Liver retransplantation in adults: the largest multicenter Italian study.

This study is the largest Italian survey on liver retransplantations (RET). Data report on 167 adult patients who received 2 grafts, 16 who received 3 grafts, and one who received 4 grafts over a 11 yr period.There was no statistically significant difference in graft survival after the first or the second RET (52, 40, and 29% vs 44, 36, and 18% at 1,5,and 10 yr, respectively: Log-Rank test, p = 0.30).Survivals at 1, 5, and 10 years of patients who underwent 2 (n = 151) or 3 (n = 15) RETs, were 65, 48,and 39% vs 59, 44, and 30%, respectively (p = 0.59).Multivariate analysis of survival showed that only the type of graft (whole vs reduced) was associated with a statistically significant difference (HR = 3.77, Wald test p = 0. 05); the donor age appeared to be a relevant factor as well, although the difference was not statistically significant (HR = 1.91, Wald test p = 0.08).Though late RETs have better results on long term survival relative to early RETs, no statistically significant difference can be found in early results, till three years after RET.Considering late first RETs (interval>30 days from previous transplantation) with whole grafts the difference in graft survival in RETs due to HCV recurrence (n = 17) was not significantly different from RETs due to other causes (n = 53) (65-58 and 31% vs 66-57 and 28% respectively at 1-5 and 10 years, p = 0.66).

Improvement in perioperative and long-term outcome after surgical treatment of hilar cholangiocarcinoma: results of an Italian multicenter analysis of 440 patients.

OBJECTIVE: To evaluate improvements in operative and long-term results following surgery for hilar cholangiocarcinoma. DESIGN: Retrospective multicenter study including 17 Italian hepatobiliary surgery units. PATIENTS: A total of 440 patients who underwent resection for hilar cholangiocarcinoma from January 1, 1992, through December 31, 2007. MAIN OUTCOME MEASURES: Postoperative mortality, morbidity, overall survival, and disease-free survival. RESULTS: Postoperative mortality and morbidity after liver resection were 10.1% and 47.6%, respectively. At multivariate logistic regression, extent of resection (right or right extended hepatectomy) and intraoperative blood transfusion were independent predictors of postoperative mortality (P = .03 and P = .006, respectively); in patients with jaundice, mortality was also higher without preoperative biliary drainage than with biliary drainage (14.3% vs 10.7%). During the study period, there was an increasingly aggressive approach, with more frequent caudate lobectomies, vascular resections, and resections for advanced tumors (T stage of 3 or greater and tumors with poor differentiation). Despite the aggressive approach, the blood transfusion rate decreased from 81.0% to 53.2%, and mortality slightly decreased from 13.6% to 10.8%. Median overall survival significantly increased from 16 to 30 months (P = .05). At multivariate analysis, R1 resection, lymph node metastases, and T stage of 3 or greater independently predicted overall and disease-free survival. CONCLUSIONS: Surgery for hilar cholangiocarcinoma has improved with decreased operative risk despite a more aggressive surgical policy. Long-term survival after liver resection has also increased, despite the inclusion of cases with more advanced hilar cholangiocarcinoma. Preoperative biliary drainage was a safe strategy before right or right extended hepatectomy in patients with jaundice. Pathologic factors independently predicted overall and disease-free survival at multivariate analysis.

Liver resection for noncolorectal and nonneuroendocrine metastases: results of a study on 56 patients at a single institution.

The usefulness of surgical treatment for hepatic metastases of noncolorectal nonneuroendocrine (NCRNNE) tumors is not yet clear due to the natural history of these tumors, their frequent systemic dissemination and their histological heterogeneity. The aim of this study was to evaluate the long-term outcome of patients who underwent liver resection for NCRNNE metastases. For this purpose we retrospectively analyzed 202 patients who underwent liver resection for metastasis between January 1989 and December 2006 at the Department of Surgery of the University Hospital of Udine. Fifty-six patients underwent liver resection because of NCRNNE metastases. The preoperative assessment was based on hepatic ultrasonography and CT scan; PET was used in a few patients. All patients had intraoperative liver ultrasonography to evaluate the lesions and to define the resection. Gender, age, primary tumor site (gastrointestinal or nongastrointestinal), synchronous or metachronous metastasis, unilobar or bilobar localization, number and diameter of the lesion(s), type of resection, margin status, positive lymph nodes in the hepatoduodenal ligament, and time between surgery and diagnosis of liver metastases were evaluated as possible prognostic factors for survival. Univariate analysis showed that the location of the primary tumor and the disease-free interval since the treatment of the primary tumor were positive predictive factors for longer survival. Multivariate analysis showed that the only independent significant factor was gastrointestinal versus nongastrointestinal origin. Demographic data, the synchronous or metachronous appearance of metastases, their unilobar or bilobar location, number and size, the type of resection, the resection margin status and the involvement of lymph nodes did not prove to be prognostic factors.

Incidental pancreatic cysts on 3D turbo spin echo magnetic resonance cholangiopancreatography: prevalence and relation with clinical and imaging features.

PURPOSE: To estimate the prevalence of incidental pancreatic cysts (IPCs) in asymptomatic patients addressed to magnetic resonance cholangiopancreatography (MRCP), and to correlate it with clinical and imaging features. MATERIALS AND METHODS: Magnetic resonance cholangiopancreatography performed over 26-months on 152 patients with unsuspected/unknown pancreatic disease were reviewed to assess IPCs' features of presentation. Multivariate analysis was performed to evaluate the correlation of IPCs with clinical information and type of pancreaticobiliary findings at MRCP. RESULTS: Prevalence of IPCs was 44.7%. Cysts sized 3-24 mm (mean, 6.08 mm), and were ≤4 in number in 83.8% of patients. Based on number, dimensions and relation with the main pancreatic duct, IPCs presented with intraductal-papillary-mucinous neoplasm (IPMN)-like or indeterminate patterns in 31.7% and 13.1% of patients, respectively. At follow-up on 24 patients, no evolution was found, except in one patient with proven IPMN showing increase in cysts number and dimensions (evolution rate of 4.1%). Features correlating with IPCs were age ≥60 years old, and history of autoimmune hepatobiliary disease, showing odds ratios of 5.95 (95% CI 2.77-12.79) and 0.13 (95% CI 0.04-0.44), respectively. CONCLUSIONS: Incidental pancreatic cysts represent a frequent finding at MRCP, correlating positively with increasing age, and negatively with biliary autoimmune disease. Cysts more frequently present with IPMN-like pattern.

Steatosis of the hepatic graft as a risk factor for post-transplant biliary complications.

BACKGROUND: Despite recent advances in organ preservation, immunosuppression, and surgical techniques, the biliary tree is still considered the Achilles' heel of liver transplantation. The aim of this study is to retrospectively analyze the incidence of biliary complications and identify risk factors that might predispose to the development of biliary problems. METHODS: From January 2004 to December 2007, 117 consecutive liver transplantations were retrospectively analyzed for the development of biliary complications by the review of medical records. Patients were divided into group 1 with biliary complications (n = 43) and group 2 without biliary complications (n = 74). RESULTS: The overall biliary complication rate was 36.8% (leakage 6% and stricture 30.8%). Univariate analysis indicated that significant predictors of biliary complications were the time interval between portal and arterial reperfusion (p = 0.037) and macrovacuolar steatosis of the graft > 25% (p = 0.004). Stepwise logistic regression model demonstrated that a macrosteatosis of the graft > 25% (OR = 5.21 CI 95% [1.79-15.15], p = 0.002) was the only independent risk factor predicting biliary complications after liver transplantation. No differences in patient's and graft's survival were noted between the two groups. CONCLUSION: According to our experience, transplanting a liver with > 25% of steatosis is a risk factor for the development of biliary complication.

[Lack of prognostic predictive value of hepatic agobiopsy in a group of patients operated of hepatic resection for hepatocellular carcinoma]. / Mancanza di valore prognostico predittivo dell'agobiopsia epatica sull'outcome di una serie consecutiva di pazienti resecati per epatocarcinoma.

AIM: To determine prior to surgery whether a fine needle biopsy is able to define a hepatocellular carcinoma grading, or not. MATERIAL OF STUDY: Thirty patients, who all underwent liver resection for HCC. In every case a fine needle biopsy of the neoplasm was taken prior to surgery, and after the operation a complete microscopic assessment of tumor grade according to Edmondson and Steiner classification was taken. RESULTS: We found no correlation between fine needle biopsy grading and post surgical one. We also found no correlation between fine needle grading and other relevant elements, alpha-fetoprotein levels and number of neoplastic nodules. DISCUSSION: Considering the small number of patients in the study, fine needle biopsy seems to be unfit to determine HCC grading before surgery, this is probably due to the different levels of neoplastic differentiation present into every single nodule and to the characteristics of Edmondson and Steiner classification. In Literature there is at least one study, similar to ours, showing problems in the correct attribution of grading level using this classification. Other authors consider the possibility to modify the scale from a 4-levels one to a 3-levels one. CONCLUSIONS: In spite of these discouraging results, and with a strict follow up monitoring any tumor seeding, we think fine needle biopsy is still fundamental for controversial cases, and for new studies on hepatocellular carcinoma, like those over vascular invasion or the molecular profile of the neoplasm.

Postoperative complications linked to pancreaticoduodenectomy. An analysis of pancreatic stump management.

AIMS: To analyze the role of different procedures in the management of pancreatic stump according to the incidence of postoperative morbidity derived from the data of a single center surgical population. METHODS: From 1989 to 2005 we performed 76 pancreaticoduodenectomies (PD) and 26 distal pancreatectomies (DP). The surgical reconstruction after PD was as follows: 11 manual non-absorbable stitches closure of the main duct, 24 closures of the main duct with linear stapler, 17 occlusions of the main duct with neoprene glue and 24 duct-to-mucosa anastomosis. RESULTS: In the PD group, the morbidity rate was 60%, caused by: pancreatic leakage in 48% of patients, hemorrhagic complications in 10% following surgical procedure and infectious complications in 15%. After DP we recorded: leakage in 3.9%, haemoperitoneum in 15.4% and no complications in 80.7%. The multivariate analysis showed that the in-hospital mortality was linked to the surgical procedure (PD, p=0.003) and to the following complications: pancreatic leakage (p=0.004), haemoperitoneum (p=0.00045) and infectious complications (p=0.0077). Bleeding complications, biliary anastomosis leakage and infectious complications were consequences of pancreatic leakage (p=0.025, p=0.025 and p=0.025 respectively). CONCLUSION: Manual non-absorbable stitch closure of the main duct and occlusion of the main duct with neoprene glue should be avoided in the reconstructive phase.

Minimally invasive esophagectomy: a comparative study of transhiatal laparoscopic approach versus laparoscopic right transthoracic esophagectomy.

BACKGROUND: The development of minimally invasive surgery gave birth to an interest in a mini-invasive approach to esophageal cancer; however, it is still considered to be one of the most complex gastrointestinal surgical operations, and many questions still remain unanswered, regarding the oncologic results of a mini-invasive approach in long-term follow-ups. Here, the authors report on the short-term and long-term results of a series of laparoscopic esophagectomies. PATIENTS AND METHODS: From January 2002 to March 2006, 22 nonrandomized patients were recruited to undergo an esophagectomy for neoplastic disease. The esophagectomy and esophagogastroplasty were carried out using the laparoscopic transhiatal technique in 9 patients; whereas, a combined laparoscopic and right-transthoracic incision was performed in the other 13 patients. RESULTS: The mean follow-up was 21+/-3.23 months (mean+/-SD); range, 2 to 46 months. The overall survival rate resulted 84.0% at 12 months, 61.3% at 24 months, and 51.0% at 36 months. The proportions of cumulative survival showed significant differences when the following variables were considered: site of neoplasm (lower esophagus), American Society of Anesthesiologists 2, chronic obstructive pulmonary disease, type of surgical procedure, and inclusion in neoadjuvant protocol and staging. Recurrence rates were 3 (25%) in the radio-chemotherapy-treated group, and 5 (50%) in the primary surgery group (P=n.s.). CONCLUSIONS: The two-year survival rates (61.3%) recorded in our series are comparable with those reported in other series of both laparoscopic and open surgeries. The logical conclusion was that a less invasive procedure did not imply a less curative one.

Superiority of transplantation versus resection for the treatment of small hepatocellular carcinoma.

The best therapy for hepatocellular carcinoma (HCC) is still debated. Hepatic resection (HR) is the treatment of choice for single HCC in Child A patients, whereas liver transplantation (LT) is usually reserved for Child B and C patients with single or multiple nodules. The aim of this study was to compare HR and LT for HCC within the Milan criteria on an intention-to-treat basis. Forty-eight patients were treated by LT and 38 by HR. The median time on the waiting list for transplantation was 118 days. The estimated overall survival was significantly higher (P = 0.005) in the LT group than in the HR one. The estimated freedom from recurrence was also significantly higher (P < 0.0001) for LT patients than for HR ones. Indeed, the probability of HCC recurrence after resection was higher than after transplantation achieving 31% and 76% for HR and 2% and 2% for LT at 3 and 5 years after surgery. Multivariate analysis confirmed that transplantation was superior to resection in terms of patient's survival and risk of HCC recurrence. We conclude that LT is superior to HR for small HCC in cirrhotic patients assuming that LT should be performed within 6-10 months after listing to reduce the dropouts for reasons of tumor progression.

The role of pancreatic leakage on rising of postoperative complications following pancreatic surgery.

INTRODUCTION: The variations in methods of pancreatic stump management and the volume of literature available on both main pancreatic duct and pancreaticoenetric anastomosis leak indicates the concern associated with the leak and the continuing efforts to prevent it. Herein we analyzed the role of pancreatic leakage followed by pancreatic surgery on the incidence of postoperative morbidity. PATIENTS AND METHODS: From 1989 to 2005, we performed 76 pancreaticoduodenectomy (PD) and 26 distal pancreatectomy (DP), assumed as control case). During DP the parenchymal transection was performed with a linear stapler. The surgical reconstruction after PD was as follows: 11 manual nonabsorbable stitch closure of the main duct, 24 closure of the main duct with linear stapler, 17 temporary occlusion of the main duct with neoprene glue, and 24 duct-to-mucosa anastomosis. RESULTS: In the PD group, morbidity rate was 60%, caused by pancreatic leakage, with an incidence of 48%, hemorrhagic complication, occurred in 10% of patients following surgical procedure and infectious complication, with an incidence of 15%. After distal pancreatectomy we recorded 80, 7% no complications, 3, 9% leakage, 15, 4% hemoperitoneum. By multivariate analysis bleeding complications, biliary anastomosis leakage, and infectious complications were consequences of pancreatic leakage (P = 0.025, P = 0.025, and P = 0.025, respectively). A significant statistical difference was recorded analyzing re-operation rates between closure of the main duct with linear stapler versus temporary occlusion of the main duct with neoprene glue (t = 0.049) and closure of the main duct with linear stapler versus duct-to-mucosa anastomosis (t = 0.003). CONCLUSIONS: On the ground of our results of bleeding complication, biliary anastomosis leakage and infectious complication were consequences of pancreatic leakage: failure of a surgical anastomosis has serious consequences, particularly in case of anastomosis of the pancreas to the small bowel, because of the digestive capacities of activated pancreatic secretions.

Treatment of perforation in the healthy esophagus: analysis of 12 cases.

BACKGROUND: Perforation of the esophagus still carries high morbidity and mortality rates, and there is no gold standard for the surgical treatment of choice. MATERIALS AND METHODS: We reviewed the records of patients treated for esophageal perforation in the last decade at the General Surgery Unit of the University of Udine. Patients suffering from perforation secondary to surgical procedures or neoplastic disease were ruled out. RESULTS: Eight males (66.7%) and four females (33.3%) met the inclusion criteria. The cause of perforation was iatrogenic in seven cases (58.3%) and spontaneous in five (41.7%). The perforation was in the cervical esophagus in five cases (41.7%) and at thoracic level in the other seven (58.3%). Two patients (16.7%) with cervical lesions were treated conservatively; two (16.7%) underwent primary closure and the insertion of a drainage tube; one patient with a distal cervical lesion underwent diversion esophagostomy; six patients had resection of the entire thoracic esophagus and terminal cervical esophagostomy; one had segmental resection of the distal thoracic esophagus and lateral diversion esophagostomy. In the five patients whose reconstruction was postponed, esophagogastroplasty surgery was performed with an anastomosis at cervical level in four cases and at thoracic level in one. The global mortality rate was 25%. Late diagnosis-more than 24 h after the perforation event-seems to be the only factor correlated with fatal outcome (p = 0.045). CONCLUSIONS: The choice of treatment for perforation in a healthy esophagus depends mainly on the site and size of the lesion. Cervical lesions may be amenable to conservative treatment or require primary surgical repair, while thoracic lesions with associated sepsis or major loss of substance demand an aggressive approach, with esophageal resection and delayed reconstruction seeming to be the safest option.

Liver resection for hepatocellular carcinoma: a multivariate analysis of factors associated with improved prognosis. The role of clinical, pathological and surgical related factors.

AIMS AND BACKGROUND: Hepatocellular carcinoma (Hcc) is the third most common cause of cancer death. The aim of this study is to examine the factors associated with improved prognosis in Hcc after liver resection. PATIENTS AND METHODS: From September 1989 to March 2005, 134 consecutive patients had liver resection for Hcc on cirrhosis at our department. We performed 54 major liver resections and 80 limited resections. All patients enrolled in the study were followed-up three times during the first year after resection and twice the next years. RESULTS: In-hospital mortality rate was 7.4%, about 50% of these cases were Child-Pugh B patients. Morbidity rate was 47.7%, caused by the rising of ascites, temporary liver impairment function, biliary fistula, hepatic abscess, hemoperitoneum and pleural effusion. Overall survival resulted to be influenced by etiology (P = 0.03), underlying liver disease, in particular Child A vs BC (P = 0.04), Endmondson-Steiner grading (P = 0.01), the absence of a capsule (P = 0.004), the presence of more than one lesion (P = 0.02), lesion's size over 5 cm (P = 0.04), Pringle maneuver length over than 20 minutes (P = 0.03), an amount of resected liver volume lesser than 50% of total liver volume (P = 0.03), and the relapse of Hcc (P= 0.01). CONCLUSIONS: The treatment of hepatocellular carcinoma should be both the most radical to obtain the best outcome and to reduce the recurrence's rate, and the most suitable according to the patient's condition, lesion's characteristics and underlying liver disease: because of the large number of factors affecting the outcome of Hcc, unfortunately, we are still far from an agreement upon a group of criteria useful to select the best candidates for liver resection.

Percutaneous transhepatic portography for the treatment of early portal vein thrombosis after surgery.

We treated three cases of early portal vein thrombosis (PVT) by minimally invasive percutaneous transhepatic portography. All patients developed PVT within 30 days of major hepatic surgery (one case each of orthotopic liver transplantation, splenectomy in a previous liver transplant recipient, and right extended hepatectomy with resection and reconstruction of the left branch of the portal vein for tumor infiltration). In all cases minimally invasive percutaneous transhepatic portography was adopted to treat this complication by mechanical fragmentation and pharmacological lysis of the thrombus. A vascular stent was also positioned in the two cases in which the thrombosis was related to a surgical technical problem. Mechanical fragmentation of the thrombus with contemporaneous local urokinase administration resulted in complete removal of the clot and allowed restoration of normal blood flow to the liver after a median follow-up of 37 months. PVT is an uncommon but severe complication after major surgery or liver transplantation. Surgical thrombectomy, with or without reconstruction of the portal vein, and retransplantation are characterized by important surgical morbidity and mortality. Based on our experience, minimally invasive percutaneous transhepatic portography should be considered an option toward successful recanalization of early PVT after major liver surgery including transplantation. Balloon dilatation and placement of a vascular stent could help to decrease the risk of recurrent thrombosis when a defective surgical technique is the reason for the thrombosis.

Liver resection for HCC: analysis of causes and risk factors linked to postoperative complications.

BACKGROUND/AIMS: Hepatic resection is widely accepted as the best treatment for localized hepatocellular carcinoma (HCC), even in those patients affected by cirrhosis after a sharp selection. Notwithstanding technical advances and high experience of liver resection of specialized centers, the rate of complication after surgical resection could be high. Herein we analyzed causes and foreseeable risk factors on the grounds of data derived from a single center surgical population. METHODOLOGY: From September 1989 to March 2005, 134 consecutive patients had liver resection for HCC on cirrhosis at our department. We performed 54 major liver resections and 80 limited resections. RESULTS: In-hospital mortality rate was 7.4%, about 50% of these cases were Child-Pugh B patients. Morbidity rate was 47.7%, caused by the rising of ascites, hepatic insufficiency, biliary fistula, hepatic abscess, hemoperitoneum and pleural effusion. Intraoperative mortality resulted to be influenced by the amount of resected liver volume (p < 0.05), and the rising of complication (p = 0.006). Some technical aspects of surgical procedure are responsible of the rising of complication as: Pringle maneuver length (p = 0.02), the amount of resected liver volume (p = 0.03) and the request of blood transfusion (p = 0.03). CONCLUSIONS: Complications that arise during the postoperative period, although treatable, delay patient's recovery and resumption of liver function; the evaluation of causes and foreseeable risk factors linked to postoperative morbidity during the planning of surgical treatment should play the same role as other factors weighted in the selection of patients eligible for liver resection.

Analysis of survival after pancreatic resection for oncological pathologies.

Surgical treatment of pancreatic cancer is to date the only modality that offers a chance of long-term survival. Potentially curative surgery is an option for only about 15% of patients with pancreatic adenocarcinoma. The aim of this study was to determine the survival and to assess the association of clinical, pathological, and treatment features with survival of patients who underwent resection of pancreatic cancer at the Department of Surgery of Udine University Hospital. From November 1989 to December 2005, 137 consecutive patients, who underwent surgical procedures for pancreatic cancer, were followed in our department. We performed 76 pancreatico-duodenectomy, 26 distal pancreatectomies and 35 total pancreatectomies. The surgical reconstruction after pancreatico-duodenectomy was as follows: 11 closures of the main duct with manual nonabsorbable stitches, 24 closures of the main duct with a linear stapler, 17 occlusions of the main duct with neoprene glue and 24 duct-to-mucosa anastomoses. Mean survival time was 27.7 +/- 26.93 months (mean +/- SD) and mean disease-free survival time was 25.4 +/- 23.06 months (mean +/- SD). 1, 3, 5, 7 and 9-year survival rates were 63.9, 33.7, 21.17, 12.7 and 10.2%, respectively. Significant differences in survival were recorded by the Log-rank test for age > 70 (p = 0.001), surgical procedures (p = 0.00046) and presence of metastases (p = 0.0055) The treatment of pancreatic cancer is undertaken with two different aims. The first is radical surgery for patients with early-stage disease, mainly stage I and partly stage II. In all other cases, the aim of treatment is the palliation of the several distressing symptoms related to this cancer. The standard treatment option for resectable tumours is radical pancreatic resection according to the Whipple procedure or total pancreatectomy.

A comparative study of the transhiatal laparoscopic approach versus laparoscopic gastric mobilisation and right open transthoracic esophagectomy for esophageal cancer management.

AIM: Regarding the surgical treatment of esophageal cancer, a question was raised by the introduction of minimally invasive surgery, because of the technical complexity of the techniques involved and its uncertain benefits. We evaluated the impact of laparoscopic esophagectomy on the surgical approach to esophageal cancer. PATIENTS AND METHODS: From January 2002 to March 2006, 22 non-randomized patients were recruited to undergo esophagectomy for neoplastic disease. The esophagectomy and esophagogastroplasty were performed using the laparoscopic transhiatal technique (THE) in 9 cases, while a combined laparoscopic gastric mobilisation and right transthoracic incision (TT/LE) was performed in the other 13. RESULTS: Mean follow up was 21+/-3.23 months, range 2-46 months. Overall cumulative survival was 84.0% at 12 months, 61.3% at 24 months, 51.0% at 36 months. THE achieved better results than TT/LE on the ground with regard to the time it took to complete the procedure (p=0.046) and the hospital stay times (p=0.039), and the time in ICU, postoperative oral feeding resumption, number of retrieved lymph nodes. CONCLUSION: The clinical benefits of minimally invasive techniques regard the time it takes to complete the procedure, the time in ICU, postoperative oral feeding resumption and the hospital stay times. Minimally invasive surgery might be not less curative and effective than open surgical procedures, as found in our small non-randomzed series of patients. Larger series should confirm these results.

Instrumental clinical restaging, pathological evaluation, and tumor regression grading: how to assess the response to neoadjuvant chemoradiotherapy for rectal cancer.

INTRODUCTION: The object of neoadjuvant chemoradiotherapy regimens is a downstaging or downsizing of advanced rectal tumor to increase the rate of curative resection and reduce loco-regional failure. A reliable method of assessing response to adjuvant therapies is required to help standardize the assessments of new multimodality therapies. The purpose of this study was to evaluate the role played by tumor regression grading on the evaluation of pathological response to chemoradiotherapy, compared with both the predicting value of the clinical response to neoadjuvant therapy and pathologic response evaluation. METHODS: From 1994 to 2003, 58 patients with a primary diagnosis of rectal cancer were studied at our department and enrolled in a single center, not randomized study based on 5-week sessions of radiotherapy associated with a 30-day 5-fluorouracil (FU) infusion, followed by surgical resection. Instrumental restaging and routine histological examination, including tumor regression grading, were performed to asses the response to neoadjuvant therapy. RESULTS: The cCR rate corresponds to pCR rate, while a 3.5% of cPR and a 3.4% of cSD corresponded to a pPD. cPR and cSD show a PPV of 92.8% and 90.9% respectively, while cPD NPV is 20%. No case was found with no regression (grade 0). Tumor regression was defined grade 1 in 24.5% of cases, grade 2 was found in 58.5% of cases, 7.5% were grade 3, and 9.5% showed complete regression (grade 4). Pathologic response resulted to be associated with regression grade (p=0.006). Tumor regression grading is an independent variable for pT (p=0.0002), pN status (p=0.00004), pathologic staging (p=0.000001) and local recurrence (p=0.003). CONCLUSION: Our results lead us to consider only pathologic evaluation to determine the response to neoadjuvant treatment: the application of tumor regression grading on the specimens obtained after combined neoadjuvant chemoradiotherapy and surgery is useful to plan a better therapeutic strategy on the ground of a quantitative evaluation of the response to neoadjuvant treatment; it shows it is an important comparable pathological feature, useful in comparing different protocols' results and differences between patient's response as well as prognostic factors.

Long-term placement of subcutaneous Rüsch-type stents for double biliary stenosis in a living-donor liver transplant recipient.

Biliary reconstruction continues to be a major source of morbidity following liver transplantation. The spectrum of biliary complications is evolving due to the increasing number of split-liver and living-donor liver transplantation, which are even associated with a higher incidence of biliary complications. Bile duct strictures are the most common cause of late biliary complications and account for up to 40% of all biliary complications. Optimal therapy for posttransplantation anastomotic biliary strictures remains uncertain and requires a multidisciplinary approach. We report the case of a 54-year-old Caucasian male affected by hepatocarcinoma and hepatitis C-related cirrhosis who underwent right-lobe living-donor liver transplantation from his son complicated by double anastomotic stenosis of the main right hepatic duct and of an accessory biliary duct draining segments 6 and 7 of the graft that was successfully treated by percutaneous transhepatic cholangiography with long-term subcutaneous placement of two internal Rüsch-type biliary stents.

Liver resective surgery: a multivariate analysis of postoperative outcome and complication.

INTRODUCTION: Notwithstanding technical advances and high experience of liver resection of specialized centers, the rate of complications after surgical resection could be high. In this study, we analyzed causes and foreseeable risk factors linked to postoperative morbidity on the ground of data derived from a single center surgical population. MATERIALS AND METHODS: From September 1989 to March 2005, 134 consecutive patients had liver resection for Hcc and 153 consecutive patients with liver metastasis (derived from either colorectal cancer or noncolorectal cancer) at our department. We performed 22 major hepatectomy, 20 left hepatectomy, 14 trisegmentectomy, 77 bisegmentectomy and/or left lobectomy, 74 segmentectomy, and 80 wedge resection. RESULTS: In-hospital mortality rate was 4.5%, about 7% in Hcc cases and 2.6% in liver metastasis. Morbidity rate was 47.7%, caused by the rising of ascites (10%), temporary impairment liver function (19%), biliary fistula (6%), hepatic abscess (25%), hemoperitoneum (10%), and pleural effusion (30%) sometimes combined each other. Some variables, associated with the technical aspects of surgical procedure, are responsible of the rising of complication as: Pringle maneuver length of more than 20 minutes (p=0.001); the type of liver resection procedure [major hepatectomy (p=0.02), left hepatectomy (p=0.04), trisegmentectomy (p=0.04), bisegmentectomy and/or left lobectomy (p=0.04)]; and the request of an amount of blood transfusion of more than 600 cc (p=0.04). Also, both liver dysfunction, in particular Child A vs B and C (p=0.01), and histopathological grading (p=0.01) are associated with a high rate of postsurgical complication in Hcc cases. CONCLUSION: We make the following recommendations: every liver resection should be planned after intraoperative ultrasonography, anatomical surgical procedure should be preferred instead of wedge resection, and modern devices should be used, like Argon Beam and Ligasure dissector, to reduce the incidence of both intraoperative and postoperative bleeding and biliary leakage.