cirrhosis. Sixteen patients (10 men, 6 women; mean age 60.1 years) underwent laparoscopic surgery for HCC associated with well compensated HCV-related liver cirrhosis (Child-Pugh class A; mean tumour size 2.9 cm). Seven of these lesions were located in the left liver and 9 in the right lobe. Laparoscopy was performed with a CO2 pneumoperitoneum (12-14 mmHg). The Pringle manoeuvre was not used. There was one conversion to laparotomy due to inadequate exposure. We performed 13 non-anatomical resections, 1 VI segmentectomy and 1 anatomical left lobectomy. None of the patients required blood transfusions. One patient died of severe respiratory distress syndrome on postoperative day 3. Major morbidity included 2 moderate postoperative ascites successfully resolved with conservative treatment. To date (mean follow-up: 18 months) no recurrences at the resection site or port-site metastases have been observed. Limited laparoscopic liver resections for HCC in cirrhotic patients are technically feasible and safe when careful selection criteria are adopted (hepatic involvement limited and located in the left or anterior right segments, tumour size smaller than 5 cm, Child-Pugh class A).

Mils for HCC: the state of art.

After an initial skepticism, minimally invasive liver surgery (MILS) gained popularity and is nowadays a consolidated option in specialized centers for the surgical treatment of selected patients affected by both benign and malignant liver diseases. Nevertheless, the role of MILS in the surgical treatment of hepato-cellular carcinoma (HCC) developed on the background of chronic liver disease is still a matter of debate. The indications and the current evidences on MILS for HCC are discussed in this paper. MILS being less invasive and harmful for the patients proved to offer a reduction in post-operative morbidity and specific benefits have been highlighted in case of patients affected by HCC and chronic liver disease. In fact, by minimizing liver manipulation and mobilization and by preserving the collateral blood and lymphatic flow, MILS seems to reduce the incidence of post-operative ascites and post-operative liver failure without compromising the oncologic outcomes. This has been confirmed by an analysis of 21 comparative studies and 5 metanalyses comparing MILS and open surgery for HCC. With an adequate surgical training, MILS for HCC can be undertaken safely even in case of major hepatectomies and technically demanding operations such as resections of posteriorly located tumors proved to be feasible in specialized centers. Therefore, with an appropriate patients' selection, MILS for HCC is becoming the preferred option for the surgical treatment of HCC in cirrhotic patients.

Laparoendoscopic single site liver resection for recurrent hepatocellular carcinoma in cirrhosis: first technical note.

INTRODUCTION: Single port access laparoscopic redo liver resection for hepatocellular carcinoma on cirrhosis through a single transumbilical skin incision has not been reported in the literature so far. METHODS: A wedge resection of segment III lesion with a laparoendoscopic single site surgical incision is described in detail analyzing the technical aspects of the procedure. RESULTS: There were no intraoperative complications with no intraoperative or perioperative blood transfusions. A Pringle maneuver was not used. Operating time was 130 minutes. The patient had an uneventful postoperative course and was discharged on the second postoperative day. The surgical resection margin was not invaded and had a width of 1.8 cm. CONCLUSIONS: In this case report, we found that liver resection performed by laparoendoscopic single site surgery for peripherally located hepatocellular carcinoma on cirrhosis seems a feasible technique. Such technique is technically demanding and should be undertaken only with proper training and in high volume centers, by surgeons with expertize in both liver and advanced laparoscopic surgery.

Revision surgery for incidentally detected early gallbladder cancer in laparoscopic era.

BACKGROUND: Incidentally detected early gallbladder cancer (IDEGB) is an early carcinoma first diagnosed on microscopic examination after a cholecystectomy for symptomatic benign gallbladder disease. After diagnosis of IDEGB it is often necessary a completion of treatment by a second tailored revision procedure. Despite early reports contraindicating laparoscopic approach because of high risk of neoplastic seeding, recent data seem to demonstrate that this approach per se does not influence clinical outcomes. We refer our experience in revision surgery by a totally laparoscopic approach that includes hepatic resection, lymphadenectomy, and port-sites excision. METHODS: From January 2006 to March 2008, four patients with IDEGB were carried out to revision procedure by a totally laparoscopic approach. The mean operative time of procedure has been 162 minutes, whereas blood loss has been <100 mL (mean 85.1±23.3 mL). The postoperative course has been uneventful in all patients and perioperative mortality (within 40 days from intervention) 0. Hospital stay has been, respectively, 4, 5, 5, and 6 days (mean 5 days). During follow-up, at the last fluorine-18-labeled fluordesoxyglucose-positron emission tomography (FDG-PET) scan examination, respectively, 4, 3, and--for 2 patients--2 years after revision laparoscopic procedure, pathologic FDG accumulation was not reported. CONCLUSIONS: Totally laparoscopic revision surgery for IDEGC seems to be a legitimate procedure, and, in our experience, reports satisfactory clinical outcomes in terms of perioperative and middle term oncological results. Larger and prospective studies are needed to support definitively oncological safety of this approach.

Sorafenib plus octreotide is an effective and safe treatment in advanced hepatocellular carcinoma: multicenter phase II So.LAR. study.

PURPOSE: Advanced hepatocellular carcinoma (HCC) not eligible for local therapies has limited chances of cure. Sorafenib is a multikinase inhibitor with proven activity in advanced HCC. Octreotide is used in this setting with conflicting results. Treatment with sorafenib and long-acting octreotide was tested in advanced HCC to evaluate safety and activity. METHODS: Fifty patients with advanced HCC, Child-Pugh A or B, received sorafenib at a dosage of 800 mg/day for 28 days with a following week of rest and long-acting octreotide at a dose of 40 mg, administered every 28 days. RESULTS: All patients were assessable for safety and efficacy. Sixteen patients out of 50 (34%) were naïve from other therapies, while all the others were previously treated with local and/or systemic treatments. We achieved 5 partial responses (10%), 33 stable diseases (66%) and 12 progressions of disease (24%). Median time to progression was 7.0 months (95% CI, 3.0-10.9 months), and median overall survival was 12 months (95% CI, 6.3-17.4 months). Treatment was well tolerated. Diarrhoea (6%) and hypertension (4%) were the most frequent grade 3 toxicities. CONCLUSIONS: Our data suggest that the combination between sorafenib and long-acting octreotide is active and well tolerated in patients with advanced HCC and could represent another efficacious chance for the management of this population.

Laparoscopic segment VI liver resection using a left lateral decubitus position: a personal modified technique.

BACKGROUND: Laparoscopic technique for lesions located in the left liver is well described in the literature. On the contrary, the best laparoscopic approach for lesions located in the right liver, such as in segment VI, is still debated. AIM: In this article, we provide a detailed description of a laparoscopic segment VI liver resection using a left lateral decubitus position with the right side up, facilitated by a personal technique. We also discuss potential advantages and disadvantages of this procedure.

Laparoscopic left lateral hepatic lobectomy: a safer and faster technique.

BACKGROUND/PURPOSE: Laparoscopy for liver resection is highly specialized field because laparoscopic liver surgery presents severe technical difficulties, such as control of bleeding and risk of gas embolism. At present, a limited number of laparoscopic anatomical left lobectomies have been reported in the literature, but we believe that the use of stapling devices has made this technique safer and faster. METHODS: From January 2000 to May 2005, eight patients (five men, three women; mean age, 60.5 years) underwent laparoscopic anatomical left lobectomy at our department. Seven patients presented with hepatocellular carcinoma and cirrhosis, while one patient had a large symptomatic angioma. The average size of the lesions was 4.18 cm (range, 3.6-7.1 cm); all the lesions were localized in the anatomical left lobe (segments II-III). Transection of the liver parenchyma, together with sectioning of the vascular pedicle for segment II and III and of the left hepatic vein, was obtained by the use of stapling devices. RESULTS: The mean operative time was 142 min (range, 120-180 min). There were no intraoperative or postoperative complications, and blood transfusions were not required. The mean postoperative hospital stay was 5.75 days. CONCLUSIONS: The key points of the technique are: late mobilization of the liver; no transection of the round ligament; no surrounding or taping of the portal pedicles or of the left hepatic vein; and the use of three consecutive linear staplers, turned to the left for transecting the liver parenchyma and vascular pedicle together. This technique, in our opinion, should be considered a new good option for patients with isolated lesions of the left lateral segments, but it must be performed by surgeons trained in both liver and advanced laparoscopic surgery.