Total laparoscopic management of lesions involving liver segment 7.

BACKGROUND: Until recently, laparoscopic resection of tumors involving segment 7 (s7) of the liver was seen as a relative contraindication. We analyzed our experiences with laparoscopic resection of tumors in s7. METHODS: Retrospective analysis of prospective database on operative and postoperative characteristics and surgical outcomes of patients in whom the intention was to remove tumors located in s7 of the liver laparoscopically. We defined two groups: those with laparoscopic metastasectomy of s7 (s7 group) and those undergoing laparoscopic right posterior sectionectomy (RPS group). RESULTS: Of 400 patients undergoing laparoscopic liver resection, 20 patients (5 %) underwent total laparoscopic resections of tumors in s7 (7 metastasectomy of s7 and 13 RPS). The type of resection was decided on the basis of tumor size and location. Median age was 70 years (range 46-82), and the indication for surgery was mainly CRLM (n = 13, 65 %) and HCC (n = 4, 20 %). There was 1 (5 %) conversion. Mean operative times were 252 min (±69) for s7 and 271 min (±102) for RPS. The mean intraoperative blood loss was 400 mL (±493) for s7 and 625 mL (±363) for RPS. A Pringle maneuver was used in 86 % of patients in s7 group and 75 % of patients in RPS group. Mean total hospital stay was 4.6 days (±2.5) in s7 and 6.9 days (±7.8) for RPS. The overall R0 resection rate was 95 % (s7 100 %, RPS 92 %). CONCLUSION: Although resection of lesions in s7 is technically demanding, a laparoscopic approach can be performed safely and effectively in experienced hands.

Disease-related intestinal transplant in adults: results from a single center.

Intestinal transplantation is gaining worldwide acceptance as the main option for patients with irreversible intestinal failure and complicated total parenteral nutrition course. In adults, the main cause is still represented by short bowel syndrome, but tumors (Gardner syndrome) and dismotility disorders (chronic intestinal pseudo-obstruction [CIPO]) have been treated increasingly by this kind of transplantation procedure. We reviewed our series from the disease point of view: although SBS confirmed results achieved in previous years, CIPO is nowadays demonstrating an excellent outcome similar to other transplantation series. Our results showed indeed that recipients affected by Gardner syndrome must be carefully selected before the disease is to advanced to take advantage of the transplantation procedure.

Safety of hepatic resection in overweight and obese patients with cirrhosis.

BACKGROUND: The simultaneous incremental increase in incidence of both obesity and hepatocellular carcinoma (HCC) will soon lead to more overweight and obese patients with cirrhosis needing surgery. At present, little is known about postoperative mortality and morbidity in such patients. This study investigated outcomes after hepatectomy in relation to obesity in a homogeneous cohort of patients with cirrhosis. METHODS: Perioperative data from 235 patients with cirrhosis who had hepatectomy for HCC were related to the presence of normal bodyweight (body mass index (BMI) 18.5-24.9 kg/m(2)), overweight (BMI 25.0-29.9 kg/m(2)) and obesity (BMI at least 30 kg/m(2)). Complications after surgery were graded according to the expanded Accordion Severity Classification of Postoperative Complications (T92). RESULTS: One hundred and one patients (43.0 per cent) were of normal bodyweight, 88 (37.4 per cent) were overweight and 46 (19.6 per cent) were obese; none was underweight. Overweight and obese groups showed a male preponderance (P = 0.024), and metabolic disorders were frequently the cause of cirrhosis in these patients (P < 0.001 and P = 0.014 for non-B non-C hepatitis and alcoholic cirrhosis respectively). Liver function tests, tumour stage and extent of hepatectomy did not significantly differ between BMI groups. The intraoperative course and postoperative mortality were unaffected by BMI. Overweight and obese patients had significantly more mild respiratory complications (P = 0.044). Severe complications and organ system (including liver) failure were not significantly affected by BMI. CONCLUSION: Hepatic resection can be performed safely in overweight and obese patients with cirrhosis, although morbidity is increased in these patients.

Sirolimus in liver transplant recipients: a large single-center experience.

Sirolimus (SRL) is a newer immunosuppressant whose possible benefits and side effects in comparison to calcineurin inhibitors (CNIs) still have to be addressed in the liver transplantation setting. We report the results of the use of SRL in 86 liver transplant recipients, 38 of whom received SRL as the main immunosuppressant in a CNI-sparing regimen. Indications for the use of SRL were: impaired renal function (n = 32), CNI neurotoxicity (n = 16), hepatocellular carcinoma (HCC) at high risk of recurrence (n = 21), recurrence of HCC (n = 6), de novo malignancies (n = 4), cholangiocarcinoma (n = 1), and the need to reinforce immunosuppression (n = 6). Among patients on SRL-based treatment, four episodes of acute rejection were observed, three of which occurred during the first postoperative month. Renal function significantly improved when sirolimus was introduced within the third postoperative month, while no change was observed when it was introduced later. Neurological symptoms resolved completely in 14/16 patients. The 3-year recurrence-free survival of patients with HCC on SRL was 84%. Sixty-two patients developed side effects that required drug withdrawal in seven cases. There was a reduced prevalence of hypertension and new-onset diabetes among patients under SRL. In conclusion, SRL was an effective immunosuppressant even when used in a CNI-sparing regimen. It was beneficial for patients with recently developed renal dysfunction or neurological disorders.

Daclizumab and alemtuzumab as induction agents in adult intestinal and multivisceral transplantation: rejection and infection rates in 40 recipients during the early postoperative period.

BACKGROUND: Allograft rejection in intestinal transplantation occurs frequently, and bacterial, fungal, and viral infections related to strong immunosuppression regimens remain an important complication posttransplantation. Induction therapy has enabled improvement in graft and patient survival rates. OBJECTIVES: In analyze the effects of daclizumab and alemtuzumab as induction therapies on inflections complications and incidence of acute cellular rejection (ACR) during the early posttransplantation period. PATIENTS AND METHODS: Between December 2000 and August 2009, we performed 43 intestinal transplantation procedures in 42 adult recipients (median [SD] age, 34.8 [9.5] years; male-female ratio, 22:20; isolated or multivisceral graft, 32/11), and compared findings during the first 30 days posttransplantation in 40 recipients. Patients were divided into 2 groups: 12 treated with daclizumab (Zenapax; Hoffman-La Roche Ltd, Basel, Switzerland): 8 isolated intestinal grafts and 4 multivisceral grafts) and 28 treated with alemtuzumab (Campath-1H: 22 isolated intestinal grafts and 6 multivisceral grafts). Maintenance immunosuppression was based on tacrolimus and steroids in the first group and low-dose tacrolimus in the second group. RESULTS: During the first month posttransplantation, 8 daclizumab recipients (66.6%) experienced 9 episodes of mild ACR, which were successfully treated with steroid therapy, and 8 patients (66.6%) developed a bacterial infection requiring treatment. Fourteen episodes of ACR occurred in 12 alemtuzumab recipients (42.8%): 11 mild, 1 mild to moderate, and 2 moderate; 16 patients (57.1%) required treatment for infections. Five-year patient cumulative survival was 66% in daclizumab recipients and 43% in alemtuzumab recipients. Five-year graft survivals was 66% in daclizumab recipients and 41% in alemtuzumab recipients. In both groups, P was not statistically significative. CONCLUSIONS: The infection rate is considerably high with both protocols. Alemtuzumab seems to offer better immunosuppression against ACRs during the first month posttransplantation.

Comprehensive surgical intestinal rescue and transplantation program in adult patients: Bologna experience.

INTRODUCTION: Surgical approaches to complicated benign intestinal failure are accepted worldwide, especially in the pediatric population. Intestinal transplant surgery is thought to rescue patients in whom complications of total parenteral nutrition (TPN) develop. OBJECTIVE: To report our experience with surgical intestinal rescue in an adult population with intestinal failure. PATIENTS AND METHODS: An intestinal rehabilitation program initiated at our institution included comprehensive medical rehabilitation, surgical bowel rescue, and transplantation. From 2000 to 2009, of 81 adult patients referred by our gastroenterologists for bowel rehabilitation, 42 (51,8%) underwent 43 transplantations (32 isolated intestinal grafts and 11 multivisceral grafts). Underlying diseases were primarily short-bowel syndrome, Gardner syndrome, and intestinal pseudo-obstruction. Thirty-nine patients (48,2%) underwent surgical rescue (40 cases) consisting of bowel resection, adhesiolysis, stricturoplasty, liver transplantation with portocaval hemitransposition (6 cases in 5 patients). Underlying diseases were primarily intestinal fistulas, stenosis, or perforations, short-bowel syndrome, cocoon syndrome, and complete portal thrombosis. RESULTS: After a mean (SD) follow-up of 1043 (1016) days, in the transplantation population, 21 patients (50%) are alive, with a 1-, 3-, 5-year patient survival of 76%, 59%, and 52%, respectively, and graft survival of 66%, 54%, and 48%, respectively. After 901 (404) days in the rescue population, 32 patients (82%) are alive (2 died, and 5 were lost to follow-up); in 75%, TPN 25% was discontinued, and are receiving oral feeding with TPN support. The 1- and 3-year survival rate was 100% and 83%, respectively. CONCLUSIONS: Deaths occurred primarily in the transplantation population. Intestinal surgical rescue, when possible, is optimal.

The role of liver surgery in the treatment of non-colorectal non-neuroendocrine metastases (NCRNNE). Analysis of 134 resected patients.

AIM: The aim of this study was to evaluate the role of surgery in the treatment of non-colorectal, non-neuroendocrine (NCRNNE) liver metastases. METHODS: One hundred and thirty-four patients undergoing curative liver resection for NCRNNE liver metastases were retrospectively analyzed. Perioperative results (blood transfusion, hospital stay, morbidity and mortality), 3 and 5-year overall and disease-free survival were evaluated. The following prognostic factors were analyzed: age (cut-off 50 year old), single vs. multiple nodules, diameter (cut-off 5 cm), disease-free interval less vs. more than one year, type of primary tumor, blood transfusion, major hepatectomy vs. minor hepatectomy. Survival of patients undergoing liver resection for metastatic colorectal cancer was also analyzed to compare the results with the study population. RESULTS: Mortality and morbidity rate were 3% and 23.1%, respectively. The 3 and 5-year survival were 56.5% and 40%, respectively. The 3 and 5-year disease-free survival were 44% and 30%, respectively. Diameter, disease-free interval and metastases from gastrointestinal cancers were independently related to the survival at the multivariate analysis. Thirty-nine patients (27%) survived over five years. Patients with liver metastases from gastrointestinal primary tumors were those with a worse survival (25% and 19% at 3 and 5 years, respectively). CONCLUSIONS: Surgery is an effective treatment for patients with NCRNNE liver metastases, providing satisfactory long-term outcomes with acceptable morbidity and mortality, in particular when excluding patients with gastro-intestinal metastases.

Risk of Kaposi sarcoma after solid-organ transplantation: multicenter study in 4,767 recipients in Italy, 1970-2006.

Given the high prevalence of infection with human herpesvirus type 8, Italy is an area of utmost interest for studying Kaposi sarcoma (KS). We investigated the risk of KS in transplant recipients compared with the general population. A longitudinal study was performed from 1970 to 2006 in 4767 kidney, heart, liver, and lung transplant recipients from 7 Italian transplantation centers. The sample included 72.3% male patients with an overall patient median age of 48 years. Patient-years (PYs) at risk for KS were computed from 30 days posttransplantation to the date of KS, death, last follow-up, or study closure (December 31, 2007). Standardized incidence ratios (SIRs) and 95% confidence intervals were computed to quantify the risk of KS in transplant recipients compared with the general Italian population. Incidence rate ratios were computed to identify risk factors using adjusted Poisson regression. Based on 33,621 PYs, KS was diagnosed in 73 patients (62 men): 31 in kidney recipients, 27 in heart recipients, 8 in liver recipients, and 7 in lung recipients. The overall incidence was 217 cases per 10(5) PYs, with a significantly increased SIR of 125. SIR was particularly high in women (n = 34) and lung recipients (n = 428) but decreased significantly with time posttransplantation. The primary predictors of increased risk of KS were male sex, older age, and lung transplantation. A 5-fold reduction was observed after 18 months posttransplantation. After adjustment, patients born in southern Italy compared with northern Italy demonstrated a significant 2.2-fold increased risk. Our findings confirm that in the early posttransplantation period, Italian patients who have undergone solid-organ transplantation, particularly those from southern Italy and those who are lung recipients, are at greater risk of KS compared with the general population. These findings underscore the need for appropriate models for monitoring transplant recipients for KS, especially those at greater risk and, in particular, in the early postoperative period.

Model for End-Stage Liver Disease (MELD) system to allocate and to share livers: experience of two Italian centers.

BACKGROUND: The use of the Model for End-stage Liver Disease (MELD) score to prioritize patients on liver waiting lists and to share organs among centers was effective according to US data, but few reports are available in Europe. MATERIALS AND METHODS: We evaluated the outcome of 887 patients listed between April 2004 and July 2006 in a common list by two transplant centers (University of Bologna [BO] and University of Modena [MO] ordered according to the MELD system. Patients with hepatocellular carcinoma had a score calculated according to their real MELD, tumor stage, and waiting time. RESULTS: Five hundred eighty-six (67%) patients were listed from BO and 291 (33%) from MO. The clinical features of recipients (sex, age, blood group, and real MELD) were comparable between centers. The number of liver transplantations performed was 307, and 273 (89%) recipients had a calculated MELD >or=20. Liver transplantations were equally distributed according to the number of patients listed: 215 out of 586 (36.7%) for BO and 92 out of 291 (31.6%) for MO. The median real MELD of patients transplanted was 20, and 246 out of 307 (80.1%) grafts transplanted were functioning. The dropouts from the list were 124 (14%), and 87 (70%) of these patients had a calculated MELD >or=20. CONCLUSION: The MELD system was effective to share livers among the two Italian centers. According to this policy, livers were allocated to the recipients with the highest probability of dropout and who had a satisfactory survival after liver transplantation.

[Study of eight cases of coccidioidomycosis in a hospital of Buenos Aires.]. / Estudio de ocho casos de coccidoidomicosis en un hospital de Buenos Aires.

Some clinical, epidemiological and diagnostic aspects from eight patients with chronic coccidioidomycosis (five pulmonary and three disseminated), diagnosed in the Muñiz Hospital, were retrospectively analyzed. At diagnosis, lung cavitation and hemoptysis were present in five and four patients, respectively. Smoking (three cases) and alcoholism (two cases) were the most frequent predisposing factors. Diagnosis was achieved by microscopy and cultures from sputum (five cases), tongue and lymph node biopsies and scraping of cutaneous lesion achieved diagnosis. At diagnosis, most patients had positive coccidioidin skin test and serology. Four patients were born within the endemic area and two worked in contact with the soil of the same area.