Comparison of different second line treatments for metastatic pancreatic cancer: a systematic review and network meta-analysis.

BACKGROUND: In metastatic pancreatic ductal adenocarcinoma (mPDAC), first line treatment options usually include combination regimens of folinic acid, 5-fluorouracil (5-FU), irinotecan, and oxaliplatin (FOLFIRINOX or mFOLFIRINOX) or gemcitabine based regimens such as in combination with albumin-bound paclitaxel (GEM + nab-PTX). After progression, multiple regimens including NALIRI + 5-FU and folinic acid, FOLFIRINOX, 5-FU-based oxaliplatin doublets (OFF, FOLFOX, or XELOX), or 5-FU-based monotherapy (FL, capecitabine, or S-1) are considered appropriate by major guidelines. This network meta-analysis (NMA) aimed to compare the efficacy of different treatment strategies tested as second-line regimens for patients with mPDAC after first-line gemcitabine-based systemic treatment. METHODS: Randomized phase II and III clinical trials (RCTs) were included if they were published or presented in English. Trials of interest compared two active systemic treatments as second-line regimens until disease progression or unacceptable toxicity. We performed a Bayesian NMA with published hazard ratios (HRs) and 95%confidence intervals (CIs) to evaluate the comparative effectiveness of different second-line therapies for mPDAC. The main outcomes of interest were overall survival (OS) and progression free survival (PFS), secondary endpoints were grade 3-4 toxicities. We calculated the relative ranking of agents for each outcome as their surface under the cumulative ranking (SUCRA). A higher SUCRA score meant a higher ranking for efficacy outcomes. RESULTS: A NMA of 9 treatments was performed for OS (n = 2521 patients enrolled). Compared with 5-FU + folinic acid both irinotecan or NALIRI + fluoropyrimidines had a trend to better OS (HR = 0.76, 95%CI 0.21-2.75 and HR = 0.74, 95%CI 0.31-1.85). Fluoropyrimidines + folinic acid + oxaliplatin were no better than the combination without oxaliplatin. The analysis of treatment ranking showed that the combination of NALIRI + 5-FU + folinic acid was most likely to yield the highest OS results (SUCRA = 0.7). Furthermore, the NMA results indicated that with the highest SUCRA score (SUCRA = 0.91), NALIRI + 5-FU + folinic acid may be the optimal choice for improved PFS amongst all regimens studied. CONCLUSIONS: According to the NMA results, NALIRI + 5-FU, and folinic acid may represent the best second-line treatment for improved survival outcomes in mPDAC. Further evidence from prospective trials is needed to determine the best treatment option for this group of patients.

First line therapy in stage IV BRAF mutated colorectal cancer.

Introduction: The molecular profile of colorectal cancer (CRC) plays a crucial role in understanding patient prognosis and treatment response. Within CRC, a distinct subgroup can be identified by the presence of the BRAF V600E mutation. This specific mutation, classified as Class I of BRAF mutations, is known to be associated with a poor prognosis and resistance to standard therapy. To determine the most effective treatment approach for this specific subgroup of CRC, we conducted a network meta-analysis (NMA) to compare various pharmacological interventions and evaluate their relative effectiveness in BRAF-mutated CRCs. Materials and methods: On July 31, 2023, we conducted a systematic search of PubMed, Cochrane Central Register of Controlled Trials, and Embase. The inclusion criteria were as follows: 1) reporting of outcomes in patients with BRAF-mutated CRC who underwent first-line chemotherapy; 2) reporting of survival information as hazard ratios (HR); and 3) publication in English. The data were combined using HRs for overall and progression-free survival (OS and PFS) using random-effects models. NMA was performed under the Bayesian framework, utilizing the GeMTC package. The relative rankings of the treatments were determined using SUCRA scores. Results: A total of 16 studies were included. When compared to standard chemotherapy (CT) doublets (such as FOLFOX or FOLFIRI), none of the comparison arms demonstrated a gain in OS. CT doublet + bevacizumab did not show significant superiority over either CT doublet alone or 5FU/capecitabine + bevacizumab. FOLFOXIRI and FOLFOXIRI + bevacizumab did not show superiority over any other treatment schedule that was compared. CT doublets + bevacizumab had the highest SUCRA score (0.87), followed by single-agent fluoropyrimidines + bevacizumab (0.61), and FOLFOXIRI (0.56). Regarding PFS, no regimen was found to be superior to the combination of CT doublet plus bevacizumab. However, FOLFOXIRI + bevacizumab + atezolizumab showed a tendency towards better results (HR = 0.26, 95 % CI 0.05-1.1). Conclusions: Our review suggests that a CT doublet with bevacizumab is the most favorable option for OS. However, a reasonable alternative could be a triplet CT without bevacizumab.

BRAF mutations and survival with surgery for colorectal liver metastases: A systematic review and meta-analysis.

INTRODUCTION: Mutations in the BRAF gene (BRAFmut) are associated with an unfavorable prognosis in patients with metastatic colorectal cancer (CRC). The aim of this meta-analysis was to evaluate the prognosis of colorectal cancer (CRC) patients with liver metastases and the potential benefits of liver resection in patients with BRAFmut CRC. MATERIAL AND METHODS: A systematic search of PubMed, Cochrane Central Controlled Trials, and Embase databases was conducted on May 31, 2023. The inclusion criteria were as follows:1) reporting of outcomes in patients with BRAFmut CRC who underwent surgery for liver metastases and/or comparison of outcomes between those who underwent and those who did not undergo resection; 2) reporting of survival information as hazard ratios (HR); and 3) publication in English. RESULTS: 34 studies were included. Median follow up was 48 months for prognostic BRAF status meta-analysis. BRAFmut status showed a significantly increased risk of mortality (hazard ratio [HR] = 2.56, 95% confidence interval [CI] 2.04-3.22; P < 0.01) and relapse (HR = 1.97, 95% CI 1.44-2.71; P < 0.01). Resection of liver metastases was associated with a survival benefit (median follow up 46 months). The HR for survival was 0.44 (95% confidence interval [CI] 0.33-0.59; P < 0.01) in favor of surgery. CONCLUSIONS: and Relevance: Our analysis indeed confirms that BRAF mutation is associated with poor survival outcomes after liver resection of CRC metastases. However, upon quantitatively assessing the survival benefit of surgical intervention in patients with BRAF-mutated CRC liver metastases, we identified a significant 56% reduction in the risk of death.

Hepatocellular carcinoma in patients with nonalcoholic fatty liver disease: A systematic review and meta-analysis: HCC and Steatosis or Steatohepatitis.

BACKGROUND AND AIMS: Hepatic steatosis of nonalcoholic etiology (nonalcoholic fatty liver disease; NAFLD) is an emergent condition that may lead to hepatic cirrhosis and finally to liver cancer. We evaluate the risk of developing hepatocellular carcinoma (HCC) and quantify the prognosis in terms of recurrence (DFS) as well as HCC-specific and overall survival (CSS and OS) of patients with and without NAFLD. METHODS: We searched published articles that evaluated the risk and outcomes of HCC in patients with steatosis/steatohepatitis from inception to July 2021 were identified by searching the PubMed, EMBASE, and Cochrane Library databases. Prospective cohort, case-control, or retrospective studies were selected that were published in English and provided incidence and survival rates of HCC patients with NAFLD. A random-effects model was created to estimate the pooled effect size. The primary outcome of interest was HCC incidence. The secondary endpoints were DFS, CSS, and OS. RESULTS: In total, 948 217 patients with NAFLD were analyzed, from n = 103 observational studies. NAFLD significantly increased the risk of HCC (HR = 1.88 [95% CI, 1.46-2.42]; P < .01] but not risk of recurrence (HR = 0.99 [95% CI, 0.85-1.15]; P = .9) or overall mortality (HR = 1.04 [95% CI, 0.88-1.24]; P = 0.64). Conversely, NAFLD increased HCC-related mortality risk (HR = 2.16 [95% CI, 0.85-5.5]; P = .1). Risk of HCC was increased in Western countries but not in Asian countries. CONCLUSIONS: Patients with NAFLD have an increased risk of HCC as compared to patients without NAFLD. NAFLD also increases liver cancer (HCC) mortality. These results justify applying general measures to patients with proven NAFLD and monitoring patients with NASH and fibrosis.

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.

"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.

[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.

Successful treatment of hemolytic uremic syndrome after liver-kidney transplantation.

INTRODUCTION: Hemolytic-uremic syndrome (HUS) is a rare complication in organ transplantation, characterized by hemolytic microangiopathic anemia, thrombocytopenia, and severe renal failure. The syndrome is a well-recognized complication in bone marrow transplantation, and has been likewise described in several cases of solid organs transplantation, but never in patients receiving combined liver and kidney transplantation. CASE REPORT: We describe a case of HUS in a 59-year-old woman who underwent combined liver-kidney transplantation for hepato-renal polycystic disease. Clinical and laboratory manifestations of the syndrome were severe and included renal failure, hemolytic anemia, severe thrombocytopenia, hypertension, and neurological damage. The initial treatment consisted of withdrawal of cyclosporine, introduction of low-dose tacrolimus, and administration of fresh frozen plasma (FFP) transfusion and heparin. Since there was no improvement in clinical or biochemical features, plasmapheresis with FFP replacement (2000 mL/day) followed by intravenous immunoglobulin (0.4 mg/Kg/day) was started. A rapid improvement in renal function, platelet count, and hemolytic anemia was observed. CONCLUSIONS: Based on the good response observed in our patient, we feel that an aggressive treatment with plasmapheresis and intravenous immunoglobulin should be offered to organ transplant recipients with severe HUS.

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.

Percutaneous vs. surgical placement of hepatic artery indwelling catheters for regional chemotherapy.

BACKGROUND/AIMS: Intra-arterial hepatic chemotherapy based on floxuridine infusion is an effective treatment for hepatic metastases from colorectal cancer. The aim of the present study is the comparative analysis of surgical and percutaneous transaxillary approaches to implant a catheter into the hepatic artery for intra-arterial hepatic chemotherapy with floxuridine. METHODOLOGY: Fifty-six patients received an arterial device for intra-arterial hepatic chemotherapy. Twenty-eight patients (LPT group) underwent laparotomy to implant the catheter into the hepatic artery, the other 28 patients (PCT group) received a percutaneous catheter into the hepatic artery through a transaxillary percutaneous access. Safety and efficacy of surgical and percutaneous transaxillary approaches were comparatively analyzed in terms of number of intra-arterial hepatic chemotherapy cycles administered, device-related complications causing suppression of intra-arterial hepatic chemotherapy, and biological costs of the procedures. RESULTS: Mean postoperative hospitalization was 8.2 +/- 2.2 days in the LPT group and 1.8 +/- 0.7 days in the PCT group (P < 0.0001), while mean analgesic requirements were 9.7 +/- 3.2 doses in the LPT group and 2 +/- 0.9 doses in the PCT group (P < 0.0001). Mean number of intra-arterial hepatic chemotherapy cycles administered was 6.5 +/- 4.2 in the LPT group and 4.3 +/- 3.4 in the PCT group (P = 0.038). The overall incidence of device-related complications causing suppression of intra-arterial hepatic chemotherapy was 42.7% in the PCT group and 7.1% in the LPT group (P = 0.005). CONCLUSIONS: Surgical implantation is still recommended when laparotomy has to be performed for other contextual procedures, such as colorectal or hepatic resection, while percutaneous transaxillary catheter placement is indicated for palliative or neoadjuvant intra-arterial hepatic chemotherapy.

[Impact of preoperative locoregional chemotherapy with fluorodeoxyuridine on the outcome of liver resection]. / Impatto della chemioterapia locoregionale preoperatoria con fluorodesossiuridina (FUDR) sulla chirurgia resettiva epatica.

The aim of the study was to evaluate the effects of preoperative intra-arterial hepatic chemotherapy (IAHC) on the outcome of liver resections for hepatic metastases from colorectal cancer. Twelve patients (IAHC group) treated by IAHC with fluorodeoxyuridine (FUdR) and subsequent liver resection and 40 patients who underwent liver resection without preliminary IAHC (non-IAHC group) were analysed comparatively in terms of age, gender, concomitant diseases, previous abdominal surgery, type of hepatic resection, use of portal clamping, and associated surgical procedures. For the purposes of the study, length of operation, intraoperative blood losses, perioperative transfusions, length of hospitalisation, complications and mortality were also recorded. The two groups were comparable (p = n.s.) for those variables affecting the perioperative course. As regards the end points of the study, no significant differences were recorded in length of operation, intraoperative blood losses, perioperative transfusions [except for more postoperative plasma transfusions in the IAHC group (16.7% vs 5.0%, p = 0.009)] and postoperative complications (9.1% vs 17.5%, p = 0.415). Postoperative mortality consisted in one patient in the IAHC group. Postoperative hospitalization was significantly longer in the non-IAHC group (median: 8 vs 10, range: 6-13 vs 5-33 days; p = 0.004). IAHC does not negatively affect the outcome of subsequent liver resection.

Impact of type of liver resection on the outcome of colorectal liver metastases: a case-matched analysis.

BACKGROUND: Wedge resection (WR) for colorectal liver metastases (CLM) has become more common in an attempt to preserve liver parenchyma. However, some investigator have reported that WR is associated with a higher incidence of positive margin and an inferior survival compared with anatomic resection (AR) 1. OBJECTIVES: This study evaluated survival, margin status, and pattern of recurrence of patients with CLM treated with WR or AR. METHODS: We identified 208 consecutive patients, in a single institutional database from 1995 to 2004, who underwent either WR or AR. WR was defined as a nonanatomic resection and AR was defined as single resection of one or two liver segments. Patients with combined WR-AR and patients requiring resection of more than two segments or radiofrequency ablation were excluded from the analysis. RESULTS: One hundred six patients underwent WR and 102 patients had AR. There were no differences in the rate of positive surgical margin (P = 0.146), overall recurrence rates (P = 0.211), and patterns of recurrence between the two groups (P = 0.468). The median survival was 32 months for WR and 42 for AR, with 5-year survival rates of 29% and 27% respectively, with no significant difference (P = 0.308). Morbidity was similar between the two groups. CONCLUSIONS: WR is a safe procedure and does not disadvantage the patients in terms of tumor recurrence and overall survival.