Intraductal papillary neoplasm of the bile duct: The new frontier of biliary pathology.

Intraductal papillary neoplasms of the bile duct (IPNBs) represent a rare variant of biliary tumors characterized by a papillary growth within the bile duct lumen. Since their first description in 2001, several classifications have been proposed, mainly based on histopathological, radiological and clinical features, although no specific guidelines addressing their management have been developed. Bile duct neoplasms generally develop through a multistep process, involving different precursor pathways, ranging from the initial lesion, detectable only microscopically, i.e. biliary intraepithelial neoplasia, to the distinctive grades of IPNB until the final stage represented by invasive cholangiocarcinoma. Complex and advanced investigations, mainly relying on magnetic resonance imaging (MRI) and cholangioscopy, are required to reach a correct diagnosis and to define an adequate bile duct mapping, which supports proper treatment. The recently introduced subclassifications of types 1 and 2 highlight the histopathological and clinical aspects of IPNB, as well as their natural evolution with a particular focus on prognosis and survival. Aggressive surgical resection, including hepatectomy, pancreaticoduodenectomy or both, represents the treatment of choice, yielding optimal results in terms of survival, although several endoscopic approaches have been described. IPNBs are newly recognized preinvasive neoplasms of the bile duct with high malignant potential. The novel subclassification of types 1 and 2 defines the histological and clinical aspects, prognosis and survival. Diagnosis is mainly based on MRI and cholangioscopy. Surgical resection represents the mainstay of treatment, although endoscopic resection is currently applied to nonsurgically fit patients. New frontiers in genetic research have identified the processes underlying the carcinogenesis of IPNB, to identify targeted therapies.

Segmental Thoracic Spinal Anesthesia for Laparoscopic Cholecystectomy with the "Hypobaric" Technique: A Case Series.

Purpose: Several studies have applied lumbar spinal anesthesia (SA) with isobaric/hyperbaric bupivacaine and opioids in elective laparoscopic cholecystectomy (LC), documenting a superiority of the methodic over general anesthesia (GA) in terms of perioperative pain, nausea, and vomiting, though with a notable incidence of intraoperative right shoulder pain, potentially responsible for conversion to GA. This case series presents an opioid-free scheme of segmental thoracic spinal anesthesia (STSA) with hypobaric ropivacaine, reporting its benefits mainly in terms of shoulder pain occurrence. Patients and Methods: Hypobaric STSA was performed in nine patients undergoing elective LC between May 1 and September 1, 2022. The level of the needle insertion was included between T8 and T9, via a median or a paramedian approach. Midazolam (0.03 mg/kg) and Ketamine (0.3 mg/kg) were used as adjuvants for intrathecal sedation, followed by the administration of hypobaric ropivacaine 0.25% at a dose of 5 mg and then isobaric ropivacaine at a dose of 10 mg. Patients were placed in anti-Trendelenburg position for the entire duration of surgery. LC was conducted through the standard 3 or 4 ports technique with pneumoperitoneum maintained at a pressure of 8-10 mmHg. Results: Mean patient age was 75.7 (±17.5) years, with a mean ASA score and Charlson comorbidity index (CCI) of 2.7 (±0.7) and 4.9 (±2.7), respectively. STSA was completed without complications in all patients, with no need for conversion to GA. Mean operative time and SA duration were 37.5 (±8.7) and 145.2 (±21.8) min, respectively. Intraoperatively, no shoulder or abdominal pain and nausea were reported, with only four and two patients requiring vasopressor and sedative intravenous drugs, respectively. Postoperatively, overall mean VAS pain score and within the first 12 hafter surgery were 3 (±2) and 4 (±2), respectively. Median length of stay was 2 (range = 1-3) days. Conclusion: Hypobaric opioid-free STSA appears to be a promising approach for laparoscopic surgeries, with minimal to null occurrence of shoulder pain. Larger prospective studies are required to validate these findings.

Uniportal robotic-assisted thoracoscopic surgery for early-stage lung cancer with the Da Vinci Xi: Initial experience of two cases.

BACKGROUND: Minimally invasive surgery (MIS) techniques, currently considered the gold standard in the treatment of early-stage non-small cell lung cancer (NSCLC), are mainly represented by video-assisted thoracoscopic surgery (VATS), both uniportal and multiportal, and by robotic-assisted thoracoscopic surgery (RATS). While multiportal RATS has been accepted as a valid alternative to VATS, carrying the advantages of three-dimensional high-definition visualisation and improved maneuverability, very few reports exist in literature on the application of uniportal RATS (U-RATS). Therefore, we describe our initial experience with this recently developed method in the treatment of early-stage NSCLC. MATERIALS AND METHODS: U-RATS was conducted through a single 4 cm long antero-lateral mini-thoracotomy (ALMT) in the sixth intercostal space at the mid-axillary line. Three 8 mm robotic trocars were positioned and connected, from back to front, to robotic arms as follows: 30° camera arm, robotic arm 2 (bipolar fenestrated grasper) and 1 (Maryland bipolar forceps). Assistant access was identified as the most anterior part of ALMT. RESULTS: Case 1: an 82-year-old woman (American Society of Anaesthesiologists [ASA III]) underwent a left S6 segmentectomy for a clinical stage IA2 NSCLC, complicated by an air leak that resolved spontaneously by postoperative day three (POD 3). Case 2: a 75-year-old man (ASA III) underwent an uncomplicated right lower lobectomy for a clinical stage IA3 NSCLC. Case 1 and 2 were discharged on POD 5 and 4, respectively. CONCLUSIONS: From what emerged in our small series, U-RATS with the Da Vinci Xi surgical system might be considered a safe, reliable, and effective alternative to other MIS techniques. Larger prospective studies are required to validate these findings.

Crohn's Disease and Jejunal Artery Aneurysms: A Report of the First Case and a Review of the Literature.

Background and Objectives: Jejunal artery (JA) and ileal artery (IA) aneurysms constitute less than 3% of all visceral artery aneurysms (VAAs), carrying a risk of rupture as high as 30%, and a mortality of 20%. Though many etiologies have been reported in the literature, no mention exists on a causal association between these aneurysms and inflammatory bowel diseases (IBD). We present the first case of a JA aneurysm related to Crohn's Disease (CD) together with a review of the literature. Materials and Methods: A 74-year-old male presenting with CD intestinal relapse and an incidental finding at the computed tomography enterography (CTE) of a 53 × 47 × 25mm apparently intact JA pseudoaneurysm, arising from the first and second jejunal branches, underwent coil embolization followed by small bowel resection, with an uneventful outcome. We also included the review of literature on JA and IA aneurysms, analyzing all reports published in PubMed and Scopus from 1943 to July 2022. Results: 60 manuscripts with 103 cases of JA and IA aneurysms in 100 patients were identified. Among cases with available data, 34 (33.0%) presented acutely with rupture, 45 (43.7%) were described as non-ruptured. 83 (80.6%), and 14 (13.6%) were JA and IA aneurysms, respectively, having a median size of 15 (range:3.5-52) mm. Atherosclerosis (16.5%), infections (10.7%), and vasculitides/connective tissue disorders (9.7%) represented the main causes mentioned. Mean age was 53.6 (±19.2) years, male patients being 59.4%. One third of patients (32.4%) were asymptomatic. Overall, treatment was indicated in 63% of patients, with surgery and endovascular procedures performed in 61.9% and 38.1% cases, respectively. The technical success rate of endovascular treatment (EVT) was 95.8%. The mortality rate was 11.8%, being higher (21.2%) in the rupture group. Conclusions: The prompt treatment accomplished in our case granted a successful outcome. JA and IA aneurysms should be included among local complications of IBD. Considering their high potential for rupture, regardless of size, a low threshold for endovascular or surgical treatment should be applied.

Opioid-Free Segmental Thoracic Spinal Anesthesia with Intrathecal Sedation for Breast and Axillary Surgery: Report of Four Cases.

Purpose: Few studies have described segmental thoracic spinal anesthesia (STSA) as primary anesthesiologic method in breast and axillary surgery, documenting the association of intrathecal local anesthetics and opioids. This case series reports an opioid-free scheme of STSA in four elderly patients undergoing major breast and axillary oncological surgery. Patients and Methods: STSA was performed in three female patients undergoing unilateral mastectomy ± axillary lymph node dissection (ALND) or sentinel lymph node biopsy for invasive ductal carcinoma and in one male patient undergoing ALND for melanoma metastases. The level of needle insertion was included between T6-8, via a median or paramedian approach. Midazolam (2 mg) and ketamine (20 mg) were used as adjuvants for intrathecal sedation, followed by the administration of hypobaric ropivacaine 0.25% at a dose of 8 mg. The level of sensory blockade achieved was comprised between C2-3 and T11-12. Postoperative analgesia was maintained through continuous intravenous administration of Ketorolac by an elastomeric pump (90 mg over 24 hrs.). Results: Spinal anesthesia was completed without complications in all patients. Conversion to general anesthesia (GA) and perioperative intravenous sedation were not required. No major postoperative complications and no episodes of postoperative nausea and vomiting (PONV) were reported. No rescue analgesic was administered. All patients were discharged in postoperative day 2 and are alive at 30, 29, 27 and 13 months after surgery, respectively. High grade of satisfaction on the anesthesiologic method was expressed by all cases. Conclusion: STSA with local anesthetic plus midazolam and ketamine might be considered a safe and effective alternative to GA, even in surgeries involving the breast and axillary region, particularly in elderly and frail patients. Larger prospective studies are required to validate these findings.

Predictors of Kidney Delayed Graft Function and Its Prognostic Impact following Combined Liver-Kidney Transplantation: A Recent Single-Center Experience.

Combined liver−kidney transplantation (CLKT) improves patient survival among liver transplant recipients with renal dysfunction. However, kidney delayed graft function (kDGF) still represents a common and challenging complication that can negatively impact clinical outcomes. This retrospective study analyzed the incidence, potential risk factors, and prognostic impact of kDGF development following CLKT in a recently transplanted cohort. Specifically, 115 consecutive CLKT recipients who were transplanted at our center between January 2015 and February 2021 were studied. All transplanted kidneys received hypothermic pulsatile machine perfusion (HPMP) prior to transplant. The primary outcome was kDGF development. Secondary outcomes included the combined incidence and severity of developing postoperative complications; development of postoperative infections; biopsy-proven acute rejection (BPAR); renal function at 1, 3, 6, and 12 months post-transplant; and death-censored graft and patient survival. kDGF was observed in 37.4% (43/115) of patients. Multivariable analysis of kDGF revealed the following independent predictors: preoperative dialysis (p = 0.0003), lower recipient BMI (p = 0.006), older donor age (p = 0.003), utilization of DCD donors (p = 0.007), and longer delay of kidney transplantation after liver transplantation (p = 0.0003). With a median follow-up of 36.7 months post-transplant, kDGF was associated with a significantly increased risk of developing more severe postoperative complication(s) (p < 0.000001), poorer renal function (particularly at 1 month post-transplant, p < 0.000001), and worse death-censored graft (p = 0.00004) and patient survival (p = 0.0002). kDGF may be responsible for remarkable negative effects on immediate and potentially longer-term clinical outcomes after CLKT. Understanding the important risk factors for kDGF development in CLKT may better guide recipient and donor selection(s) and improve clinical decisions in this increasing group of transplant recipients.

How to Deal With Kidney Retransplantation-Second, Third, Fourth, and Beyond.

Kidney transplantation is the best health option for patients with end-stage kidney disease. Ideally, a kidney transplant would last for the lifetime of each recipient. However, depending on the age of the recipient and details of the kidney transplant, there may be a need for a second, third, fourth, or even more kidney transplants. In this overview, the outcome of multiple kidney transplants for an individual is presented. Key issues include surgical approach and immunologic concerns. Included in the surgical approach is an analysis of transplant nephrectomy, with indications, timing, and immunologic impact. Allograft thrombosis, whether related to donor or recipient factors merits investigation to prevent it from happening again. Other posttransplant events such as rejection, viral illness (polyomavirus hominis type I), recurrent disease (focal segmental glomerulosclerosis), and posttransplant lymphoproliferative disease may lead to the need for retransplantation. The pediatric recipient is especially likely to need a subsequent kidney transplant. Finally, noncompliance/nonadherence can affect both adults and children. Innovative approaches may reduce the need for retransplantation in the future.

Recurrent Renal Allograft Torsion After Simultaneous Kidney and Pancreas Transplantation: Is it Still Possible to Salvage the Graft? A Case Report.

BACKGROUND: Kidney allograft torsion (KAT) is defined as a rotation of the renal allograft around its vascular pedicle. It is a rare complication with high rate of graft loss. The nonspecific presentation and inability to provide a definitive diagnosis by imaging, mainly in cases of partial torsion, often delay the diagnosis and treatment. We report a case of recurrent complete torsion of the renal allograft after simultaneous kidney and pancreas transplantation, requiring 2 emergency exploratory laparotomies. CASE REPORT: A 38-year-old woman with a history of intraperitoneal simultaneous kidney and pancreas transplantation underwent 2 separate emergency exploratory laparotomies secondary to complete renal allograft torsion, respectively, 7 and 11 months after the transplant. In both episodes, no adhesions were encountered. During the first operation, nephropexy was performed. During the second operation, an abdominal wall mesh was placed and fixed to the abdominal wall. Acute kidney injury related to KAT recovered in both occasions with a creatinine of 1.3 mg/dL at 4 months follow-up. CONCLUSIONS: Renal torsion always should be suspected in intraperitoneally placed kidneys presenting with nonspecific symptoms, abdominal pain, oliguria, and worsening kidney function. Surgical exploration should be considered to salvage the renal graft. This case illustrates the reversibility of a severe injury related to this vascular complication with an adequate return to baseline kidney function even when diagnosis and surgical treatment of KAT might be delayed secondary to its misleading clinical presentation.

Transplantation of En Bloc Pediatric Kidneys With a Bladder Segment Patch After a Complex Vascular Reconstruction: A Case Report.

BACKGROUND: En bloc pediatric kidney (EBPK) allografts represent one potential solution to increase the number of organs available in the donor pool, thus facilitating transplantation of kidneys from young donors into adult recipients. However, EBPK transplantation has been traditionally considered suboptimal because of concerns for perioperative complications. METHODS: An extensive reconstruction and successful transplantation of an EBPK allograft using same pediatric donor vascular grafts and a bladder patch aiming to avoid postoperative complications is presented in this report. RESULTS: The warm ischemia time was 25 minutes. No surgical drainage or ureteral stent were used. Postoperative Doppler ultrasound showed laminar blood flow and normal parameters in both the external iliac and graft arteries, no collections, and no signs of obstructive uropathy. The patient had an uneventful recovery showing a creatinine level of 0.86 mg/dL and 0.85 mg/dL at 1 month and 3 months, respectively. CONCLUSIONS: A refined back-table reconstruction of these allografts is crucial to avoid mishaps in the postoperative period.

No Benefit of Prophylactic Surgical Drainage in Combined Liver and Kidney Transplantation: Our Experience and Review of the Literature.

Background: Contrasting results have emerged from limited studies investigating the role of prophylactic surgical drainage in preventing wound morbidity after liver and kidney transplantation. This retrospective study analyzes the use of surgical drain and the incidence of wound complications in combined liver and kidney transplantation (CLKTx). Methods: A total of 55 patients aged ≥18 years were divided into two groups: the drain group (D) (n = 35) and the drain-free group (DF) (n = 20). Discretion to place a drain was based exclusively on surgeon preference. All deceased donor kidneys were connected to the LifePort Renal Preservation Machine® prior to transplantation, in both simultaneous and delayed technique of implantation of the renal allograft. The primary outcome was the development of superficial/deep wound complications during the study follow-up. Secondary outcomes included the development of delayed graft function (DGF) of the transplanted kidney, primary non-function (PNF) and early allograft dysfunction (EAD) of the transplanted liver, graft failure, graft and patient survival, overall post-operative morbidity rate and length of hospital stay. Results: With a median follow-up of 14.4 months after transplant, no difference in the incidence of superficial/deep wound complications, except for hematomas, in collections size, intervention rate, PNF, EAD, graft failure and patient survival, was observed between the 2 groups. Significantly lower level of platelets, higher INR values, DGF, morbidity rates and length of hospital stay were reported post-operatively in the D group. Pre-operative hypoalbuminemia and longer CIT were included in the propensity score for receiving a drain and were associated with a significantly higher rate of developing a hematoma post-transplant. Conclusions: Absence of the surgical drain did not appear to adversely affect wound morbidity compared to the prophylactic use of drains in renal transplant patients during CLKTx.

Transplantation of 2-Month-Old En Bloc Pediatric Kidneys After a Complex Vascular Reconstruction - Traveling 2500 Miles to Get Transplanted: A Case Report.

BACKGROUND En bloc pediatric kidneys (EBPK) are one potential solution to increase the number of organs available in the donor community, thus promoting transplantation of these allografts into adult recipients. However, EBPK transplantation has been traditionally considered suboptimal due to concerns for perioperative complications, mainly vascular thrombosis. We report an en bloc kidney transplantation using vascular grafts from another deceased donor to extend the EBPK aorta and vena cava and create a tension-free anastomosis with recipient external iliac vessels. CASE REPORT A pair of 2-month-old female en bloc kidneys weighting 6 kg were transplanted to a 30-year-old adult male. Prolonged cold ischemic time (CIT) was related to high refusal rate and long travel from Nevada to Miami. Prior to transplantation, the EBPK were connected to the LifePort Renal Preservation Machine® and deemed transplantable only after showing a significant improvement in perfusion parameters. Back-table reconstruction was conducted through an end-to-end anastomosis between an adult deceased donor common iliac artery and vein grafts to the inferior vena cava and aortic distal ends, respectively. The patient displayed immediate graft function (IGF) without any postoperative complications, showing a creatinine of 1.5 mg/dl at 4-month follow-up. CONCLUSIONS Use of renal preservation machine (RPM) and refined back-table reconstruction of these allografts are important tools to improve the significant discard rate and improve outcomes of EBPK.

Complex Surgical Reconstruction of Upper Pole Artery in Living-Donor Kidney Transplantation.

BACKGROUND The use of allografts with multiple renal arteries has increased in the era of laparoscopic donor nephrectomy. Although several studies recommend reconstructing lower pole arteries (LPAs) to reduce risk of urologic complications, it is common opinion to ligate upper pole arteries (UPAs) with a diameter less than 2 mm because of increased risk of thrombosis related to their reconstruction. This retrospective study evaluates the feasibility and safety of reconstructing thin UPAs during living-donor kidney transplantation, with the goal of maintaining the integrity of the graft and assuring its maximal function. MATERIAL AND METHODS Data from 922 living-donor kidney transplants performed between 2009 and 2019 were reviewed. Six cases with UPAs were identified (0.65%). The study endpoints were incidence of allograft vascular and urologic complications, slow graft function, delayed graft function, graft failure, and graft and patient survival. RESULTS The UPAs had a mean diameter of 1.8±0.28 mm. Methods of reconstruction included: interposition graft (n=2), end-to-side anastomosis inside the renal hilum to a branch of the main renal artery (n=3), and side-to-side anastomosis with the main renal artery (n=1). Additional reconstruction of LPAs (n=2) and main renal arteries (n=2) was performed. During a median (range) follow-up of 14.5 (9-49) months no complications were observed. CONCLUSIONS Ex vivo reconstruction of UPAs with a diameter less than 2 mm is worth attempting, particularly in the setting of living-donor kidney transplantation.

Results of a previously unreported extravesical ureteroneocystostomy technique without ureteral stenting in 500 consecutive kidney transplant recipients.

Urologic complications can still occur following kidney transplantation, sometimes requiring multiple radiological and/or surgical procedures to fully correct the problem. Previously proposed extravesical ureteral reimplantation techniques still carry non-negligible risks of the patient developing urologic complications. About 10 years ago, a new set of modifications to the Lich-Gregoir technique was developed at our center, with the goal of further minimizing the occurrence of urologic complications, and without the need for initial ureteral stent placement. It was believed that an improvement in the surgical technique to minimize the risk of developing urologic complications was possible without the need for stent placement at the time of transplant. In this report, we describe the advantages of this technique (i.e., mobilized bladder, longer spatulation of the ureter, inclusion of bladder mucosa with detrusor muscle layer in the ureteral anastomosis, and use of a right angle clamp in the ureteral orifice to ensure that it does not become stenosed). We also retrospectively report our experience in using this technique among 500 consecutive (prospectively followed) kidney transplant recipients transplanted at our center since 2014. During the first 12mo post-transplant, only 1.4%(7/500) of patients developed a urologic complication; additionally, only 1.0%(5/500) required surgical repair of their original ureteroneocystostomy. Five patients(1.0%) developed a urinary leak, with 3/5 having distal ureteral necrosis, and 1/5 subsequently developing a ureteral stricture. Two other patients developed ureteral stenosis, one due to stricture and one due to ureteral stones. These overall results are excellent when compared with other reports in the literature, especially those in which routine stenting was performed. In summary, we believe that the advantages in using this modified extravesical ureteroneocystostomy technique clearly help in lowering the early post-transplant risk of developing urologic complications. Importantly, these results were achieved without the need for ureteral stent placement at the time of transplant.

Continuous thoracic spinal anesthesia with local anesthetic plus midazolam and ketamine is superior to local anesthetic plus fentanyl in major abdominal surgery.

BACKGROUND: Limited studies have applied thoracic continuous spinal anesthesia in abdominal surgery, relying exclusively on opioids. This retrospective study analyzes 2 different schemes of thoracic continuous spinal anesthesia and postoperative analgesia in elderly patients undergoing major abdominal surgery. METHODS: A total of 98 patients aged ≥ 75 years were divided into 2 groups. The control group (60 patients) received bupivacaine plus fentanyl, whereas the study group (38 patients) received bupivacaine plus ketamine and midazolam. Both received analogous postoperative continuous intrathecal analgesia. Several perioperative variables were evaluated. RESULTS: Spinal anesthesia was performed without complications in all patients. Doses of noradrenaline administered, incidence of respiratory depression, need for intraoperative sedation, and time to first flatus were significantly reduced in the bupivacaine plus ketamine and midazolam group. CONCLUSION: In a population of frail, elderly patients, thoracic continuous spinal anesthesia with local anesthetic plus midazolam and ketamine was superior to local anesthetic plus fentanyl. In the group receiving local anesthetic plus midazolam and ketamine, the incidence of respiratory depression was reduced, and doses of norepinephrine and intraoperative sedating medications were lower. Intraoperative anesthesia and postoperative analgesia were similar in both groups.

Thoracic continuous spinal anesthesia for high-risk comorbid older patients undergoing major abdominal surgery: one-year experience of an Italian geriatric hospital.

BACKGROUND: General anesthesia is associated with high morbidity/mortality in comorbid older adults. Thoracic continuous spinal anesthesia/analgesia (TCSA) may be an alternative for major abdominal surgery. We report a one-year experience of the use of TCSA in an Italian geriatric center. METHODS: Retrospective review of case notes of high-risk older patients (ASA class ≥III) who underwent TCSA for major abdominal surgery between May 2017-May 2018. TCSA was performed with a 21-gauge Tuohy-shaped spinal needle and a 24-gauge catheter (level of insertion between T6-7 and T10-11). Hyperbaric bupivacaine or levobupivacaine (two boluses of 2.5 mg) plus fentanyl (10-25 µg) were injected before incision, followed by additional doses if needed. Intrathecal levobupivacaine plus fentanyl were infused for 72 hours after surgery. We described the anesthesiologic management and evaluated the incidence of postoperative complications. RESULTS: Ninety patients (age 84.4±6.9 years, 53.3% male) were enrolled. High comorbidity, according to the Geriatric Index of Comorbidity, was found in 64.4% of the patients. Mean Metabolic Equivalents were 2.58±0.99. Switching to general anesthesia was required in one case. Intraoperative noradrenaline (0.17±0.12 mcg/kg/min) was required in 70.6%. Additional intravenous paracetamol or weak opioids were required in 23% and 2.2% of patients, respectively. No direct complications of TCSA were reported. Cardiac, respiratory and surgical complications occurred in 15.6%, 13.3% and 13.3% of patients, respectively. Delirium occurred in 14.4%. Hospital mortality was 5.6%. CONCLUSIONS: TCSA may be a valid alternative to general anesthesia in high-risk older patients undergoing major abdominal surgery. Further studies are needed to confirm its safety and benefits.

Fast track program in liver resection: a PRISMA-compliant systematic review and meta-analysis.

BACKGROUND: FT program (FT) is a multimodal approach used to enhance postoperative rehabilitation and accelerate recovery. It was 1st described in open heart surgery, then modified and applied successfully in colorectal surgery. FT program was described in liver resection for the 1st time in 2008. Although the program has become widely accepted, it has not yet been considered the standard of care in liver surgery. OBJECTIVES: we performed this systematic review and meta-analysis to evaluate the impact of using the FT program compared to the traditional care (TC), on the main clinical and surgical outcomes for patients who underwent elective liver resection. METHODS: PubMed/Medline, Scopus, and Cochran databases were searched to identify eligible articles that compared FT with TC in elective liver resection to be included in this study. Subgroup meta-analysis between laparoscopic and open surgical approaches to liver resection was also conducted. Quality assessment was performed for all the included studies. Odds ratios (ORs) and mean differences (MDs) were considered as a summary measure of evaluating the association in this meta-analysis for dichotomous and continuous data, respectively. A 95% confidence interval (CI) was reported for both measures. I was used to assess the heterogeneity across studies. RESULTS: From 2008 to 2015, 3 randomized controlled trials (RCTs) and 5 cohort studies were identified, including 394 and 416 patients in the FT and TC groups, respectively. The length of hospital stay (LoS) was markedly shortened in both the open and laparoscopic approaches within the FT program (P < 0.00001). The reduced LoS was accompanied by accelerated functional recovery (P = 0.0008) and decreased hospital costs, with no increase in readmission, morbidity, or mortality rates. Moreover, significant results were found within the FT group such as reduced operative time (P = 0.03), lower intensive care unit admission rate (P < 0.00001), early bowel opening (P ≤ 0.00001), and rapid normal diet restoration (P ≤ 0.00001). CONCLUSION: FT program is safe, feasible, and can be applied successfully in liver resection. Future RCTs on controversial issues such as multimodal analgesia and adherence rate are needed. Specific FT guidelines should be developed for liver resection.

Prevalence and clinical outcome of hepatic haemangioma with specific reference to the risk of rupture: A large retrospective cross-sectional study.

BACKGROUND: Prevalence and incidence of hepatic haemangioma are estimated from autopsy series only. Although benign and generally asymptomatic, hepatic haemangioma can cause serious complications. AIMS: The aim of the study was to assess the prevalence of hepatic haemangioma and to attempt to quantify the risk of major complications such as spontaneous rupture. METHODS: We retrospectively analyzed the radiology database of a Regional University Hospital over a 7-year period: the radiological records of 83,181 patients who had an abdominal computed tomography or magnetic resonance scan were reviewed. Diagnoses made at imaging were reviewed and related to clinical course. RESULTS: Hepatic haemangioma was diagnosed in 2071 patients (2.5% prevalence). In 226 patients (10.9%), haemangioma had diameter of 4 cm or more (giant haemangioma). The risk of bleeding was assessed on patients without concomitant malignancies. Spontaneous bleeding occurred in 5/1067 patients (0.47%). All 5 patients had giant haemangioma: 4 had exophytic lesions and presented with haemoperitoneum; 1 with centrally located tumour experienced intrahepatic bleeding. CONCLUSION: Giant haemangiomas have a low but relevant risk of rupture (3.2% in this series), particularly when peripherally located and exophytic. Surgery might be considered in these cases.

ALPPS Procedure for Extended Liver Resections: A Single Centre Experience and a Systematic Review.

AIM: To report a single-centre experience with the novel Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) technique and systematically review the related literature. METHODS: Since January 2013, patients with extended primary or secondary liver tumors whose future liver remnant (FLR) was considered too small to allow hepatic resection were prospectively assessed for the ALPPS procedure. A systematic literature search was performed using PubMed, Scopus and the Cochrane Library Central. RESULTS: Until July 2014 ALPPS was completed in 9 patients whose mean age was 60 ± 8 years. Indications for surgical resection were metastases from colorectal cancer in 3 cases, perihilar cholangiocarcinoma in 3 cases, intrahepatic cholangiocarcinoma in 2 cases and hepatocellular carcinoma without chronic liver disease in 1 case. The calculated FLR volume was 289 ± 122 mL (21.1 ± 5.5%) before ALPPS-1 and 528 ± 121 mL (32.2 ± 5.7%) before ALLPS-2 (p < 0.001). The increase in FLR between the two procedures was 96 ± 47% (range: 24-160%, p < 0.001). Additional interventions were performed in 4 cases: 3 patients underwent Roux-en-Y hepaticojejunostomy, and one case underwent wedge resection of a residual tumor in the FLR. The average time between the first and second step of the procedure was 10.8 ± 2.9 days. The average hospital stay was 24.1 ± 13.3 days. There was 1 postoperative death due to hepatic failure in the oldest patient of this series who had a perihilar cholangiocarcinoma and concomitant liver fibrosis; 11 complications occurred in 6 patients, 4 of whom had grade III or above disease. After a mean follow-up of 17.1 ± 8.5 months, the overall survival was 89% at 3-6 and 12 months. The recurrence-free survival was 100%, 87.5% and 75% at 3-6-12 months respectively. The literature search yielded 148 articles, of which 22 articles published between 2012 and 2015 were included in this systematic review. CONCLUSION: The ALPPS technique effectively increased the resectability of otherwise inoperable liver tumors. The postoperative morbidity in our series was high in accordance with the data from the systematic review. Age, liver fibrosis and presence of biliary stenting were predisposing factors for postoperative morbidity and mortality.

Immunological risk factors in biliary strictures after liver transplantation.

BACKGROUND: The purpose of this study was to investigate immunological risk factors associated with BS (Biliary Strictures) after LT (Liver Transplantation). MATERIAL AND METHODS: The study included 192 patients out of 273 adult liver transplantations performed from August 2005 to December 2012, with a radiological or surgically proven biliary stricture. About 35 potential risk factors for biliary strictures were studied. Results A biliary stricture was diagnosed in 22.9% of transplants; the anastomotic type and the non-anastomotic type complicated the transplantation in 18.2% and 7.8% of cases, respectively. Six patients (3.1%) presented both of forms. Univariate analysis using logistic regression showed that preoperative serum bilirubin level >2 mg/dl (P=0.040), donor age >46 years old (P=0.007), positive crossmatch (P=0.007), product of donor age and preoperative Model for End Stage Liver Disease (DMELD) >710 (P=0.011), occurrence of acute or chronic rejection (P=0.004; P=0.003), and biliary leak (P=0.002) were all significantly associated with the development of biliary stricture. At the multivariate analysis, Primary Biliary Cirrhosis (PBC) (P=0.019), donor age >46 years (P=0.008), crossmatch positivity (P=0.001), and acute or chronic rejection (P=0.005; P=0.043) appeared to be the only variables independently associated with the development of a biliary stricture. Conclusions Immunological risk factors (PBC, crossmatch positivity, acute and chronic rejection) emerged as being the most important variables associated to the development of biliary strictures after LT.

Metastatic breast cancer mimicking a hilar cholangiocarcinoma: case report and review of the literature.

BACKGROUND/AIMS: Breast cancer is the most common tumor in women and the first cause of death for malignancy in the female population. Bile ducts are not among the common sites of metastasis from breast cancer; few cases of obstructive jaundice due to metastatic breast cancer have been described in the literature and they mostly resulted from widespread liver metastases that eventually involved the bile ducts. We report an exceptional case of metastatic infiltration of the extrahepatic bile ducts in absence of liver metastases. CASE PRESENTATION: A 56-year-old woman who had undergone a right mastectomy 13 years earlier due to infiltrating ductal breast cancer and had remained tumor free, presented at a follow-up examination with obstructive jaundice.Imaging (computed tomography, magnetic resonance and endoscopic retrograde cholangiopancreatography) scans showed features that were suggestive of a primary tumor of the extrahepatic bile duct. At surgery, the intraoperative findings were also those of a tumor of the bile duct, however, an histological examination showed no evidence of malignancy in the mucosa, but did shown an infiltration of the external wall from adenocarcinoma. Immunohistochemistry analysis demonstrated that the tumor was metastatic breast cancer. CONCLUSIONS: Indeterminate stenosis of the extrahepatic bile ducts should be examined with suspicion in women with a history of breast cancer, and bile duct metastases are to be considered among the possible diagnoses. A differential diagnosis from cholangiocarcinoma is of paramount importance and mainly relies on pathology.