Perioperative and long-term outcomes of laparoscopic liver resections for non-colorectal liver metastases.

BACKGROUND: Liver is a common metastatic site not only of colorectal but of non-colorectal neoplasms, as well. However, resection of non-colorectal liver metastases (NCRLMs) remains controversial. The aim of this retrospective study was to analyze the short- and long-term outcomes of patients undergoing laparoscopic liver resection (LLR) for NCRLMs. METHODS: From a prospectively maintained database between 2000 and 2018, patients undergoing LLR for colorectal liver metastases (CRLMs) and NCRLMs were selected. Clinicopathologic, operative, short- and long-term outcome data were collected, analyzed, and compared among patients with CRLMs and NCRLMs. RESULTS: The primary tumor was colorectal in 354 (82.1%), neuroendocrine in 21 (4.9%), and non-colorectal, non-neuroendocrine in the remaining 56 (13%) patients. Major postoperative morbidities were 12.7%, 19%, and 3.6%, respectively (p = 0.001), whereas the mortality was 0.6% for patients with CRLMs and zero for patients with NCRLMs. The rate of R1 surgical margin was comparable (p = 0.432) among groups. According to the survival analysis, 3- and 5-year recurrence-free survival (RFS) rates were 76.1% and 64.3% in the CRLM group, 57.1% and 42.3% in the neuroendocrine liver metastase (NELM) group, 33% and 20.8% in the non-colorectal, non-neuroendocrine liver metastase (NCRNNELM) group (p = 0.001), respectively. Three- and 5-year overall survival (OS) rates were 88.3% and 82.7% in the CRLM group, 85.7% and 70.6% in the NELM group, 71.4% and 52.9% in the NCRNNELM group (p = 0.001), respectively. In total, 113 out of 354 (31.9%) patients with CRLMs, 2 out of 21(9.5%) with NELMs, and 8 out of 56 (14.3%) patients with NCRNNELMs underwent repeat LLR for recurrent metastatic tumors. CONCLUSION: LLR is safe and feasible in the context of a multimodal management where an aggressive surgical approach, necessitating even complex procedures for bilobar multifocal metastases and repeat hepatectomy for recurrences, is the mainstay and may be of benefit in the long-term survival, in selected patients with NCRNNELMs.

Treatment with Mesna and n-3 polyunsaturated fatty acids ameliorates experimental ulcerative colitis in rats.

Oxidative damage is a central feature of ulcerative colitis. Here, we tested whether the antioxidant Mesna, when administered alone or in combination with n-3 polyunsaturated fatty acids (n-3 PUFAs), affects the outcome of dextran sodium sulphate (DSS)-induced ulcerative colitis in rats. After the induction of colitis, DSS-treated rats were further treated orally (p.o), intraperitoneally (i.p) or intrarectally (i.r) for either 7 or 14 days with Mesna, n-3 PUFAs or both. Rats were euthanized at the end of each treatment period. Clinical disease activity index was recorded throughout the experiment. At necropsy colorectal gross lesions were scored. Colitis was scored histologically, and the expression of myeloperoxidase (MPO), caspase-3, inducible nitric oxide synthase (iNOS) and nuclear factor κB (NF-κΒ) in colonic tissue was assessed by immunohistochemistry. Mesna alone was sufficient to significantly reduce colorectal tissue damage when administered orally or intraperitoneally. Orally coadministered n-3 PUFAs enhanced this effect, resulting in the significant suppression of DSS colitis after 7 days, and a remarkable recovery of colorectal mucosa was evident after 14 days of treatment. The amelioration of colon pathology co-existed with a significant decrease in MPO expression, overexpression of iNOS and reduction of nuclear NF-κB p65 in inflammatory cells, and the suppression of apoptosis in colonic epithelial cells. The simultaneous administration of Mesna and n-3 PUFAs is particularly effective in ameliorating DSS colitis in rats, by reducing oxidative stress, inflammation and apoptosis, probably through a mechanism that involves the inhibition of NF-κB and overexpression of iNOS.

Does Chemotherapy-Induced Liver Injury Impair Postoperative Outcomes After Laparoscopic Liver Resection for Colorectal Metastases?

BACKGROUND: Chemotherapy-associated liver injuries (CALI) have been associated with poor postoperative outcome after open liver resection. To date, no data concerning any correlation of CALI and laparoscopic liver resection (LLR) are available. In the present study, we evaluated the impact of CALI on short-term outcomes in patients undergoing LLR. MATERIALS AND METHODS: All patients who underwent in our department LLR for colorectal liver metastases (CRLM) from 2000 to 2016 were retrospectively reviewed. Patients were divided in 4 groups according to their pathological histology. In group 1 patients had normal liver parenchyma. Group 2 included patients with steatosis and steatohepatitis. Patients with sinusoidal obstruction syndrome (SOS) and nodular regenerative hyperplasia (NRH) were allocated to group 3, whereas the remaining with fibrosis and cirrhosis, were assigned to group 4. RESULTS: A total of 490 LLR for CRLM were included in the study. Perioperative details and morbidity did not differ significantly between the four groups. Subgroup analysis showed that NRH was associated with higher amount of blood loss (p = 0.043), overall (p = 0.021) and liver-specific morbidity (p = 0.039). CONCLUSION: NRH is a severe form of CALI that may worsen the short-term outcomes of patients undergoing LLR for CRLM. However, the remaining forms of CALI do not have a significant impact on perioperative outcomes after LLR.

Efficacy and Safety of Adjunctive Cilostazol to Clopidogrel-Treated Diabetic Patients With Symptomatic Lower Extremity Artery Disease in the Prevention of Ischemic Vascular Events.

Background Type 2 diabetes mellitus is a risk factor for lower extremity arterial disease. Cilostazol expresses antiplatelet, anti-inflammatory, and vasodilator actions and improves the claudication intermittent symptoms. We investigated the efficacy and safety of adjunctive cilostazol to clopidogrel-treated patients with type 2 diabetes mellitus exhibiting symptomatic lower extremity arterial disease, in the prevention of ischemic vascular events and improvement of the claudication intermittent symptoms. Methods and Results In a prospective 2-arm, multicenter, open-label, phase 4 trial, patients with type 2 diabetes mellitus with intermittent claudication receiving clopidogrel (75 mg/d) for at least 6 months, were randomly assigned in a 1:1 ratio, either to continue to clopidogrel monotherapy, without receiving placebo cilostazol (391 patients), or to additionally receive cilostazol, 100 mg twice/day (403 patients). The median duration of follow-up was 27 months. The primary efficacy end point, the composite of acute ischemic stroke/transient ischemic attack, acute myocardial infarction, and death from vascular causes, was significantly reduced in patients receiving adjunctive cilostazol compared with the clopidogrel monotherapy group (sex-adjusted hazard ratio [HR], 0.468; 95% CI, 0.252-0.870; P=0.016). Adjunctive cilostazol also significantly reduced the stroke/transient ischemic attack events (sex-adjusted HR, 0.38; 95% CI, 0.15-0.98; P=0.046) and improved the ankle-brachial index and pain-free walking distance values (P=0.001 for both comparisons). No significant difference in the bleeding events, as defined by Bleeding Academic Research Consortium criteria, was found between the 2 groups (sex-adjusted HR, 1.080; 95% CI, 0.579-2.015; P=0.809). Conclusions Adjunctive cilostazol to clopidogrel-treated patients with type 2 diabetes mellitus with symptomatic lower extremity arterial disease may lower the risk of ischemic events and improve intermittent claudication symptoms, without increasing the bleeding risk, compared with clopidogrel monotherapy. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02983214.

Tips and tricks for a safe laparoscopic pancreatoduodenectomy.

Minimally invasive pancreatoduodenectomy has been revolutionized during the last decades and, although not as rapidly or widely adopted, the laparoscopic approach seems to be feasible with various potential advantages compared to traditional open pancreatoduodenectomy. Laparoscopic pancreatoduodenectomy is a technically demanding procedure with a steep learning curve mainly due to the fact that the technique is not standardized. Technical details as well as tips and tricks of the operation are described. Standardization of the procedure is the cornerstone of the learning curve of minimally invasive pancreatoduodenectomy. One of the largest barriers of this complex procedure is the reconstruction phase with the creation of three separate anastomoses. A hybrid approach may help surgeons - especially during the initial phase of the learning curve - to overcome the difficulties associated with a fully laparoscopic reconstruction, while retaining the advantages of laparoscopy.

Does the difficulty grade of laparoscopic liver resection for colorectal liver metastases correlate with long-term outcomes?

INTRODUCTION: Prognosis of patients with colorectal liver metastases (CRLM) is strongly correlated with the oncological outcome after liver resection. The aim of this study was to analyze the impact of laparoscopic liver resection (LLR) difficulty score (IMM difficulty score) on the oncological results in patients treated for CRLM. METHODS: All patients who underwent LLRs for CRLM from 2000 to 2016 in our department, were retrospectively reviewed. Data regarding difficulty classification, -according to the Institute Mutualiste Montsouris score (IMM)-, recurrence rate, recurrence-free survival (RFS), overall survival (OS) and data regarding margin status were analyzed. RESULTS: A total of 520 patients were included. Patients were allocated into 3 groups based on IMM difficulty score of the LLR they underwent: there were 227 (43,6%), 84 (16,2%) and 209 (40,2%) patients in groups I, II and III, respectively. The R1 resection rate in group I, II and III were 8,8% (20/227), 11,9% (10/84) and 12,4% (26/209) respectively (p = 0.841). Three- and 5-year RFS rates were 77% and 73% in group I, 58% and 51% in group II, 61% and 53% in group III, respectively (p = 0.038). Three and 5-year OS rates were 87% and 80% for group I, 77% and 66% for group II, 80% and 69% for group III respectively (p = 0.022). CONCLUSION: The higher LLR difficulty score correlates with significant morbidity and worse RFS and OS, although the more technically demanding and difficult cases are not associated with increased rates of positive resection margins and recurrence.

Complications of laparoscopic cholecystectomy: our experience in a district general hospital.

BACKGROUND: Laparoscopic cholecystectomy is the procedure of choice for the treatment of symptomatic gallstone disease. Some of the associated complications are rare, but often serious. The purpose of this study is to present our data about the type and the incidence of these complications and our experience in their management, in a district hospital, during the last 8 years. PATIENTS AND METHODS: A retrospective study was performed on 1009 patients, 229 males and 780 females, with age ranging from 19 to 84 years, who underwent laparoscopic cholecystectomy for symptomatic gallstone disease, during the period from January 2000 to January 2008. The procedure was performed urgently due to acute cholecystitis in 78 patients (7.73%). RESULTS: Complications occurred in 96 (9.51%) patients. Bile leakage occurred in 15 patients (1.49%). One patient (0.10%) had a major bile duct injury (common bile duct transection). Bleeding occurred in 9 patients (0.89%), wound infection in 14 patients (1.39%), abdominal wall hematomas in 3 patients (0.30%), omental hematoma in 3 patients (0.30%), port site hernias in 3 patients (0.30%), subphrenic abscess in 1 patient (0.10%), subcapsular liver hematoma in 1 patient (0.10%), bowel injury in 5 patients (0.51%), postoperative acute pancreatitis in 4 patients (0.40%), respiratory and cardiovascular complications in 11 patients 1.09%). Finally in 14 patients (1.39%), the gallbladder was unintentionally opened during laparoscopic procedure and spillage of gallstones occurred into the peritoneal cavity. All patients had satisfactory results and no death occurred. CONCLUSIONS: We conclude that laparoscopic cholecystectomy is a safe procedure, although it is associated with some serious complications. The most usual complication during laparoscopic cholecystectomy is bile leakage, which remains a significant cause of morbidity. Early identification and management of these complications will minimize a potentially devastating outcome.

Ectopic Liver Tissue Attached to the Gallbladder Wall: a case report.

INTRODUCTION: Ectopic liver tissue is a rare entity, reported to occur in several intra-, retro- and extra- peritoneal sites, including the gallbladder. It is usually detected incidentally, during laparoscopy, laparotomy, or autopsy. Several possible mechanisms may explain the development of liver ectopia. Although ectopic liver tissue is usually asymptomatic, it behaves like orthotopic liver, developing the same pathologic conditions. CASE PRESENTATION: We describe the case of a 54-year-old woman who was found to have a nodule attached to the gallbladder wall without any connection with the main liver, during an elective laparoscopic cholecystectomy for gallstone disease. The nodule was removed with the gallbladder and identified histologically as normal ectopic liver tissue. CONCLUSION: It would seem sensible to resect the ectopic tissue if encountered during cholecystectomy for gallstones. Laparoscopic management of ectopic liver can be feasible.