Albi Score as a Predictor of Survival in Patients with Compensated Cirrhosis Resected for Hepatocellular Carcinoma: Exploratory Evaluation in Relationship to Palbi and Meld Liver Function Scores.

The aim of the study was to explore predictive value of the ALBI, PALBI and MELD scores on survival in patients resected for hepatocellular carcinoma with compensated liver cirrhosis and no macrovascular infiltration. In this retrospective study, longitudinal survival analysis was performed. We analyzed patient/tumor characteristics and MELD, ALBI and PALBI scores as liver function tests for predicting survival outcome. Survival was analyzed from the date of liver resection until death, liver transplantation, or end of follow-up. Patients were stratified for age, cirrhosis etiology, presence of esophageal varices, hepatocellular carcinoma stage, microvascular invasion, histologic differentiation, and resection margins. We identified 38 patients (alcoholic cirrhosis in 84.2% of patients) resected over an 8-year period. Median preoperative MELD score was 8, ALBI score -2.63, and PALBI score -2.38. During the follow-up period, 24 patients died. Estimated median survival time was 36 months. Microvascular invasion was observed in 33 patients. Higher ALBI score was associated with 23.1% higher relative risk of death. PALBI score was associated with 12.1% higher relative risk of death, whereas MELD score was not associated with the risk of death. In conclusion, ALBI score demonstrated significant predictive capabilities for survival in patients with compensated cirrhosis resected for hepatocellular carcinoma.

Comparison of hepatoprotective effect from ischemia-reperfusion injury of remote ischemic preconditioning of the liver vs local ischemic preconditioning of the liver during human liver resections.

AIM: To compare and evaluate the hepatoprotective effect of remote ischemic preconditioning (RIPC) with local ischemic preconditioning (LIPC) of the liver during human liver resections. METHODS: A prospective, single-centre, randomised control trial was conducted in the Clinical Hospital "***" from April 2017 to January 2018. A total of 60 patients, who underwent liver resection due to colorectal cancer liver metastasis, were randomised to one of three study arms: 1) a RIPC group, 2) an LIPC group and 3) a control group (CG) in which no ischemic preconditioning was done before liver resection. The hepatoprotective effect was evaluated by comparing serum transaminase levels, bilirubin levels, albumin, and protein levels, coagulograms and through pathohistological analysis. The trial was registered on ClinicalTrials.gov (NCT****). RESULTS: Significant differences were found in serum levels of liver transaminases and bilirubin levels between thegroups, the highest level in the CG and the lowest level in the LIPC group. Levels of cholinesterase were also significantly higher in the LIPC group. Pathohistological findings graded by the Rodriguez score showed favourable changes in the LIPC and RIPC groups versus the CG. CONCLUSION: Strong evidence supports the hepatoprotective effect of RIPC and LIPC preconditioning from an ischemia-reperfusion injury of the liver. Better synthetic liver function preservation in these two groups supports this conclusion.

Diagnostic specificity and sensitivity of PIVKAII, GP3, CSTB, SCCA1 and HGF for the diagnosis of hepatocellular carcinoma in patients with alcoholic liver cirrhosis.

Introduction Despite some new treatment possibilities, the improvement in survival rate for hepatocellular carcinoma (HCC) patients is still poor due to late diagnosis. The aim of this study was to investigate the diagnostic sensitivity and specificity of protein induced by vitamin K absence or antagonist-II (PIVKAII), Glypican-3 (GP3), Cystatin B (CSTB), squamous cell carcinoma antigen 1 (SCCA1) and hepatocyte growth factor (HGF) as potential tumour markers for HCC in patients with alcoholic liver cirrhosis (ALC) using imaging techniques (MSCT and MRI) as reference standards. Patients and methods Eighty-three participants were included: 20 healthy volunteers, 31 patients with ALC and 32 patients with HCC. Peripheral blood sampling was performed for each participant, and serum concentrations of PIVKAII, GP3, CSTB, SCCA1 and HGF were determined using commercial ELISA kits. Results Only serum concentrations of PIVKAII were significantly higher in HCC patients as compared with ALC and healthy controls (cut-off: 2.06 µg/L; AUC: 0.903), whereas individual diagnostic performance of other individual compounds was inadequate. The 'best' combination of tumour markers in our study includes all tested markers with AUC of 0.967. Conclusion While novel diagnostic tumour markers are urgently needed, the examined potential tumour markers, with the exception of PIVKAII seem to be inadequate for diagnosing HCC in ALC. Furthermore, probably the future is in finding the best optimal combination of tumour markers for diagnosing HCC based on cost-effectiveness.

Neutrophil-to-lymphocyte and platelet-to-lymphocyte ratio help identify patients with lung cancer, but do not differentiate between lung cancer subtypes.

AIM: To assess the diagnostic value of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in lung cancer (LC). We compared the ratios between healthy participants and all LC patients, as well patients with different pathohistological LC subtypes. METHODS: We retrieved the data on neutrophil, lymphocyte, and platelet levels in 449 patients with different pathohistological LC subtypes (non-small cell LC, small-cell LC, atypical or metastatic LC, neuroendocrine, and sarcomatoid carcinoma) and 47 healthy controls. NLR and PLR were calculated by dividing the absolute number of neutrophils or platelets with the absolute number of lymphocytes. RESULTS: There were significant differences in both NLR and PLR (P<0.001) between all LC patients and the control group, but there were no differences between patients with different LC subtypes. Reciever operating characteristics analysis for NLR showed the optimal cut-off value of 2.71, with a sensitivity of 77.05% and specificity of 87.23%. The optimal cut-off value for PLR was 182.31, with a sensitivity of 51.09% and specificity of 91.49%. CONCLUSION: The results showed that the NLR and PLR may have added value in the early diagnosis of LC, but further research is needed to confirm these results.

High Expression of DARPP-32 in Colorectal Cancer Is Associated With Liver Metastases and Predicts Survival for Dukes A and B Patients: Results of a Pilot Study.

The purpose of this study was to investigate prognostic significance of Dopamine and cAMP-Regulated neuronal Phosphoprotein 32 (DARPP-32) expression in primary colorectal cancer. The study material consisted of clinical and histopathological data of 100 patients operated for colorectal cancer between 1994 and 1997. For immunohistochemical analysis, specific rabbit antibodies for DARPP-32 were used and the percentage of stained tumor cells was calculated under gross magnification (400 times) on a sample of 500 tumor cells. DARPP-32 expression in the primary tumor was significantly greater in patients with distant metastases compared to patients with no distant metastases (p=0.002). In multivariate regression analysis, DARPP-32 expression in the primary tumor was a significant predictor of distant metastases. With a cut-off point of 76.5%, DARPP-32 expression in the primary tumor significantly influenced both overall and disease free survival, especially for Dukes A and B patients (p=0.037). The results of this study indicate that DARPP-32 may be a potential marker of worse prognosis and a valuable tool for managing further adjuvant treatment in patients with stages Dukes A and B colorectal cancer.

[LAPAROSCOPIC PARTIAL PERICYSTECTOMY OF SPLENIC HYDATID CYST - A CASE REPORT]. / LAPAROSKOPSKA PARCIJALNA PERICISTEKTOMIJA EHINOKOKNE CISTE SLEZENE - PRIKAZ BOLESNICE.

Echinococcal cyst of the spleen is usually a result of infection with the parasite Echinococcus granulosus. The spleen is the third most frequent localization of echinococcus after liver and lungs. Partial laparoscopic pericystectomy can be done without the loss of blood and scattering of scolexes with spleen preservation and conservation of its immune function. We present the patient with a large (1 8 x 16 x 12 cm) echinococcal cyst of the spleen that compressed the surrounding organs (stomach, transverse colon, pancreas and left kidney), and prevented normal passage causing vomiting after every meal. In this patient, PAIR procedure (puncture, aspiration, injection, reaspiration) and conservative treatment was attempted on several occasions without success. Finally, laparoscopic partial pericystectomy was performed, evacuating the contents of the cyst. The surgery lasted 120 minutes. Postoperatively the patient was without complications. Hospitalization lasted five days. Six months later, the patient is without problems. These echinococcus cysts of the spleen cannot be solved using PAIR technique and conservative treatment. Laparoscopic partial pericystectomy is a better solution than open surgery due to less trauma to the patient, especially in elderly people.

Gallbladder cancer.

Gallbladder cancer is the fifth most common cancer involving gastrointestinal tract, but it is the most common malignancy of the biliary tract, accounting for 80-95% of biliary tract cancers. This tumor is a highly lethal disease with an overall 5-year survival of less than 5% and mean survival mere than 6 months. An early diagnosis is essential as this malignancy progresses silently with a late diagnosis. The percentage of patients diagnosed to have gallbladder cancer after simple cholecystectomy for presumed gallbladder stone disease is 0.5-1.5%. Patients with preoperative suspicion of gallbladder cancer should not be treated by laparoscopy. Epidemiological studies have identified striking geographic and ethnic disparities-inordinately high occurrence in American Indians, elevated in Southeast Asia, yet quite low elsewhere in the Americas and the world. Environmental triggers play a critical role in eliciting cancer developing in the gallbladder, best exemplified by cholelithiasis and chronic inflammation from biliary tract and parasitic infections. Improved imaging modalities and improved radical aggressive surgical approach in the last decade has improved outcomes and helped prolong survival in patients with gallbladder cancer. The overall 5-year survival for patients with gallbladder cancer who underwent R0 curative resection was from 21% to 69%. In the future, the development of potential diagnostic markers for disease will yield screening opportunities for those at risk either with ethnic susceptibility or known anatomic anomalies of the biliary tract.

Potential use of Doppler perfusion index in detection of occult liver metastases from colorectal cancer.

Many clinical and preclinical studies demonstrated that measurements of liver hemodynamic [Doppler perfusion index (DPI)] may be used to accurately diagnose and predict liver metastases from primary colorectal cancer in a research setting. However, Doppler measurements have some serious limitations when applied to general population. Ultrasound is very operator-dependent, and requires skilled examiners. Also, many conditions may limit the use of Doppler ultrasound and ultrasound in general, such as the presence of air in digestive tract, cardiac arrhythmias, vascular anomalies, obesity and other conditions. Therefore, in spite of the results from clinical studies, its value may be limited in everyday practice. On the contrary, scientific research of the DPI in detection of liver metastases is of great importance, since current research speaks strongly for the presence of systemic vasoactive substance responsible for observed hemodynamic changes. Identification of such a systemic vasoactive substance may lead to the development of a simple and reproducible laboratory test that may reliably identify the presence of occult liver metastases and therefore increase the success of adjuvant chemotherapy through better selection of patients. Further research in this subject is therefore of great importance.

The laparoscopic liver resections-an initial experience and the literature review.

The laparoscopic liver resection (LLR) represents a new pathway in hepatic surgery. Several studies have reported its application in both malignant and benign liver diseases. The most common liver resections performed laparoscopically are wedge, segmental resections and metastasectomy; although in large centers the laparoscopic right and left hepatectomies have begun to perform more frequently. We report the initial experience in LLRs at our department including a case of the first laparoscopic left lateral liver bisegmentectomy performed in patient with follicular nodular hyperplasia and the 15 cases of wedge laparoscopic resections of echinococcic liver cysts. According to literature the mortality rate in LLRs is up to 0.3% and morbidity rate up to 10.5%. The most common cause of the death is liver failure, while the most frequent complication is the bile leakage. Advantages for patients include smaller incisions, less blood loss, and shorter lengths of hospital stay. The LLRs in experienced hands were shown to be safe with acceptable morbidity and mortality for both minor and major hepatic resections in benign and malignant diseases.

The surgical treatment of patients with colorectal cancer and liver metastases in the setting of the "liver first" approach.

A surgical resection is the only curative method in the therapy of colorectal carcinoma and liver metastases. Along with the development of interventional radiological techniques the indications for surgery widen. The number of metastases and patients age should not present a contraindication for surgical resection. However, there are still some doubts concerns what to resect first in cases of synchronous colorectal carcinoma and liver metastases and how to ensure the proper remnant liver volume in order to avoid postoperative liver failure and achieve the best results. Through this review the surgical therapy of colorectal carcinoma and liver metastases was revised in the setting of "liver-first" approach and the problem of ensuring of remnant liver volume.

Laparoscopic surgery for large hydatide liver cyst after two previous laparotomies.

Laparoscopic surgery for hepatic echinococcosis is a technically difficult and demanding surgical procedure even for the most experienced abdominal surgeon. Surgery is performed after the conservative treatment with albendazole for 28 days. We report a case of laparoscopic partial pericystectomy with biliostasis and omentoplasty in a patient with two previously open surgeries (laparotomies)--right subcostal laparotomy for acute inflammation of the gallbladder and right pararectal laparotomy for perforated gangrenous appendix. The patient underwent extensive laparoscopic adhesiolysis due to pronounced intra-abdominal adhesions to gain access to a large hydatid cyst with the diameter of 11 cm. Laparoscopic surgery is much less traumatic to the patient with a better cosmetic effect.

Emergency surgery for large bowel obstruction caused by cancer.

There are several options for surgical treatment of large bowel obstruction caused by cancer, depending on location of obstruction, intraoperative local findings (perforation, peritonitis, bowel dilatation proximal to obstruction) and patients' condition. Resection and anastomosis as one stage surgery would be prefered procedure. Anastomotic leakage, on the other hand, highly elevates risk of mortality and mobidity. The most important question is whether to, in resectable cases, perform primary resection with anastomosis or not. This study was retrospective and included 40 patients that have undergone emergency surgery for large bowel obstruction caused by cancer. According to whether resection and anastomosis was made at initial surgery or not, patients were grouped in group A (N = 18) and group B (N = 21), respectively. We have analysed the type of surgical procedure, days of hospitalization, mortality, anastomotic leakeage, wound infection and other postoperative complications. Our results show that there is no major difference in mortality and morbidity in these two groups, suggesting that for selected patients primary resection and anastomosis is a safe option of tratment with acceptable risk. Since there are no strict guidelines or scorring system which would point the tratment option the decision about the choice of procedure still remains the burden of surgeon and depends on its experience and subspeciality. Our experience recomends primary resection and anastomosis except in cases of bowel perforation on tumor site, in cases of extreme dilatation and atony of bowel proximal to obstruction site and severe hypoproteinemia and anemia.

Analysis of endoloops and endostaples for closing the appendiceal stump during laparoscopic appendectomy.

PURPOSE: An inadequate closure of the appendiceal stump can lead to intra-abdominal surgical site infections. The aim of this study was to assess the efficiency of different closure techniques by focusing on the intraoperative and postoperative complications versus cost. METHODS: From June 2011 to June 2013, 333 patients from two different hospitals undergoing laparoscopic appendectomy were included in this study. The patients were divided into two groups based on the technique used for appendiceal stump closure: there were 104 patients in the stapler group and 229 in the loop group. RESULTS: Among the 333 patients who underwent laparoscopic appendectomy, there were two (0.6%) intraoperative complications and 22 (6.6%) postoperative complications. There were no significant differences between the groups with respect to the intraoperative and postoperative complications. The length of the operation was 7 min shorter when the endoloop was used (p = 0.014). The mean costs of the operation were significantly lower when the loop was used ( 554.93) compared to the stapler ( 900.70) (p = 0.000). CONCLUSIONS: There is no clinical evidence supporting the routine use of endoscopic staplers. The appendiceal stump can be secured safely with the use of endoloops in the majority of patients. Surgeons have to be more selective when choosing how to perform closure, and an endostapler should be used only in cases where it is clinically indicated.

Primary malignant fibrous histiocytoma of the spleen: recurrence eight years after splenectomy--report of a case and literature review.

Primary intraabdominal malignant mesenchymal tumors are very rare. There are just few cases of intraabdominal visceral malignant fibrous histiocytoma in the literature. We report a case of primary malignant fibrous histiocytoma of the spleen in a 57-year-old man, with a recurrence eight years after the splenectomy. After the initial surgery the patient was without complaints, and refused to receive chemotherapy or radiotherapy. Eight years after the surgery the patient reported due to general weakness and malaise when the diagnosis of disease relapse was established. Radical surgery was performed although the tumor involved large curvature of the stomach, left crus of the diaphragm, splenic flexure of the colon and tail of pancreas. Four months after the surgery patient died. To the best of our knowledge, to date, only 18 cases have been reported in the literature, describing malignant fibrous histiocytoma of the spleen.

[Laparoscopic versus open appendectomy: our experience and literature review]. / Laparoskopska ili otvorena apendektomija: nasa iskustva i pregled literature.

AIM: The controversy of the choice between open and laparoscopic appendectomy still remains. The benefits as well as disadvantages of laparoscopy are well known. METHODS: We designed a prospective 3-year clinical study (January 1, 2008-December 31,2010) with 123 patients operated on for acute appendicitis. They were prospectively divided into laparoscopic appendectomy (LA) group with 42 results and open appendectomy (OA) group with 81 results. The following parameters were analyzed: age, sex, preoperative leukocyte count, C-reactive protein (CRP) value, preoperative ultrasound finding (US), analgesic administration and histopathologic finding. The length of the operation, length of hospitalization (LOS) and complications were compared between the two groups, along with personal postoperative satisfaction estimated by telephone survey after discharge from the hospital. RESULTS: In 90% of cases, histopathology was positive for inflammation. CRP was determined in 42 (34%) patients preoperatively, with a mean value of 59; positive histopathology finding was recorded in 31 (74%) patients with increased preoperative CRP. US was performed in 68 (55%) patients; positive US was consistent with histopathology in 44 (65%) cases. The mean time of LA/ OA was 75/72 minutes. The only statistical difference was found for LOS: 4 versus 6 days (p < 0.01). CONCLUSION: LA and OA are comparable for the number of complications. The slight benefit of LA offers the surgeon free hand in decision when dealing with acute appendicitis needing urgent operation.

Richter type of incarcerated obturator hernia: misleading all the way.

Obturator hernia is a rare type of abdominal hernia where herniation occurs through the obturator canal. It develops predominantly in elderly underweight women. It has unspecific early symptoms, which is the reason these hernias are usually discovered only after they have become incarcerated. Incarcerated obturator hernias are usually discovered on abdominal computed tomography (CT) scan or emergency surgery due to bowel obstruction. We present a case of an 85-year-old female patient who was admitted because of intermittent abdominal pain and vomiting. Consecutive upright abdominal x-rays failed to show bowel obstruction. Abdominal CT scan revealed a right-sided incarcerated femoral hernia that was not found during emergency surgery. After laparotomy had been performed, a Richter type of right-sided incarcerated obturator hernia was discovered with a small necrotic area on the small bowel. Bowel resection was performed and obturator hernia was closed with interrupted sutures. The patient recovered without complications. Obturator hernia, due to its rarity and unspecific early symptoms, can still be misleading even to the most experienced surgeons. Delayed diagnosis of obturator hernia can lead to bowel necrosis and perforation with significant postoperative morbidity and mortality.

Effect of carotid sinus nerve blockade on hemodynamic stability during carotid endarterectomy under local anesthesia.

OBJECTIVE: To find out whether routine carotid sinus nerve blockade with lidocaine during carotid endarterectomy under local anesthesia results in perioperative changes in blood pressure and heart rate. METHODS: This was a prospective, randomized, single-center study, conducted in a university hospital. A total of 120 patients undergoing carotid endarterectomy under local anesthesia were randomly assigned to three equal groups. Patients with previous carotid endarterectomy were excluded from the study. During the operation the carotid sinus area was infiltrated as follows: group 1 received 2 mL of 1% lidocaine; group 2 received 2 mL of 0.9% NaCl; and group 3 received no infiltration. The carotid sinus nerve was spared in all patients. Blood pressure and heart rate were invasively monitored during the operation and 12 hours postoperatively over the radial artery cannula. Preoperative values were calculated as a mean of three noninvasive measurements on the day before surgery. Data comprised of arterial blood pressures and heart rates from 32 time point measurements for each patient were analyzed. RESULTS: There was no significant difference among the groups regarding the mean arterial blood pressures and mean heart rates during the follow-up period. There was no significant difference among groups regarding the number of patients that required vasoactive therapy at any time of measurement. CONCLUSION: Routine infiltration of carotid sinus area with 1% lidocaine during carotid endarterectomy performed under local anesthesia has no significant impact on mean arterial blood pressure and heart rate during the operative procedure and the following 12 postoperative hours.

Isolated splenic metastasis from colorectal carcinoma in a high risk patient: a case report.

Isolated splenic metastasis arising from a colorectal carcinoma is a rare finding. We report a case of 74-year-old man with a medical history of diabetes type II and paroxysmal atrial fibrillation, who underwent a right hemicolectomy for an adenocarcinoma of caecum in August 2004. In June 2007 the patient was diagnosed with high grade aortic valve stenosis as well as long segment stenosis of the first obtuse marginal branch of left coronary artery. He was suggested aortic valve replacement with coronary artery bypass grafting but he refused the surgery. In October 2007 the patient underwent alpha 18FDG - PET scanning, due to increasing values of CEA serum level, which showed a 5 cm big isolated hypermetabolic lesion in the spleen. Due to operative risk, splenectomy was refused by surgeons. The patient underwent a chemotherapy with capecitabine in total of 8 cycles before his CEA level began to rise and MSCT showed a progression in size of splenic metastasis. The patients condition was reevaluated by a team of experts and splenectomy was performed in September 2008. In May 2009 during the postoperative follow up, MSCT scanning revealed enlarged lymph nodes in celiac region and hepatic lesion suspicious of metastasis and the patient was admitted for further chemotherapy treatment. There is still no standardized treatment for this condition due to small number of cases reported in literature. Splenectomy followed by chemotherapy seems to be an optimal treatment but still no final conclusions can be made.

[Laparoscopic partial pericystectomy of hepatic hydatid cysts --Papadimitriou operation: a case report]. / Laparoskopska parcijalna pericistektomija ehinokokne ciste jetre po papadimitriouu: prikaz bolesnika.

Operative treatment of hepatic hydatid cyst is technically demanding procedure. The method of choice is conservative treatment with Albendazolum followed by surgery. Open laparotomy or laparoscopic operation can be performed. We prefere laparoscopic exploration followed by laparoscopic total pericystectomy or laparoscopic partial pericystectomy. If laparoscopic operation is not possible due to technical reasons and patient safety, conversion to an open operation should be done, followed by total or partial pericystectomy. The case and our detailed technique of laparoscopic partial pericystectomy with biliostasis and omentoplasty is described. Laparoscopic operation is equally safe for the patient, yet with minor trauma and better aesthetic effect.