Outcomes of liver resection for haemorrhagic hepatocellular adenoma.

BACKGROUND: Intratumoral bleeding and/or intraperitoneal rupture occurs in up to 20% of patients with hepatocellular adenoma (HCA). Hepatectomy in the presence of haemorrhagic HCA has been associated with increased morbidity and mortality rates. This study evaluates the outcomes of hepatectomy for haemorrhagic HCA at a single institution. METHODS: Between January 1997 and December 2012, 52 consecutive patients underwent liver resection for HCA. Among them, 14 patients were resected for haemorrhagic (H)-HCAs (including 9 cases of intratumoural bleeding and 5 cases of intraperitoneal bleeding) and 38 for non-haemorrhagic (NH)-HCAs. RESULTS: The preoperative characteristics were similar between the two groups except for younger age (p = .001) and shorter duration of hormonal use (p = .001) in (H)-HCAs. There were no mortalities. Intraoperative blood loss, transfusion rate, and postoperative morbidity were comparable between the two groups of patients (p = ns). The length of hospital stay was significantly longer in (H)-HCAs (p = .03). In all the resected H-HCAs, pathology showed central haemorrhagic changes with tumoral cells at the periphery of the lesions. CONCLUSIONS: Liver resection for H- and NH-HCAs can be achieved with no mortality and comparable short-term outcomes.

First and repeat liver resection for primary and recurrent intrahepatic cholangiocarcinoma.

BACKGROUND: Recurrence after resection of intrahepatic cholangiocarcinoma (ICC) remains common. The present study sought to evaluate risk factors for recurrence and the results of repeat liver resection (RLR) for recurrent ICC. METHODS: Between 1997 and 2012, clinical data and outcomes of 125 consecutive patients undergoing liver resection for ICC were retrospectively analyzed. RESULTS: The rate of R0 resection was 89% (n = 110). Overall median survival was 35 months, and 1-, 3-, and 5-year actuarial survival rates were 80%, 48%, and 28%, respectively. Recurrence occurred in 76 patients (63.5%) and was intrahepatic only for 39 patients (51%). Tumor size greater than 5 cm was identified as an independent risk factor for recurrence (P ≤ .0001). RLR for recurrent ICC was feasible in 10 patients (25%) with a median survival after recurrence of 25 months (16 to 76). CONCLUSIONS: Tumor size more than 5 cm represents an independent risk factor for recurrence after resection of ICC. RLR in case of recurrent ICC, when feasible, is associated with longer overall survival.

Resection of Borderline Resectable and Locally Advanced Pancreatic Adenocarcinomas after Neoadjuvant Chemotherapy.

OBJECTIVE: To report the outcomes of surgical resection of borderline resectable (BL) and locally advanced (LA) 'unresectable' pancreatic cancer after neoadjuvant chemotherapy. METHODS: A review of a prospectively maintained database for pancreatic resections was undertaken to identify patients undergoing resection for BL and LA pancreatic cancer after neoadjuvant chemotherapy between January 2007 and December 2012. Clinicopathological, surgical and survival outcomes were analyzed. RESULTS: A total of 45 patients with LA (n = 34) or BL cancer (n = 11) underwent surgery after a mean (± SD) of 7 ± 4 preoperative chemotherapy cycles. Ninety-day mortality was 6.7%, and overall morbidity was 33.3%. An R0 resection was achieved in 34 patients, and 4 patients showed a complete pathological response. Overall median postoperative survival was 17 months (21 after the start of neoadjuvant treatment). Overall and disease-free survival was 74.9 and 43.6% at 1 year and 21.2 and 10.3% at 3 years, respectively. In BL cancer patients, the 3-year survival was significantly higher compared to that of LA cancer patients (p = 0.02). CONCLUSIONS: Curative intent resection in BL and LA cancer patients after neoadjuvant chemotherapy can be achieved with reasonable mortality and morbidity and an encouraging 3-year survival. After neoadjuvant therapy, resection provides a better overall survival for BL compared to LA cancer patients.

Post-hepatectomy liver failure in patients with colorectal liver metastases.

Liver resection remains the standard treatment for colorectal liver metastases (CLM). Major hepatic resection is now performed frequently and with relative safety, but postoperative mortality is still reported to occur in up to 6 % of the patients with CLM undergoing liver resection even at high-volume centers. Post-hepatectomy liver failure (PHLF) is a key factor involved in mortality. The frequency of PHLF is reported to be 1-16 %, and has varied greatly among studies since a clear definition of PHLF has been lacking. Recently, the International Study Group of Liver Surgery (ISGLS) proposed a simple definition of PHLF, which includes the combination of the severity of PHLF and does not use an arbitrary cut-off value for the serum bilirubin concentration and INR. Hence, it may be the most useful definition in the clinical setting. Advanced age, a small future liver remnant volume, preoperative chemotherapy and chemotherapy-induced liver injury may all be associated with PHLF. Once PHLF occurs, it is difficult to reverse, and thus, strategies aimed at prevention are keys to reducing the mortality after liver surgery.

Predicting early intrahepatic recurrence after curative resection of colorectal liver metastases with molecular markers.

BACKGROUND: The aim of this case-control study was to identify clinicopathological factors and test three relevant biomarkers for their ability to predict early intrahepatic recurrence after curative liver resection for colorectal liver metastases (CLM). METHODS: Of the 184 patients with CLM undergoing hepatectomy between January 2007 and December 2009, thirty patients had intrahepatic disease recurrence within 6 months. The control group was randomly selected from a cohort of patients between April 1997 and December 2005 who have survived without disease recurrence after CLM resection for over 5 years. Both groups were matched for size of metastasis greater than 5.0 cm, the presence of multiple metastases, and synchronous versus metachronous CLM. The final study population consisted of 60 patients with CLM undergoing R0 hepatectomy, 30 of whom had early intrahepatic-only recurrences (study group) and 30 patients without recurrence for more than 5 years (control group). Both groups were analyzed and compared for the presence of clinical factors and expression levels of CD133, survivin, and Bcl-2 within tumor tissue. RESULTS: Characteristics of patients were similar between the two groups except primary tumor location and administration of postoperative chemotherapy. Expression level of CD133 and survivin were significantly increased in tumors of patients with recurrence compared to patients without recurrence. On multivariate analysis high tumor expression levels of CD133 (odds ratio [OR] 14.7, confidence interval [CI] 1.8-121.3, p = 0.012) and survivin (OR 9.5, CI 2.1-44.3, p = 0.004) and postoperative chemotherapy (OR 4.8, CI 1.01-22.9, p = 0.049) were independent factors associated with early intrahepatic recurrence. CONCLUSIONS: Tumor expression levels of CD133 and survivin may be a useful predictor of early intrahepatic recurrence after hepatectomy for CLM. Administration of postoperative chemotherapy may prevent early intrahepatic recurrence.

Pancreatic metastasis from clear cell renal cell carcinoma: outcome of an aggressive approach.

OBJECTIVE: To evaluate the long-term results of patients surgically treated for metastatic clear cell renal cell carcinoma (CCRCC) with a unique pancreatic secondary localization to assess the importance of radical treatment in this rare group of patients. PATIENTS AND METHODS: This is a retrospective monocentric study including 20 surgically treated patients between 1997 and 2012 for a unique pancreatic metastasis of a CCRCC. The main objective was to evaluate the outcome after surgical resection. RESULTS: Twenty patients were followed up for a CCRCC. The M/F ratio was 1.2. The average age of onset of kidney cancer was 57.05 ± 7.78 years. Two patients who had synchronous pancreatic metastasis and 18 patients who had metachronous metastasis appeared after an average of 130 ± 59 months (24-240 months). The average size of the metastases was 20 ± 11.6 mm. Pancreatic metastasis was unique in all patients, with 35% of patients having multiple lesions of the pancreas. All patients underwent a pancreatic resection of metastasis. Histologic examination confirmed the location of a secondary CCRCC in all patients. Median follow-up after pancreatectomy was 69 months (1-150 months). Disease-free survival at 2 years was 60%. Overall survival rates at 2 and 4 years were 79% and 72%, respectively. There was no difference found between patients with multiple and unique pancreatic metastases in overall survival. CONCLUSION: Unique pancreatic metastasis of CCRCC is rare. The literature on this subject is limited. Surgical resection might be an option and can be associated with long-term disease-free intervals in highly selected patients.

Candida albicans arteritis transmitted by preservation fluid after liver transplantation.

BACKGROUND: Fungal infections remain among the main causes of mortality in the chronically immunosuppressed liver transplant (LT) patient. Bacterial and fungal contamination of preservation fluid (PF), in which grafts are stored, represents a potential source of infection for recipients. CASE REPORT: A 54-year-old patient underwent LT for chronic alcoholic cirrhosis. Mycological culture of the liver PF was positive for Candida albicans. The patient received antimycotic prophylaxis for 4 weeks in absence of clinical and serological signs of infection. He was urgently readmitted 4 months later with hemobilia caused by an arterial pseudoaneurysm that was fistulized in the biliary anastomosis. After an unsuccessful embolization, arterial resection and reconstruction and a biliodigestive anastomosis were performed, with an uneventful postoperative course. Pathology found a mycotic arteritis of the graft artery. Mycotic culture of the arterial segment confirmed the presence of the same Candida albicans genotype previously isolated in the PF. CONCLUSIONS: Mycotic arteritis is one of the possible complications of yeast contamination of PF. Surgeons and physicians involved in the care of LT patients should be aware of this potentially lethal complication and adopt all the available means for early detection.

Use of a temporary intraoperative mesentericoportal shunt for pancreatic resection for locally advanced pancreatic cancer with portal vein occlusion and portal hypertension.

BACKGROUND: Our aim was to evaluate the perioperative morbidity and survival of a selected group of patients with locally advanced pancreatic ductal adenocarcinoma (PDAC) and malignant obstruction of portal axis inducing portal hypertension (PH) who underwent a curative intent pancreatic resection, after neoadjuvant chemotherapy, adopting a new type of temporary intraoperative mesentericoportal shunt (TMPS). METHODS: We analyzed the perioperative data and survival outcome of 15 patients with locally advanced PDAC and PH who underwent pancreatoduodenectomy combined with vascular resections between October 2008 and October 2012 using this TMPS. RESULTS: There was no perioperative mortality. Postoperative morbidity occurred in 7 patients without any postoperative liver failure. All patients underwent mesentericoportal venous resection, 11 of whom had a concomitant arterial resection. The mean ± SD follow-up was 16 ± 10 months (range, 4-40; median 15). Overall survival rates of patients were 78% and 11% at 1 and at 3 years, respectively. Median survival was 17 months. The 1-year disease-free survival was 36%. CONCLUSION: The use of this form of TMPS allowed us to achieve PD or total pancreatectomy in patients with locally advanced PDAC and PH without postoperative mortality but with increased morbidity. The relevance of such an aggressive approach is yet to be determined.

Pancreatic fistula after a pancreaticoduodenectomy for ductal adenocarcinoma and its association with morbidity: a multicentre study of the French Surgical Association.

BACKGROUNDS: A pancreatic fistula (PF) is the most relevant complication after a pancreaticoduodenectomy (PD). This retrospective multicentric study attempts to elucidate the risk factors and complications of a PF in a large cohort of patients undergoing a PD for ductal adenocarcinoma. METHODS: Using a survey tool, clinical data of 1325 patients undergoing a PD for ductal adenocarcinoma at 37 institutions, between January 2004 and December 2009, were collected. Peri-operative risk factors associated with PF and its association with morbidity and mortality were assessed. Morbidity and PF were graded according to the ISGPF (International Study group for pancreatic fistula) definition and the Dindo-Clavien classification. RESULTS: Overall PF, mortality, morbidity and relaparotomy rates were 14.3%, 3.8%, 54.4% and 11.7%, respectively. PF occurred more frequently after a pancreaticojejunostomy (PJ) compared with a pancreaticogastrostomy (PG) (16.8% vs. 10.4%; P = 0.0012). Independent risk factors for PF by multivariate analysis were absence of pre-operative diabetes (P = 0.0014), PJ reconstruction (P = 0.0035), soft pancreatic parenchyma (P < 0.0001) and low-volume centre (P = 0.0286). Clinically relevant PF (grade B and C) and severe complications (Dindo-Clavien grade IIIB, IV, V) were significantly more frequent after PJ than PG (71.6% vs. 28.3%; P = 0.030 and 24.8% vs. 19.1%; P = 0.015, respectively). Overall mortality and relaparotomy rates were similar after PG and PJ. CONCLUSIONS: A soft pancreatic parenchyma, the absence of pre-operative diabetes, PJ and low-volume centre are independent risk factors for PF after PD for ductal adenocarcinoma. A significantly higher incidence and clinical severity of PF are associated with PJ.

Reoperative surgery after repair of postcholecystectomy bile duct injuries: is it worthwhile?

BACKGROUND: Repeat repair of bile duct injuries (BDIs) after cholecystectomy is technically challenging, and its success remains uncertain. We retrospectively evaluated the short- and long-term outcomes of patients requiring reoperative surgery for BDI at a major referral center for hepatobiliary surgery. METHODS: Between January 1991 and May 2011, we performed surgical BDI repairs in 46 patients. Among them, 22 patients had undergone a previous surgical repair elsewhere (group 1), and 24 patients had no previous repair (group 2). We compared the early and late outcomes in the two groups. RESULTS: The patients in group 1 were younger (48.6 vs. 54.8 years, p = 0.0001) and were referred after a longer interval (>1 month) from BDI (72.7 vs. 41.7%, p = 0.042). Intraoperative diagnosis of BDI (59.1 vs. 12.5%, p = 0.001), ongoing cholangitis (45.4 vs. 12.5%; p = 0.02), and delay of repair after referral to our institution (116 ± 34 days vs. 23 ± 9 days; p = 0.001) were significantly more frequent in group 1 than in group 2. No significant differences were found for postoperative mortality, morbidity, or length of stay between the groups. Patients with associated vascular injuries had a higher postoperative morbidity rate (p = 0.01) and associated hepatectomy rate (p = 0.045). After a mean follow-up of 96.6 ± 9.7 months (range 5-237.2 months, median 96 months), the rate of recurrent cholangitis (6.5%) was comparable in the two groups. CONCLUSIONS: This study demonstrates that short- and long-term outcomes after surgical repair of BDI are comparable regardless of whether the patient requires reoperative surgery for a failed primary repair. Associated vascular injuries increase postoperative morbidity and the need for liver resection.

Liver transplantation for iatrogenic bile duct injuries sustained during cholecystectomy.

PURPOSE: The aim of this study was to report a single-center experience and review the literature on liver transplantation (LT) for iatrogenic bile duct injury (BDI) sustained during cholecystectomy. METHODS: A retrospective review of a prospectively maintained database of LT between 1990 and December 2012 was performed. For the same period, a review of the literature on LT for BDI was undertaken. RESULTS: Six patients, with a mean age of 55.3 years (range 52-65), referred at a mean interval of 206 months (range 96-384) from BDI underwent LT. All patients had class E Strasberg BDIs and were referred with end-stage liver disease after multiple previous attempts at BDI repairs. Mortality, morbidity, and retransplantation rates were 16.6, 50, and 16.6 %, respectively. Five patients were alive at a mean follow-up time of 80.4 ± 92 months. Fifty-eight patients listed or transplanted for BDI were identified and reviewed. Indications for LT included chronic or acute liver failure (22.4 %) and the delay between BDI and referral for LT ranged from 1 day to 180 months. Associated vascular injuries were present in 41.3 % of the patients, and 72.4 % of the patients had previous failed BDI repairs. The overall postoperative mortality was 34.4 %, and the morbidity ranged from 60 to 100 %. The overall 5-year survival reached 75 %. CONCLUSIONS: A long interval of time between BDI and referral to tertiary centers for repair, a high rate of associated vascular injuries, and multiple failed previous repair attempts characterize the clinical history of patients undergoing LT for BDI. Operative morbidity and mortality rates of LT in the setting of BDI are particularly high for patients with bilio-vascular injuries presenting with acute liver failure and for patients with chronic liver disease due to multiple previous repair attempts and recurrent preoperative biliary infection.

Tratamiento del pseudoquiste hemorrágico de páncreas / Treatment of a haemorrhagic pseudocyst of pancreas

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What is a safe future liver remnant size in patients undergoing major hepatectomy for colorectal liver metastases and treated by intensive preoperative chemotherapy?

BACKGROUND: A multidisciplinary approach involving preoperative chemotherapy has become common practice in patients with colorectal liver metastases (CLM). The definition of a safe future liver remnant (FLR) volume based on preoperative clinical data in these patients is lacking. Our aim was to identify predictors of postoperative morbidities in patients undergoing major hepatectomy after intensive preoperative chemotherapy for CLM. METHODS: Between January 2000 and August 2010, a total of 101 consecutive patients with CLM underwent major hepatectomy after preoperative chemotherapy (≥6 cycles of oxaliplatin or irinotecan regimen with or without targeted therapies). The FLR ratio was calculated by two formulas: actual FLR (aFLR) ratio, and standardized FLR (sFLR) ratio. Predictors of postoperative overall morbidity, sepsis, and liver failure were identified by univariate and multivariate analyses. RESULTS: Fifty-eight patients (57.4%) had 95 postoperative complications. Sepsis and postoperative liver failure occurred in 23 (22.8%) and 16 patients (15.8%), respectively. On univariate analysis, small aFLR ratio was significantly associated with all complications, and sFLR ratio was associated with sepsis and liver failure. In receiver-operating characteristic analysis, the cutoff of aFLR ratio in predicting overall morbidity, sepsis, and liver failure was 44.8, 43.1, and 37.7%, respectively, and that of sFLR ratio in predicting sepsis and liver failure was 43.6 and 48.5%, respectively. On multivariate analysis, these aFLR and sFLR ratio cutoffs were independent predictors of all complications and of sepsis and liver failure, respectively. CONCLUSIONS: This study provides a cutoff FLR ratio for safe postoperative outcome after major hepatectomy in CLM patients receiving six or more cycles of preoperative chemotherapy.

Double omental flap reduced perianastomotic collections and relaparotomy rates after pancreaticoduodenectomy with pancreaticogastrostomy.

INTRODUCTION: In an attempt to reduce the perioperative morbidity after pancreaticoduodenectomy, the results of double omental flap (DOF) after pancreaticoduodenectomy (PD) with pancreaticogastrostomy (PG) were compared to a standard technique. METHODS: From January 2009 to December 2009, 61 patients underwent PD with PG for pancreatic adenocarcinoma in our department. Perioperative data were prospectively recorded, and postoperative outcome of patients who underwent or not a DOF (group DOF+ = 33 and group DOF- = 28, respectively) was analyzed. RESULTS: The overall postoperative mortality was 1.6 % (n = 1). The overall postoperative morbidity rate was 27.8 % (n = 17). PF occurred in eight (13.1 %) patients and was grade A in six (9.8 %) patients. Clinically relevant PF (grade B and C) occurred in two (3.2 %) patients. The univariate analysis showed that in the DOF+ groups there was a significant reduction of perianastomotic collections (P = 0.034) and a significant reduction of the relaparotomy rate (P = 0.05). DISCUSSION: The DOF contributed to reduce the rate of perianastomotic collections as well as the rate of relaparotomy. CONCLUSIONS: A DOF should be considered a further step toward a reduction of surgical-related complications after PD with PG.