Lessons learned from 227 biological meshes used for the surgical treatment of ventral abdominal defects.

PURPOSE: The advantages of biological meshes for ventral hernia repair are still under debate. Given the high financial cost, the proper indications for biological meshes should be clarified to restrict their use to properly selected patients. METHODS: A retrospective database was instituted to register all cases of abdominal wall defect treated with biological meshes from 1/2010 to 3/2016. RESULTS: A total of 227 patients (mean age: 64 years) whose ventral abdominal defects were reconstructed with a biological mesh were included in the study. Patients were divided according to the 2010 four-level surgical-site complication risk grading system proposed by the Ventral Hernia Working Group (VHWG): Grade 1 (G1, 12 cases), Grade 2 (G2, 68 cases), Grade 3 (G3, 112 cases), and Grade 4 (G4, 35 cases). The surgical site complication rate was higher in patients with one or more risk factors (33.6% vs 19% in patients with no risk factors) (P = 0.68). Statistically significant risk factors associated with the onset of one or more postoperative surgical site complications included: diabetes, coronary artery disease, immunosuppression, and obesity. Recurrence was more common in patients with surgical site complications and mainly associated with infection (38.9%) and wound necrosis (44.4%), and in cases of inlay positioning of the mesh (36%). CONCLUSIONS: Due to their high costs, biological mesh should not be used in G1 patients. In infected fields (G4), they should only be used if no other surgical solution is feasible. There is a clear need to prospectively evaluate the performance of biological meshes.

Abdominal aortic aneurysm in liver transplant recipients.

BACKGROUND AND AIMS: To analyze the incidence, clinical features, expansion rate of, and clinical approach to abdominal aortic aneurysm in patients who had undergone orthotopic liver transplantation. To our knowledge, this is the first report on this issue in liver transplant recipients. PATIENTS/METHODS: Among 172 patients undergoing 185 liver transplantations at our institution over the last 10-year period, we identified three patients (1.7%) with infrarenal aortic aneurysm. They had all undergone routine pre-liver transplant ultrasonography screening for aortic aneurysm. RESULTS: All three patients were symptom free at the time of the discovery of a mild infrarenal abdominal enlargement before ( n=2) and after liver transplantation ( n=1), and were closely monitored by ultrasonography in the follow-up period (3.1-4.3 years). The mean aneurysm expansion rate was 0.73 cm/year. All patients underwent aneurysm repair after their aneurysm expanded significantly under observation, with a mean diameter of 5.1 cm at the time of repair. All three patients are alive and well (median follow-up: 19 months). CONCLUSIONS: Our data suggest that careful ultrasonographic surveillance is warranted in any liver transplant recipient, because of the apparent propensity for a more rapid aneurysm expansion and potentially aggressive course than in the untransplanted population. Early repair of the infrarenal aneurysm is recommended in transplant recipients, given that excellent perioperative and late outcomes can be achieved.

Liver transplantation with vena cava in situ and selective use of temporary portacaval shunt or portal clamping.

BACKGROUND/AIMS: The recipient hepatectomy with vena cava in situ in liver transplantation has overcome the need of venous-venous bypass thanks to temporary porta caval shunt or portal clamping. METHODOLOGY: 150 orthotopic liver transplants in 137 patients were performed and the vena cava in situ technique was used in 142 (venous bypass in 7, temporary porta caval shunt in 49, portal clamping in 87). The suprahepatic cava veins anastomosis was performed with Belghiti in 97 and piggyback techniques in 45. RESULTS: There were no differences in operative and warm ischemia times nor in blood requirements, while a greater stability of body temperature was documented in the vena cava In Situ group: in the latter temporary porta caval shunt preserved the temperature better than portal clamping (P < 0.01). In anhepatic phase mean artery pressure decreased in veno-venous bypass and increased in the vena cava In situ groups (P < 0.01). The venous return and the cardiac performances (anhepatic phase) were better preserved in the vena cava In Situ group. (P < 0.0001). CONCLUSIONS: Temporary portal caval shunt or portal clamping and piggyback or Belgiti Techniques allow a better hemodynamic stability through out the procedure, obviating the need for veno-venous bypass or fluid overload, if selectively used.

Role of transarterial chemoembolization before liver resection for hepatocarcinoma.

The aim of this study was to clarify whether chemoembolization (TACE) before liver resection (LR) can reduce postoperative hepatocellular carcinoma (HCC) recurrence and improve disease-free and overall survival. Eighty-nine patients with tumor-stage (TNM) I-II HCC were evaluated for LR. Patients were prospectively allocated to LR alone or TACE plus LR based on their place of residence. Twenty nonlocal patients (24%) were selected for LR, while 69 (77.5%) local patients were selected for TACE plus LR. Following TACE, the tumor stage could be confirmed in only 20 patients (29%) who then underwent LR. Operative mortality was 0%, but in the TACE-LR group, 3 patients died of liver failure between 2 and 5 months after surgery. Early recurrence (<24 months) was 59% for LR versus 20% for TACE plus LR (P <.05). Late recurrence was 18% for LR versus 10% for TACE plus LR (P = not significant [NS]). The overall recurrence rate was 76% for LR versus 30% for TACE plus LR (P <.02). Death due to HCC recurrence was 70% for LR versus 15% for TACE plus LR (P <.05). The overall 1- and 5-year survival rates did not differ significantly (71% to 38% for LR v 85% to 43% for TACE + LR; P = NS), whereas the difference in 1- and 5-year disease-free survival was highly significant (64% to 21% for LR v 82% to 57% for TACE + LR; P <.02). TACE was able to improve the HCC staging process and significantly reduce the incidence of early and overall HCC recurrence and related death after LR; it improved the disease-free interval, but not the overall survival, due to an increase in liver failure in the first 5 months.

Laparoscopic surgery after orthotopic liver transplantation.

Laparoscopic surgery is currently a widely accepted approach to several surgical fields because of its advantages in terms of postoperative pain reduction and easy patient recovery. This approach may be useful even in solid-organ transplantation surgery as a diagnostic or treatment procedure in some surgical complications. From July 1991 to December 1998, we performed 142 liver transplantations on 129 patients. During the postoperative period, many complications occurred. Here we report two cases of intestinal occlusion caused by adhesions and three cases of lymphocele, all approached with laparoscopic surgery. In all cases but one, we were able to complete the surgery by laparoscopic means; in one of the two occlusions, the procedure was switched to laparotomy because of a choledochojejunal anastomosis lesion. The three cases of lymphocele must be considered in a particular manner because such cases, to our knowledge, have never been described in the literature. They always presented with a late-onset right pleural effusion and were located in the retrohepatic, retrogastric, and left paracaval areas, close to the esophageal hiatus. In conclusion, we believe a laparoscopic approach is a useful strategy to solve some surgical complications in patients who underwent orthotopic liver transplantation; however, the use of laparoscopic surgery in this field is strictly connected to the surgeon's experience and versatility.

Reversal of type 1 hepatorenal syndrome with the administration of midodrine and octreotide.

The aim of the study was to verify the effects of the administration of an inhibitor of the release of endogenous vasodilators together with a vasoconstrictor agent in patients with hepatorenal syndrome (HRS). This new medical perspective was compared with a traditional medical approach for HRS, such as the infusion of nonpressor doses of dopamine to produce renal vasodilation. Thirteen patients with type 1 HRS were enrolled in the study. Five of them were treated with the oral administration of midodrine and the parenteral administration of octreotide. In addition, the patients received 50 to 100 mL of 20% human albumin solution daily for 20 days. Midodrine and octreotide were dosed to obtain a stable increase of at least 15 mm Hg of mean arterial pressure. Eight patients were treated with the intravenous administration of nonpressor doses of dopamine (2-4 micrograms/kg/min) and the same daily amount of albumin. After 20 days of treatment with midodrine and octreotide, an impressive improvement in renal plasma flow (RPF), glomerular filtration rate, and urinary sodium excretion was observed in patients. This was accompanied by a significant reduction in plasma renin activity, plasma vasopressin, and plasma glucagon. No side effects were observed. Three patients were discharged from the hospital. One of them successfully underwent liver transplantation. One of the two remaining patients is still alive after 472 days with a preserved renal function, and the other died from terminal liver failure after 76 days. One of the two patients who were not discharged from the hospital successfully underwent liver transplantation, and the other died from pneumonia after 29 days. Seven out of eight patients who were treated with dopamine experienced a progressive deterioration in renal function and died during the first 12 days. Only one patient recovered renal function and underwent liver transplantation. In conclusion, the long-term administration of midodrine and octreotide seems to be an effective and safe treatment of type 1 HRS in patients with cirrhosis.

Cerebral aspergillosis in a liver transplant recipient: a case report of long-term survival after combined treatment with liposomal amphotericin B and surgery.

Cerebral aspergillosis is a life-threatening complication in liver transplant recipients, with mortality rates approaching 100%; treatment with amphotericin B is of limited efficacy because of its poor distribution in the cerebrospinal fluid and its systemic side effects. We report the case of a liver transplant recipient who developed recurrent cerebral Aspergillus fumigatus infection, and was successfully treated by combined surgical excision of the lesion and administration of liposomal amphotericin B. This first report of long-term complication-free survival in a liver transplant recipient suggests that therapy with liposomal amphotericin B may reduce the risk of recurrence of cerebral aspergillosis in these immunocompromised patients.

Splenic impedance indices: a useful method to monitor patients after liver transplantation?

Splenic Doppler impedance indices are influenced, in portal hypertensive patients, by the resistance of the portal system. The aim of the study was to verify the usefulness of these indices in evaluating the presence of a pathological increase in portal resistance in patients with complications after liver transplantation. Splenic impedance indices have been evaluated in 46 patients before orthotopic liver transplantation (OLT), and 2 days, 1, 4, 8, and 12 to 18 months after transplantation. The results showed that spleen size slowly decreased after liver transplantation. From a baseline longitudinal diameter value of 18.0+/-3.6 cm (M+/-SD), the decrease was by 0%+/-3%, 8%+/-8%, 13%+/-9%, 15%+/-11%, and 14%+/-11% at 2 days and 1, 4, 8, and 12 to 18 months after liver transplantation. Splenic impedance indices-resistance index = (peak systolic - end diastolic) / peak systolic velocity; pulsatility index = (peak systolic - end diastolic) / mean velocity-which were increased before liver transplantation, showed a rapid decrease to normal values: resistance index: from 0.62+/-0.08 to 0.55+/-0.08 after 2 days, and to 0.49+/-0.09, 0.51+/-0.10, 0.54+/-0.10, 0.55+/-0.11 after 1, 4, 8, 12-18 months; pulsatility index: from 0.96+/-0.21 to 0.82+/-0.17 after 2 days, and to 0.69+/-0.19,0.72+/-0.21, 0.81+/-0.26, 0.84+/-0.26 after 1, 4, 8, and 12 to 18 months. Patients who had a good outcome, without any major complications, showed a clear and steady decrease in splenic impedance indices. On the contrary, patients who had complications affecting portal resistance (e.g., acute rejection, relapse of chronic hepatitis C virus-related hepatitis or cirrhosis, stenosis of portal anasthomosis, portal thrombosis), showed a lack of decrease, or, after an initial decrease, a subsequent re-increase in splenic impedance indices to pathological values. Splenic impedance indices measured in patients with complications were higher than those of patients without complications (P < .0004). Specificity and sensitivity of splenic impedance indices in the evaluation of the presence of complications increasing portal resistance were good. In conclusion, after OLT, splenic impedance indices could be useful aspecific parameters for identifying patients with complications that are able to affect or increase portal resistance.

Epstein-Barr virus-associated post-transplant lympho-proliferative disease of donor origin in liver transplant recipients.

BACKGROUND/AIMS: Post-transplant lymphoproliferative disease, a potential complication of solid organ transplantation, occurs in about 3% of orthotopic liver transplant recipients. We report the genetic and virological characterization of two cases of post-transplant lymphoproliferative disease that occurred early (4 and 6 months) after orthotopic liver transplant as large-cell non-Hodgkin's lymphomas located at the hepatic hilum. METHODS: Lymphomatous tissues were analyzed for clonality and presence of Epstein-Barr virus (EBV) sequences by Southern blot, polymerase chain reaction, and in situ hybridization techniques. RESULTS: The tumors in both cases were sustained by a clonal proliferation of B lymphocytes containing type A EBV DNA. Moreover, in situ hybridization with a digoxigenin-labeled EBV-specific probe evidenced a strong nuclear signal in most of the neoplastic cells. DNA microsatellite analysis at three different loci detected alleles of donor origin in both tumor samples, suggesting that the neoplastic B cells were of donor origin. CONCLUSIONS: EBV-infected donor B lymphocytes might be responsible for intragraft post-transplant lymphoproliferative disease in orthotopic liver transplant recipients. As 20 to 30% of post-transplant lymphomas involve the graft itself, donor-derived post-transplant lymphoproliferative disease might be more frequent than presently appreciated. Prospective studies are needed to assess its real incidence and identify possible risk factors.

Pancreatic cancer and retroperitoneal neural tissue invasion. Its implication for survival following radical surgery.

To analyze the implication of retroperitoneal perineural lymphatic infiltration (rpli) for the survival of patients affected by exocrine pancreatic cancer, we considered 17 cases which underwent radical resection at our Institute from 1980 to 1993. Histology of specimens showed an rpli in 15 cases, without any correlation between this anatomopathologic aspect and the neoplasm size or the presence of lymph node metastases. The 2 patients without rpli are both alive and have been free from disease during a follow-up period of more than 5 years. In the group of 15 patients with positive rpli, 3 (21.4%) have remained free from disease (2 alive and 1 dead for other reason). Eleven remained with disease (1 is alive and 10 have died). One died in the postoperative period and could not be included in the evaluation. These observations have led the surgeon to consider the necessity, during resection, of an accurate dissection not only of the regional lymph nodes but also of the retropancreatic tissue and the neural structures present in this area. This approach may lead to a more correct staging of the neoplasia, a better radical surgery and perhaps a longer survival. Moreover it may represent an important marker for an adjuvant protocol of chemotherapy and/or radiotherapy.

Implication of laparoscopy and peritoneal cytology in the staging of early pancreatic cancer.

Staging of pancreatic cancer still represents a challenge for surgeons involved in this field. Diagnostic methods of radiological imaging used routinely (CT, NMR, angiography) may understage this neoplasm. In fact, the presence of peritoneal or subglissonian hepatic micrometastases (< 2 cm) is a frequent surprise at laparotomy and forces the surgeon to use a palliative procedure. Actually this policy has not to be followed because the possibility to perform non-surgical palliation of jaundice or pain respectively by percutaneous radiological stent insertion and celiac alcoholization. In this viewpoint, preoperative staging has acquired an important role for a correct treatment, be it surgical or medical. Laparoscopy allows it to overcome the understaging produced by the more common diagnostic means, with the possibility to view directly the celomatic space and the surface of the abdominal viscera; moreover, during this procedure it is possible to perform a peritoneal washing to obtain other information about the cancer stage. In our experience, 56 patients were judged as resectable by radiologic methods; 31 were excluded from surgery by laparoscopy; 10 of the remaining 25 cases were submitted to radical resection. The operative resectability rate resulted in 40%, against 18% in cases where we submitted to surgery all the patients. Seven patients underwent peritoneal washing, always with a negative result; all were submitted to surgery and radically resected. In our opinion, laparoscopy and peritoneal washing represent useful tools in the staging of patients affected by pancreatic cancer.

[The palliative treatment of hepatocarcinoma: chemoembolization vs. the combination of tamoxifen plus beta-interferon]. / Il trattamento palliativo dell'epatocarcinoma: la chemoembolizzazione vs l'associazione tamoxifene più beta-interferon.

Clinical and experimental data show that beta-IFN enhances the effect of tamoxifen on advanced breast cancer. There is a similarity between breast and liver as far as the proliferating effect on normal and neoplastic tissue of estrogen and progestin receptors is concerned. The authors tested this pharmacological association in unresectable liver neoplasms. They considered 76 (not randomized) patients affected with HCC; 38 were treated by trans-arterial chemoembolization (TACE) and 38 to beta-INF and tamoxifen (the 2 groups were comparable according to age, sex, Child-Pugh score, Okuda and TNM stages, cirrhosis etiology). The treatment response (positive when a tumor diameter decreased or stabilization was observed) was similar in the two groups; in the TACE group, the presence of a peritumoral capsula had a significant influence on survival (p < 0.02); on the other hand, in the patients treated with beta-INF and tamoxifen important factors for a better prognosis were the TNM stage (I and II, p < 0.02) and a symptom-free condition (p < 0.04). The authors believe the beta-INF and tamoxifen treatment could represent an effective alternative in the management of unresectable HCC. A better knowledge of the presence and meaning of estrogen and progestin receptors in the neoplastic tissue may allow a better selection of patients.

[The role of laparoscopy and peritoneal cytology in the preoperative staging of pancreatic carcinoma]. / Il ruolo della laparoscopia e della citologia peritoneale nella stadiazione pre-operatoria del carcinoma pancreatico.

The staging of pancreatic cancer still represents a challenge for surgeons involved in this field; radiological diagnostic methods used routinely (CT, NMR, angiography) may under-estimate this neoplasm; in fact, the presence of peritoneal or subglissonian hepatic micrometastasis (< 2 cm) is a frequent surprise at laparotomy and force the surgeon to undertake a palliative procedure. This policy need not be followed because it is possible to perform non-surgical palliation of jaundice or pain respectively by percutaneous radiological stent insertion and coeliac alcoholisation. Pre-operative staging thus acquires an important role in the correct treatment, surgical or medical. Laparoscopy allows us to overcome the understaging of the more common diagnostic methods and view directly the coelomatic space and the surface of the abdominal viscera; moreover during this procedure it is possible to perform a peritoneal wash to obtain other information on the cancer stage. We judged 56 patients by radiological diagnosis; 31 were excluded from surgery by laparoscopy; 10 of the other 25 cases were submitted to radical resection. The resectability operative rate was 40%, compared with 18% if we had submitted patients to surgery. Several patients underwent peritoneal wash, always with negative results; all were submitted to surgery and radically resected. In our opinion, laparoscopy and peritoneal wash represent useful tools in the staging of patients affected with pancreatic cancer.

Sex hormones and trace elements in rat CCL4-induced cirrhosis and hepatocellular carcinoma.

Several biochemical events accompany and mediate the development of chronic liver disease and its evolution into cancer. Low plasma zinc and high copper levels have been observed in various liver diseases, such as liver cirrhosis and viral hepatitis, while increased oestradiol levels have been documented in chronic liver damage and hepatocellular carcinoma. We administered CCL4 intragastrically to 10 female Sprague Dawley rats for 30 weeks. All animals developed cirrhosis and four also developed hepatocellular carcinoma. Plasma levels of zinc, copper and oestradiol were significantly higher in the latter group than in animals with simple cirrhosis. Progesterone, AST and bilirubin showed a trend toward significant differences whereas testosterone and ALP levels were unchanged. These findings add to the evidence that sex hormones and trace elements are involved in the process of the development of chronic liver damage and carcinogenesis.

Selective variceal decompression and its role relative to other therapies.

Seventy patients, selected from 265 patients with proved variceal bleeding, underwent a distal splenorenal shunt (DSRS) procedure with or without splenopancreatic disconnection (SPD). Alcoholic cirrhosis was the cause of portal hypertension in 57% of the patients. The operative mortality was 13% (Child's classes A and B 2%, class C 66%). Despite fewer varices in all of the patients, variceal rebleeding and death occurred in one patient (2%). Late portal perfusion was observed in 91% of the patients, with worsening in 23%, compared with the preoperative study. Persistent hepatocyte necrosis and incomplete SPD were the most significant prognostic factors for decreased perfusion (presence and absence of necrosis, 38% and 12%, respectively; DSRS and DSRS with SPD, 43% and 12%, respectively). SPD also decreased ongoing hepatocyte damage. Post-shunt encephalopathy was clinically evident in 7% of the patients, but after electroencephalographic evaluation, it increased to 24.6%. Significant factors in its development included decreased portal perfusion (62% versus 14%), active hepatitis (48% versus 17%), and incomplete SPD (43% versus 14%). The higher late liver-related mortality was associated with a lack of or decreased portal perfusion and the absence of SPD.

The role of the leukocyte adherence inhibition (LAI), CA 19-9, and tissue polypeptide antigen (TPA) tests in the diagnosis of pancreatic cancer.

The leukocyte adherence inhibition (LAI) assay measures host cell-mediated tumor immunity. The original test used by Halliday and Miller was modified by substituting tissue extracts with purified tumor antigens (gastrointestinal cancer antigen [GICA]) with the aim of reducing false-positive results in the diagnosis of patients with early pancreatic cancer. By our modified technique, the LAI assay identified four of five pancreatic cancers at an early stage and gave only one false-positive result in 16, showing a sensitivity of 80% and a specificity of 94%. Later stages of the disease responded poorly on the test. These results were significantly better than those by the CA 19-9 and tissue polypeptide antigen (TPA) tests. Should our findings be confirmed in larger material over a longer follow-up period, the LAI test could be proposed as a useful tool in the early diagnosis of pancreatic cancer.

[The L.A.I. test and tumor markers (Ca 19-9 and TPA) in the diagnosis of pancreatic carcinoma]. / L.A.I. test e markers tumorali (Ca 19,9 e TPA) nella diagnosi del carcinoma pancreatico.

A particular cell-mediated immune response is tested in this work: the leukocyte adherence inhibition (L.A.I.) in the presence of organ tumor antigens. Forty-two patients suspected of having pancreatic cancer were submitted to the L.A.I. test and Ca 19.9 and TPA determination. The diagnosis of pancreatic cancer was eventually surgically confirmed and staged in 30 patients. The most important features of the L.A.I. test were good specificity (94%) and the ability to diagnose stage I cancers (3/4 cases, 75%), while the other markers are more likely to diagnose more advanced stages. The L.A.I. test seems to be also useful during the follow-up period since its positivity may even be some months previous to the clinical symptoms. During follow-up the L.A.I. test proved useful in supervising the neoplastic disease course from the moment of relapse to advanced clinical symptoms.