Laparoendoscopic single site (LESS) surgery for left-lateral hepatic sectionectomy as an alternative to traditional laparoscopy: case-matched analysis from a single center.

BACKGROUND: Laparoscopy is considered the "gold standard" to perform left-lateral sectionectomy with results identical to those of open surgery, yielding decreased postoperative pain and disability, reduced hospital stay, and shortened patient recovery time. As the emphasis on minimizing the invasiveness of surgical techniques continues, laparoendoscopic single site (LESS) surgery is quickly evolving. The purpose of this study was to compare the results of laparoscopic left-lateral sectionectomy performed using the traditional approach or LESS approach with a case-matched analysis for tumor size, type of resection, and surgical indications. METHODS: Thirteen patients who underwent LESS left-lateral sectionectomy are considered the study group (LESS group) and compared with 13 patients who underwent left-lateral sectionectomy with traditional laparoscopic approach (conventional group). RESULTS: There were no significant differences between groups for length of surgery (165 min in conventional group vs. 195 min in LESS group), blood loss (150 mL in conventional group vs. 175 mL in LESS group), conversion to open surgery, histological tumor exposure, and requirements of postoperative analgesics. One patient in the LESS group died of cardiac failure due to an unknown severe aortic valve stenosis. No differences were recorded for postoperative complications (23.1% in both groups) and median length of postoperative stay (4 days in both groups). CONCLUSIONS: For left-lateral hepatic sectionectomy, LESS surgery is technically feasible and as safe as traditional laparoscopic surgery in terms of intraoperative and postoperative results, even though requiring both hepatobiliary and laparoscopic technique experience.

Surgical approach to multifocal hepatocellular carcinoma with portal vein thrombosis and arterioportal shunt leading to portal hypertension and bleeding: a case report.

It is reported the case of a 69 years man who presented to the Emergency Room because of pain and abdominal distension from ascites. After admission and paracentesis placement, he developed a digestive hemorrhage due to oesophageal varices from portal ipertension secondary to the formation of a portal shunt concomitant with a multifocal HepatoCellular Carcinoma (HCC) with portal vein thrombosis (PVT). The patient underwent endoscopic varices ligation, twice transarterial embolization (TAE) of arterial branches feeding the shunt and subsequent left hepatectomy. During the postoperative course he developed mild and transient signs of liver failure and was discharged in postoperative day 16. He is alive and disease free 8 months after surgery.

Does hepatic pedicle clamping affect disease-free survival following liver resection for colorectal metastases?

OBJECTIVE: To evaluate the impact of liver ischemia from hepatic pedicle clamping (HPC) on long-term outcome after hepatectomy for colorectal liver metastases (CRLM). BACKGROUND: Liver resection offers the only chance of cure for patients with CRLM. Several clinical and pathologic factors have been reported as determinants of poor outcome after hepatectomy for CRLM. A controversial issue is that hepatic ischemia/reperfusion injury from HPC may adversely affect long-term outcome by accelerating the outgrowth of residual hepatic micrometastases. METHODS: Patients undergoing liver resection for CRLM in 2 tertiary referral centers, between 1992 and 2008, were included. Disease-free survival and specific liver-free survival were analyzed according to the use, type, and duration of HPC. RESULTS: Five hundred forty-three patients had primary hepatectomy for CRLM. Hepatic pedicle clamping was performed in 355 patients (65.4%), and intermittently applied in 254 patients (71.5%). Postoperative mortality and morbidity rates were 1.3% and 18.5%, respectively. Hepatic pedicle clamping had a highly significant impact in reducing the risk of blood transfusions and was not correlated with significantly higher postoperative morbidity. Liver recurrence rate was not significantly different according to the use, type, and duration of HPC, in patients resected after preoperative chemotherapy as well. On univariate analysis, HPC did not significantly affect overall and disease-free survival. These results were confirmed on the multivariate analysis where blood transfusions, primary tumor nodal involvement, and the size of CRLM of more than 5 cm prevailed as determinants of poor outcome. CONCLUSIONS: This study confirms the safety and effectiveness of HPC and demonstrates that in the human situation, there is no evidence that HPC may adversely affect long-term outcome after hepatectomy for CRLM.

Case-matched analysis of totally laparoscopic versus open liver resection for HCC: short and middle term results.

BACKGROUND AND OBJECTIVES: Laparoscopy is gaining acceptance as a safe procedure for resection of liver neoplasms. The aim of this study is to evaluate surgical results and mid-term survival of minor hepatic resection performed for HCC. METHODS: Data of 16 patients with HCC, undergoing laparoscopic hepatectomy from September 2005 to January 2009, were compared to a control group of 16 patients who underwent open resection (OR) during the same period. The two groups were matched in terms of type of resection, tumor size, and severity of cirrhosis. RESULTS: One patient underwent conversion to an open approach. Laparoscopic approach resulted in shorter operating time (150 min, P:0.044) and lower blood loss (258 ml, P:0.008). There was no difference in perioperative morbidity and mortality rate; laparoscopic approach was associated with a shorter hospital stay (6.3 days, P:0.039). After a mean follow up of 32 months, disease free survival and overall survival were 40.2 and 23.3 months for laparoscopic group, and 47.7 and 31.4 months for OR group (P NS). CONCLUSION: Laparoscopic resection of HCC is feasible and safe in selected patients and can result in good surgical results, with similar outcomes in terms of overall and disease-free survival.

What defines 'cure' after liver resection for colorectal metastases? Results after 10 years of follow-up.

BACKGROUND: During the last two decades, resection of colorectal liver metastases (CLM) in selected patients has become the standard of care, with 5-year survival rates of 25-58%. Although a substantial number of actual 5-year survivors are reported after resection, 5-year survival rates may be inadequate to evaluate surgical outcomes because a significant number of patients experience a recurrence at some point. OBJECTIVES: This study aimed to analyse longterm results and prognostic factors in liver resection for CLM in patients with complete 10-year follow-up data. METHODS: A total of 369 patients who underwent liver resection for CLM between 1985 and 1998 were identified from a bi-institutional database. Postoperative deaths and patients with extrahepatic disease were excluded. Clinicopathological prognostic factors were analysed using univariate and multivariate analyses. RESULTS: The sample included 309 consecutive patients with complete 10-year follow-up data. Five- and 10-year overall survival rates were 32% and 23%, respectively. Overall, 93% of recurrences occurred within the first 5 years of follow-up, but 11% of patients who were disease-free at 5 years developed later recurrence. Multivariate analysis demonstrated four independent negative prognostic factors for survival: more than three metastases; a positive surgical margin; tumour size >5 cm, and a clinical risk score >2. CONCLUSIONS: Five-year survival rates are not adequate to evaluate surgical outcomes of patients with CLM. Approximately one-third of actual 5-year survivors suffer cancer-related death, whereas patients who survive 10 years appear to be cured of disease.

Liver resection with portal vein thrombectomy for hepatocellular carcinoma with vascular invasion.

INTRODUCTION: Hepatocellular carcinoma (HCC) tends to invade the intrahepatic vasculature, especially the portal vein. The presence of portal vein tumor thrombus (PVTT) in patients with HCC is one of the most significant factors for a poor prognosis. The presence of macroscopic PVTT in patients with HCC is also a significant factor for poor prognosis, with a median survival of <3 months without treatment. In surgically resected series, in patients with gross PVTT (PVTT in the portal trunk, its first-order branch, or its second-order branch), the 3-year and 5-year survival rates are reportedly 15% to 28% and 0% to 17%, respectively. METHODS: The patient was a 77-year-old woman with well-compensated hepatitis C virus-related cirrhosis (stage A6 according to Child-Pugh classification) who sought care at our department for vague abdominal discomfort. Triphasic spiral computed tomographic scan confirmed HCC 6 cm in diameter in the left lobe of the liver. In addition, portal vein tumor thrombosis of the left branch that extended to the right portal vein was present. RESULTS: The procedure included left hepatectomy and en-bloc portal vein thrombectomy with clamping of both the common portal vein trunk and the right portal vein. The portal vein was incised at the bifurcation of the right and left portal veins, and the thrombus was extracted from the incision in the portal vein. With this procedure, we were able to examine under direct vision the exact extent of the portal vein thrombus, and we identified whether the tumor thrombus was adherent to the venous wall or was freely floating in the venous lumen. Portal clamping and length of operation were 16 and 330 minutes, respectively. Intraoperative blood loss was 550 mL. The patient was discharged on postoperative day 6, and she was free of disease at 15 months after surgery. DISCUSSION: Liver resection should be considered a valid therapeutic option for HCC with PVTT.

Results of preoperative hepatic arterial infusion chemotherapy in patients undergoing liver resection for colorectal liver metastases.

BACKGROUND: Although hepatic artery infusion chemotherapy (HAIC) of floxuridine (FUDR) for colorectal liver metastases (CLM) can produce high response rates, data concerning preoperative HAIC are scarce. The aim of this study was to assess the feasibility and results of liver resection after preoperative HAIC with FUDR. METHODS: Between 1995 and 2004, 239 patients with isolated CLM received HAIC in our institution. Fifty of these patients underwent subsequent curative liver resection (HAIC group). Short- and long-term results of the HAIC group were compared with the outcomes of 50 patients who underwent liver resection for CLM without preoperative chemotherapy. RESULTS: Postoperative morbidity rate were comparable between the two groups. Overall disease-free survival at 1 and 3 years after hepatectomy were 77.5% and 57.5% in the HAIC group and 62.9% and 37% in the control group (P = .036). Overall survival from diagnosis of CLM at 1, 3, and 5 years were 97%, 59%, and 49% in the HAIC group versus 94%, 48%, and 35% in the control group (P = .097). When patients were stratified according to clinical-risk scoring (CRS) system, patients with more advanced disease at the time of liver resection (CRS > or = 3) had a median survival of 41 months in the HAIC group (n = 37) and 35 months in the control group (n = 34) (P = .031). CONCLUSIONS: HAIC of FUDR does not negatively affect the outcome of subsequent liver resection. Preoperative HAIC of FUDR may reduce liver recurrence rate and improve long-term survival in patients with more advanced liver disease.

A prospective evaluation of laparoscopic versus open left lateral hepatic sectionectomy.

BACKGROUND: Left lateral sectionectomy is one of the most commonly performed laparoscopic liver resections, but limited clinical data are actually available to support the advantage of laparoscopic versus open-liver surgery. The present study compared the short-term outcomes of laparoscopic versus open surgery in a case-matched analysis. MATERIALS AND METHODS: Surgical outcome of 20 patients who underwent left lateral sectionectomy by laparoscopic approach (LHR group) from September 2005 to January 2007 were compared in a case-control analysis with those of 20 patients who underwent open left lateral sectionectomy (OHR group). Both groups were similar for: tumor size, preoperative laboratory data, presence of cirrhosis, and histology of the lesion. Surgical procedures were performed in both groups combining the ultrasonic dissector and the ultrasonic coagulating cutter without portal clamping. RESULTS: Compared with OHR, the LHR group had a decreased blood loss (165 mL versus 214 mL, P=0.001), and earlier postoperative recovery (4.5 versus 5.8 days, P=0.003). There were no significant differences in terms of surgical margin and operative time. Morbidity was comparable between the two groups, but two cases of postoperative ascites were recorded in two cirrhotic patients in the OHR. Major complications were not observed in either groups. CONCLUSIONS: Laparoscopic resection results in reduced operative blood loss and earlier recovery with oncologic clearance and operative time comparable with open surgery. Laparoscopic liver surgery may be considered the approach of choice for tumors located in the left hepatic lobe.

Laparoscopic liver resection without portal clamping: a prospective evaluation.

BACKGROUND: Previous comparative studies have demonstrated that laparoscopic liver resection is associated with more frequent use and longer duration of portal camping than open liver resection, a fact that may partially explain the improvement in operative blood loss reported by most series of laparoscopic liver resection. The aim of this prospective study was to evaluate the real need for portal clamping in laparoscopic liver surgery. STUDY DESIGN: Surgical outcomes of 40 consecutive patients who underwent laparoscopic liver resection for benign and malignant lesions from September 2005 to August 2007 were evaluate. Portal clamping was not systematically used. RESULTS: No patient required blood transfusion and median blood loss was 160 ml (range 100-340 ml). Mean operating time was 267 min (range 220-370 min) and portal clamping was necessary in only one patient. Surgical complications included two grade I complication, three grade II, and one case of postoperative hemorrhage (grade III). CONCLUSIONS: Laparoscopic liver surgery without clamping can be performed safely with low blood loss.

Preoperative methylprednisolone administration maintains coagulation homeostasis in patients undergoing liver resection: importance of inflammatory cytokine modulation.

Alterations in hemostatic parameters are a common finding after major hepatic resection. There is growing evidence that inflammation has a significant role in inducing coagulation disarrangement that follows major surgery. To determine whether preoperative methylprednisolone administration has a protective effect against the development of coagulation disorders, we evaluated the effect of preoperative steroids administration on changes in hemostatic parameters and plasma levels of inflammatory cytokines in patients undergoing liver surgery. Seventy-three patients undergoing liver resection were randomized to a steroid group or to a control group. Patients in the steroid group received 500 mg of methylprednisolone preoperatively. Serum levels of coagulation parameters (prothrombin time, platelets, fibrinogen, plasma fibrin degradation products [D-dimer], antithrombin III) and inflammatory mediators (IL-6 and TNF-alpha) were measured before and immediately after the operation and on postoperative days 1, 2, and 5. Multivariate analysis was performed to identify factors related to the characteristics of the patients and surgery affecting coagulation parameters between the two groups. Decreases in antithrombin III, platelet count and fibrinogen levels, prolongation of prothrombin time, and increases in the plasma fibrin degradation products were significantly suppressed by the administration of methylprednisolone. Cytokines production was also significantly suppressed by the administration of methylprednisolone, and there was significant correlation between plasma levels of cytokines and coagulation alterations. These findings suggest that preoperative methylprednisolone administration inhibits the development of coagulation disarrangements in patients undergoing liver resection, possibly through suppressing the production of inflammatory cytokines.

A prospective evaluation of ultrasonic dissector plus harmonic scalpel in liver resection.

Several techniques have been described for safe dissection of the liver parenchyma. The aim of this study was to evaluate the feasibility and effectiveness of combining two different electronic devices, the ultrasonic dissector and the harmonic scalpel, during hepatic resection. One hundred consecutive patients who underwent liver resection between January and December 2004 were enclosed in the study. Patients requiring concomitant colic resection or biliary-enteric anastomosis were excluded from the study. Operative variables (type of procedure, operating time, Pringle time, blood losses, transfusions, and histological tumor exposure at the transection surface), hospital stay, and complications were recorded. The extent of hepatic resection was a minor resection in 31 and major in 69 cases. Median blood loss was 500 mL (range, 100-2000 mL) and the Pringle maneuver was used in 58 patients. Median operative time was 367 minutes (range, 150-660 minutes). Hepatic resection was performed in 32 cirrhotic livers. Surgical complications included one postoperative hemorrhage and two bile leaks. The overall morbidity and mortality rate was 14 and 1 per cent, respectively. In conclusion, the combined use of these electronic devices allows liver resection to be safely performed, even in cirrhotic patients, with the advantage of reducing surgical complications. A prospective randomized trial is needed to clarify the clinical benefits of liver resections performed combining these two devices.

Tolerance to cannabinoid response on the myenteric plexus of guinea-pig ileum and human small intestinal strips.

1. We studied tolerance to cannabinoid agonist action by comparing the in vitro inhibition of electrically evoked contractions of longitudinal muscle from small intestine of human and guinea-pig (myenteric plexus preparations) after 48-h incubation with the synthetic agonist (+) WIN 55,212-2. We also investigated the intrinsic response to the selective cannabinoid CB(1) receptor antagonist rimonabant in control and tolerant strips. 2. (+) WIN 55,212-2 inhibited guinea-pig (IC(50) 4.8 nM) and human small intestine (56 nM) contractions with similar potency before or after 48-h incubation in drug-free conditions; this effect was competitively antagonized by rimonabant (pA(2), 8.4, 8.2). A 48-h preincubation with (+) WIN 55,212-2, but not with (-) WIN 55,212-3, completely abolished the acute agonist response in both tissue preparations. The opiate K-receptor agonist U69593 inhibited human small intestine contractions with a similar potency in control and strips tolerant to (+) WIN 55,212-2, IC(50) 39 and 43 nM. 3. Unlike human tissue, in guinea-pig small intestine, which has a high level of endocannabinoids, rimonabant alone increased the twitches induced by the electrical field stimulation (EC(50) 100 nM) with a maximal effect of 123%. 4. In strips tolerant to (+) WIN 55,212-2, rimonabant markedly increased (155%) the electrical twitches in human ileum and in guinea-pig myenteric plexus smooth muscle (133%). 5. This study shows tolerance can be induced to the cannabinoids' action in intestinal strips of human and guinea-pig by long in vitro incubation with the agonist (+) WIN 55,212-2.

"Technological" approach versus clamp crushing technique for hepatic parenchymal transection: a comparative study.

We evaluated the feasibility and effectiveness of combining two different electronic devices, the ultrasonic dissector (UD) and the harmonic scalpel (HS), during hepatic resection. One hundred consecutive patients underwent liver resection using UD plus HS between January and December 2004 (UD + HS group). The ultrasonic dissector was used to fracture liver parenchyma and the uncovered vessel was sealed using the HS. Surgical outcomes were compared with 100 consecutive patients who underwent liver resection using the clamp crushing method. Operative variables, postoperative liver function, hospital stay, and type and number of complications were compared. The two groups were equivalent in term of demographic and pathologic variables. The UD + HS group had a decreased blood loss (500 ml versus 700 ml, P = 0.005), number of patients transfused (22 versus 39, P = 0.009), tumor exposure at the transection surface (4 versus 12, P = 00.012), and hospital stay (7 versus 8.5 days, P = 0.020). Postoperative major complications, in particular, fluid collection and biliary fistula, were significantly less frequent in the UD + HS group (2 versus 9, P = 0.030). A longer operative time was recorded in the UD + HS group (385 versus 330 minutes, P = 0.001). The combined use of UD with HS allows liver resection to be safely performed, with the advantage of reducing blood losses and surgery-related complications. The only major disadvantage may be a longer transection time.

Reduced severity of liver ischemia/reperfusion injury following hepatic resection in humans is associated with enhanced intrahepatic expression of Th2 cytokines.

BACKGROUND: Based on previous studies in experimental models, pro-inflammatory Th1 cytokines (i.e. TNF-alpha and IFN-gamma) are thought to play a pathogenic role in hepatic ischemia/reperfusion injury, while anti-inflammatory Th2 cytokines (i.e. IL-4 and IL-10) have been associated with reduced liver disease severity. To test the relevance of these concepts in humans, cytokine expression profiles were characterized in liver biopsies from patients undergoing hepatic resection following intermittent portal clamping. METHODS: Twelve patients were analyzed for the intrahepatic expression of TNF-alpha, IFN-gamma, IL-4 and IL-10 before and about 90min after the last reperfusion. In addition, parameters of liver damage including sALT and serum levels of TNF-alpha were analyzed at 2, 24 and 48h after surgery. RESULTS: When compared with pre-reperfusion liver specimens, all post-reperfusion biopsies showed significantly increased levels of TNF-alpha and IFN-gamma mRNAs. Conversely IL-4 and IL-10 mRNA levels were significantly increased in only seven patients. A negative correlation was observed between Th2 cytokines (IL-4, IL-10) and ALT and serum levels of TNF-alpha. Furthermore, the presence of hepatic steatosis was significantly associated with lower intrahepatic contents of IL-4 and IL-10. CONCLUSIONS: The results suggest that the local early expression of Th2 cytokines may contribute to attenuate liver injury following ischemia reperfusion in humans. The early imbalance between pro- and anti-inflammatory cytokines seen in steatotic liver subjected to I/R could explain, at least partially, the decreased tolerance of steatotic livers to I/R injury.

Impact of common polymorphisms in candidate genes for insulin resistance and obesity on weight loss of morbidly obese subjects after laparoscopic adjustable gastric banding and hypocaloric diet.

CONTEXT: It is unknown whether genetic factors that play an important role in body weight homeostasis influence the response to laparoscopic adjustable gastric banding (LAGB). OBJECTIVE: We investigated the impact of common polymorphisms in four candidate genes for insulin resistance on weight loss after LAGB. DESIGN: The design was a 6-month follow-up study. SETTING: The study setting was hospitalized care. PATIENTS: A total of 167 unrelated morbidly obese subjects were recruited according to the following criteria: age, 18-66 yr inclusive; and body mass index greater than 40 kg/m2 or greater than 35.0 kg/m2 in the presence of comorbidities. INTERVENTION: LAGB was used as an intervention. MAIN OUTCOME MEASURE: Measure of correlation between weight loss and common polymorphisms in candidate genes for insulin resistance and obesity was the main outcome measure. RESULTS: The following single nucleotide polymorphisms were detected by digestion of PCR products with appropriate restriction enzymes: Gly972Arg of the insulin receptor substrate-1 gene, Pro12Ala of the proliferator-activated receptor-gamma gene, C-174G in the promoter of IL-6 gene, and G-866A in the promoter of uncoupling protein 2 gene. Baseline characteristics including body mass index did not differ between the genotypes. At the 6-month follow-up after LAGB, carriers of G-174G IL-6 genotype had lost more weight than G-174C or C-174C genotype (P = 0.037), and carriers of A-866A uncoupling protein 2 genotype had lost more weight as compared with G-866G (P = 0.018) and G-866A (P = 0.035) genotype, respectively. Weight loss was lower in carriers of Gly972Arg insulin receptor substrate-1 genotype than Gly972Gly carriers, but not statistically significant (P = 0.06). No difference between carriers of Pro12Ala and Pro12Pro proliferator-activated receptor-gamma genotype was observed. CONCLUSIONS: These data demonstrate that genetic factors, which play an important role in the regulation of body weight, may account for differences in the therapeutic response to LAGB.

[Prognostic factors for long-term outcome of hepatic resection for colorectal liver metastases]. / Fattori prognostici dell'outcome a lungo termine della chirurgia resettiva epatica per metastasi da carcinoma colorettale.

The aim of the study was to analyse the prognostic factors for long-term outcome of liver resections for metastases from colorectal cancer. The retrospective analysis included 297 liver resections for colorectal carcinoma liver metastases. The following prognostic factors were considered: age, gender, stage and grade of differentiation of the primary tumour, node metastases, site of the primary colorectal cancer, number and diameter of the hepatic lesions, time interval from primary cancer to liver metastases, preoperative CEA level, adjuvant chemotherapy after hepatic resection, type of hepatic resection, use of intraoperative ultrasound and portal triad clamping, blood loss and transfusions, postoperative complications and hospital stay, tumour-free surgical margins, clinical risk score (as defined by the Memorial Sloan-Kettering Cancer Centre group, MSKCC-CRS). Overall survival rates were estimated according to the Kaplan-Meier method and were compared at univariate analysis using the log-rank test. Multivariate analysis was performed including significant variables at univariate analysis using the Cox regression model. Differences were considered significant at p < 0.05. The 1, 3, 5 and 10-year overall survival rates were 90.6%, 51%, 27.5%, and 16.9%, respectively. The univariate analysis revealed a statistically significant difference (p < 0.05) in overall survival in relation to: grade of differentiation of the primary cancer (5-year survival of grades G1-G2 vs grades G3-G4: 30.7% vs 14.4%, p = 0.0016), preoperative CEA level > 5 and > 200 ng/ml (5-year survival of CEA < 5 ng/ml vs CEA > 5 ng/ml: 51.1% vs 15.5%, p = 0.0016; 5-year survival of CEA < 200 ng/ml vs CEA > 200 ng/ml: 27.9% vs 17.4%, p = 0.0001), diameter of major lesions > 5 cm (5-year survival of diameter < or = 5 cm vs > 5 cm: 30.0% vs 18.8%, p = 0.0074), disease-free interval between primary tumour and liver metastases longer than 12 months (5-year survival of patients with disease-free interval < or = 12 months vs > 12 months: 23.0% vs 36.1%, p = 0.042), high MSKCC-CRS (5-year survival of MKSCC-CRS 0-1-2 vs 3-4-5: 36.4% vs 1 6.3%, p = 0.017). The multivariate analysis showed three independent negative prognostic factors: G3-G4 primary cancer, CEA level > 5 ng/ml, and high MSKCC-CRS class. No single prognostic factor turned out to be associated with such disappointing outcomes after hepatic surgery for colorectal liver metastases as to permit the identification of specific subgroups of patients to be excluded on principle from undergoing liver resection. However, in the presence of a number of specific prognostic factors (G3-G4 grade of differentiation of the primary tumour, preoperative CEA level > 5 ng/ml, high MSKCC-CRS) enrolment of the patient in trials exploring new diagnostic tools or new adjuvant treatments may be suggested to improve the preoperative staging of the disease and reduce the incidence of tumour recurrence after liver resection.

Laparoscopic adjustable gastric banding for the treatment of morbid (grade 3) obesity and its metabolic complications: a three-year study.

Weight loss ameliorates arterial hypertension and glucose metabolism in obese patients, but the dietary approach is unsatisfactory because obesity relapses. Durable reduction of body weight, obtained through major nonreversible surgical procedures, such as jejunal and gastric bypass, allows improvement of glucose metabolism and arterial blood pressure in morbid (grade 3) obesity. Laparoscopic adjustable gastric banding (LAGB) is a minimally invasive and reversible surgical procedure that yields a significant reduction of gastric volume and hunger sensation. In this study, 143 patients with grade 3 obesity [27 men and 116 women; age, 42.9 +/- 0.83 yr; body mass index (BMI), 44.9 +/- 0.53 kg/m(2); normal glucose tolerance (NGT; n = 77); impaired glucose tolerance (IGT; n = 47); type 2 diabetes mellitus (T2DM; n = 19)] underwent LAGB and a 3-yr follow-up for clinical (BMI, waist circumference, waist to hip ratio, and arterial blood pressure) and metabolic variables (glycosylated hemoglobin, fasting insulin and glucose, insulin and glucose response to oral glucose tolerance test, homeostasis model assessment index, total and high-density lipoprotein cholesterol, triglycerides, uric acid, and transaminases). At baseline and 1 yr after LAGB, patients underwent computerized tomography and ultrasound evaluation of visceral and sc adipose tissue. One-year metabolic results were compared with 120 obese patients (51 men and 69 women; age, 42.9 +/- 1.11 yr; BMI, 43.6 +/- 0.46 kg/m(2); NGT, n = 66; IGT, n = 8; T2DM, n = 46) receiving standard dietary treatment. LAGB induced a significant and persistent weight loss and decrease of blood pressure. Greater metabolic effects were observed in T2DM patients than in NGT and IGT patients, so that at 3 yr glycosylated hemoglobin was no longer different in NGT and T2DM subjects. Clinical and metabolic improvements were proportional to the amount of weight loss. LAGB induced a greater reduction of visceral fat than sc fat. At 1-yr evaluation, weight loss and metabolic improvements were greater in LAGB-treated than diet-treated patients. We conclude that LAGB is an effective treatment of grade 3 obesity in inducing long-lasting reduction of body weight and arterial blood pressure, modifying body fat distribution, and improving glucose and lipid metabolism, especially in T2DM.

Paraplegia following coeliac plexus block.

Coeliac plexus block (CPB) is one of the few neurolytic procedures that is still considered very useful in managing chronic cancer pain. We describe what we believe to be the fifth case in the literature of paraplegia following coeliac plexus block with ethyl alcohol. Clinical and neurophysiological examination confirmed the hypothesis of an acute myelopathy probably caused by ischemia due to involvement of Adamkievicz's artery. The seriousness of this neurological complication led us to review the different pain-relieving strategies in pancreatic cancer. Several medical and surgical procedures are available for advanced pancreatic cancer, yet none of them alone can be considered the therapy of choice for all cases. Hence, only a multidisciplinary approach to pancreatic cancer pain can help in making the most appropriate choice for each patient.

Impact of age on the outcome of liver resections.

The purpose of this study was to evaluate the influence of age on the outcome of liver resections. One hundred five consecutive hepatic resections were divided into two groups: > or = 65 years old [old group (O-group)] and < 65 years old [young group (Y-group)]. The two groups were first compared to evaluate the distribution of the variables potentially affecting the postoperative course, including primary diagnosis, concomitant diseases, previous upper abdominal surgery, type of operation (major or minor resection), associated procedures, presence and length of portal clamping, intraoperative blood losses and transfusions, and length of operation. The outcome of hepatic resections in the two groups was comparatively evaluated in terms of postoperative mortality, morbidity, transfusions, and length of postoperative hospitalization. The Y-group included 61 resections in 60 patients, mean age 52 +/- 10 years (mean +/- SD), range 23-64 years, whereas the O-group included 44 resections in 43 patients, mean age 71 +/- 4 years (mean +/- SD ), range 65-82 years. The O-group included more hepatocellular carcinomas (45.4% vs 18.0%, P = 0.002) and chronic liver diseases (40.9% vs 18.7%, P = 0.017); the median length of operation was slightly higher in the Y-group (300 minutes vs 270 minutes, P = 0.003). Both O-group and Y-group were comparable (P = n.s.) when evaluated for all other listed variables. As far as concerns the outcome of hepatic resections in the two groups, the length of postoperative hospitalization was identical (median 9 days, 5-60 days), whereas transfusions of packed red cells (O-group vs Y-group: 25.0% vs 16.3%, P = 0.30) or fresh frozen plasma (O-group vs Y-group: 13.6% vs 6.5%, P = 0.053) were not statistically different. Postoperative mortality included one case among young patients whereas no deaths were recorded among elderly patients. Postoperative morbidity was higher in Y-group than in O-group (31.5% vs 20.5%, P = 0.59). The age factor does not negatively affect the outcome of liver resections.

Combined surgical-percutaneous approach for placement of arterial devices for hepatic chemotherapy.

Indwelling devices for intra-arterial hepatic chemotherapy are usually implanted either surgically or percutaneously. A combined surgical-percutaneous approach to a patient with double arterial supply to the liver is presented and we suggest performing an effective hepatic chemotherapy after surgery whenever two distinct hepatic arteries are present.