Potential for cure and predictors of long-term survival after radiofrequency ablation for colorectal liver metastases: A 20-years single-center experience.

BACKGROUND: Additional radiofrequency ablation (RFA) of liver-limited colorectal liver metastases (CRLM) improves overall (OS) and recurrence-free survival (RFS) over systemic therapy alone. We aimed to assess the potential and predictive factors of long-term survival and cure to optimize patient selection for RFA application. METHODS: Retrospective review of a prospectively maintained single-center database of consecutive patients undergoing RFA for liver-limited CRLM after systemic therapy between 2002 and 2020. Clinicopathologic characteristics and KRAS/BRAF-genotype data (tested routinely since 2010) were correlated to RFS and OS. Cure was defined as ≥10-years RFS (long-term survival as ≥5-years OS) following RFA. RESULTS: For the entire cohort of 158 patients (median follow-up 13.6 years), co-occurrence of three factors, RECIST-defined response, number of ≤3 CRLM, and ≤3 cm maximum size determined a survival plateau that distinguished cured from non-cured patients (10-years RFS: 15.5% vs 0%, p < 0.0001). Among 59 patients (37.3%) being tested, 4(6.8%) were BRAF-mt, 15(25.4%) KRAS-mt, and 40(67.8%) KRAS/BRAF-wt. OS (median follow-up 8.3 years) was estimated to be higher with KRAS/BRAF-wt compared to a mutant KRAS or BRAF status (5-years OS: 22.8% vs 3.4%, p = 0.0018). CONCLUSION: This study indicates about 15% chance of cure following RFA of low-volume liver-limited CRLM after downsizing by systemic therapy and a negative effect of KRAS or BRAF mutation on long-term survival after CRLM ablation. These findings may improve clinical decision-making in patients potentially candidate to RFA of CRLM and encourage further investigations on molecular factors determining an oligometastatic state of CRLM curable with focal ablative therapy.

Conversion From Open to Laparoscopic Surgery in Strangulated Hernia Repair: Toward a Gold Option Proposal.

INTRODUCTION: Strangulation is a common presentation of acute abdominal wall hernias that usually requires emergency surgery. The aim of this report is to propose a "reverse strategy" combining an open mesh-based anterior approach followed by a "conversion" to laparoscopy for the treatment of strangulated hernias. MATERIALS AND METHODS: A 68-year-old male patient came to the emergency room of our university hospital with a non-reducible left groin hernia. The CT scan demonstrated a left groin strangulated hernia with doubtful viability of the involved bowel loop. We decided to perform a transversal inguinotomy followed by a laparoscopic approach through the inguinal ring. RESULTS: The patient was discharged after four days in perfect general condition, with normal bowel function and no postoperative pain. CONCLUSION: We propose this unconventional conversion from open to laparoscopic surgery as a new indication for the laparoscopic approach in emergency hernia surgery. We hope it can be used as a gold option for the surgical treatment of strangulated hernia in selected cases.

Subtotal cholecystectomy for Mirizzi syndrome: Should we ever remove the stone? A case report.

INTRODUCTION AND IMPORTANCE: Mirizzi Syndrome is a rare complication of cholelithiasis.In this case report the Authors present an original surgical approach for the treatment of complicated gallbladders, based on open subtotal cholecystectomy, leaving in situ the stone. This is the first case showing safety and reliability of the present strategy at a four-year follow-up. CASE PRESENTATION: A 68-year-old patient came to our emergency room with abdominal pain, leukocytosis and fever. At surgical exploration he presented a sclerotic retraction of the gallbladder together with an intrahepatic abscess, that forced us first to perform an open subtotal cholecystectomy, resecting the gallbladder cranially and leaving in situ the stone. CLINICAL DISCUSSION: The post-operative course was uneventful. The four-year clinical, US and CT scan follow-up was negative and the patient referred a normal quality of life. The present strategy could be considered an intraoperative rescue option in such a complex operative scenario in which is impossible to safely remove the stone. CONCLUSION: This case report demonstrates how in selected cases, when absolutely necessary and unavoidable without high risks, the stone can be left in situ as an eventual stone resection would be extremely risky.

Nodular Sclerosing Mesenteritis: An Occasional Finding Mimicking a Spindle Cell Tumor.

BACKGROUND The term "sclerosing mesenteritis" includes a spectrum of rare idiopathic diseases involving the small and/or large bowel. It appears as a diffuse, localized, or multinodular thickening of the mesentery, with a variable degree of chronic non-specific inflammation, fat necrosis, and fibrosis. CASE REPORT Here, we report a case of 83-year-old woman with symptoms of intestinal occlusion, vomiting, and abdominal pain. Radiographic examinations showed air fluid levels in right and left quadrants and in the mesogastric site, while computed tomography (CT) documented a strangulated inguinal hernia with ileal obstruction. Based on clinical examination and radiologic findings, the patient underwent surgery for inguinal hernia reduction. The examination of viscera revealed 2 tracts of ileum with ischemic signs and covered by fibrin; thus, the 2 intestinal loops were resected. Histological examination revealed chronic non-specific inflammation of the whole intestinal wall, including the subserosa in the resected tract of proximal ileum, while the distal ileal loop (not herniated tract) showed a subserosal fibrous nodule of 2 cm in greatest diameter, composed of a proliferation of spindle cells haphazardly arranged in a collagenized stroma. The diagnosis of sclerosing mesenteritis was rendered. CONCLUSIONS The present case shows the possibility of an incidental diagnosis during another intervention such as hernia surgery. Pathologists should be aware of this disease to avoid confusion with aggressive tumors such as intra-abdominal desmoid-type fibromatosis and gastrointestinal stromal tumor.

Clinical pictures mimicking acute hernia complications: are we really daring to violate a traditional abdominal wall surgery dogma?

BACKGROUND: Acute abdominal wall hernia complications usually require a prompt surgical treatment. The aim of this case series is to report our experience with some unusual cases of apparent acute and subacute hernia complications not requiring surgical treatment, changing the classical paradigm of immediate surgical approach into a "wait and see" situation. CASE PRESENTATION: We shortly report here four cases of abdominal wall hernia complications in which surgical treatment could have been unsafe for the patients considering their clinical condition. Two cases were fistulated and two were apparently strangulated. After clinical evaluation and CT-scan, we opted for a conservative treatment weighting the risk-benefit balance in order to give the best quality of life to the patient. CONCLUSIONS: In selected cases and under well-defined situations, an accurate evaluation should convince every surgeon to opt for a conservative approach refraining from a promptly operative treatment of the patient. This may be particularly relevant among very old or high-risk patients affected by long-standing abdominal wall hernias.

Extending resectability of hilar cholangiocarcinomas: how can it be assessed and improved?

Until the 1980's, Klatskin tumors were considered 'desperate cases' and most of them were not resected; almost no oncologic concept was available. After many improvements, today, extended hepatectomy, including caudate lobe resection and lymphoadenectomy, have become a standard of care for oncologicaly radical resection of Klatskin tumors. Portal vein en bloc resection, if necessary, is a diffused standard assuring R0-resection without any improvement of survival in most series. Arterial resection remains episodical and controversial in its oncologic impact. Arterial resection-reconstruction was demonstrated to be feasible with many different technical possibilities. Neoadjuvant chemotherapy, refinement of associating liver partition and portal vein ligation for staged hepatectomy and liver transplantations are some possible future resources for treatment of those aggressive tumors that could be able to expand the pool of treatable patients.

Did the International ALPPS Meeting 2015 Have an Impact on Daily Practice? The Hamburg Barmbek Experience of 58 Cases.

BACKGROUND: ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) was introduced only 10 years ago and has gained wide acceptance as a variation of staged procedures in liver surgery. It has been criticized for its high morbidity and mortality, which all centers reported in their initial series. METHODS: After a world expert meeting in Hamburg in 2015 where all experts in the field met to discuss this method, caveats were extracted and formulated. We researched our complete prospective ALPPS database to see if the recommendations had any impact on outcome. RESULTS: In total, we performed 58 ALPPS procedures in our center. 33 patients were operated on before, 25 after the meeting. Results in terms of morbidity and mortality were significantly better after the meeting, as were patient selection and strategy. CONCLUSION: In our own center's experience, the implementation of the meetings' recommendations and the information gathered through this valuable exchange had a dramatic impact on results. Having performed 58 ALPPS procedures in total, we can now conclude that ALPPS has become much safer in our hands since the 2015 meeting and that morbidity and mortality are no longer the issue to be discussed. Future research must focus on oncologic outcomes in these patients.

Impact of Systemic Therapy and Recurrence Pattern on Survival Outcome after Radiofrequency Ablation for Colorectal Liver Metastases.

Background: Most patients undergoing radiofrequency ablation (RFA) of colorectal liver metastasases (CLM) develop disease recurrence, but little is known about the effect of recurrence patterns and/or systemic therapy on outcome. In this study, we examined the recurrence patterns and survival after systemic therapy plus RFA in patients with unresectable CLM without extrahepatic disease. The aims were to analyze the effect of recurrence patterns on survival and to assess the relative benefit contributed by systemic therapy and local ablation to disease control and patient outcome. Methods: From January 2002 to December 2012, 113 patients underwent RFA of liver-limited CLM after systemic therapy. Univariate and multivariate analyses for associations between clinical and/or treatment-related variables, recurrence-free survival (RFS), recurrence patterns, and overall survival (OS) were carried out. Results: Of 113 patients, 105 (92.8%) had disease recurrence (median RFS: 6.1 months). Lower post-recurrence OS was observed after early (≤6 months) than after late recurrence (8.5 versus 24.0 months, p < 0.001). Recurrence sites were RFA-sites only (4.8%), liver-only (57.1%), lung-only (10.5%), or multiple (27.6%); the corresponding post-recurrence OS was 21, 19, 39, and 7 months (p < 0.001), respectively. Response to pre-RFA systemic therapy was the strongest predictor for OS (hazard ratio [HR] 5.28), RFS (HR 3.30), early (odds ratio [OR] 6.34) and multiple-site recurrence (OR 3.83) (p < 0.01), respectively; only responders achieved 5-year OS and RFS (29% and 12% versus 0% and 0% for non-responders, p < 0.001, respectively). Conclusions: Survival after RFA for liver-limited CLM is strongly linked to the timing and pattern of non-local disease recurrence. Local ablation efficacy is necessary but not sufficient to obtain long-term disease control. Effective pre-RFA systemic therapy does favourably affect the incidence, timing and patterns of recurrence and long-term survival and appears essential for the tailoring of RFA application to maximize patient benefit.

Immunological reaction and oxidative stress after light or heavy polypropylene mesh implantation in inguinal hernioplasty: A CONSORT-prospective, randomized, clinical trial.

UNLABELLED: The relationship between mesh weight and host tissue reaction has, so far, not been fully investigated. Lightweight meshes (LWM) are thought to give less inflammatory response compared with heavyweight meshes (HWM). The present study is a randomized, controlled, double-blind clinical trial performed in 61 patients who underwent an elective inguinal hernioplasty. The primary outcome of the study was to investigate the relationship between total amount of prosthetic material (polypropylene), immunological reaction, and oxidative stress. The study was double-blinded. Sixty-one patients were recruited for the study and randomly assigned to 2 groups (groups A and B). Levels of inflammation markers (interleukin-6 [IL-6] and tumor necrosis factor-α [TNF-α]) and oxidative stress markers (reduced glutathione [GSH] and lipid hydroperoxides [LOOH]) were determined preoperatively and after undergoing inguinal hernioplasty (after 6, 72, and 288 hours), respectively, with LWM and HWM. There was no significant difference in IL-6 levels between HWM and LWM (P = 0.3, 0.7, 0.8 after 6, 72, and 288 hours, respectively). A statistically significant difference was found after 72 hours for TNF-α (P = 0.01), for GSH after 6 hours (P < 0.01), and after 6 and 72 hours for LOOH (P = 0.05, 0.01, respectively). Oxidative stress occurred at earlier time points and was pore accentuated HWM versus LWM and prodromal to TNF-α increase.Also, in randomized clinical trial, the use of LWM gives advantages in terms of less inflammatory response when compared with HWM. Moreover, there is a significant higher oxidative stress after implantation of HWM. The intensity of oxidative stress seems to be strongly related to the amount of implanted polypropylene. ( TRIAL REGISTRATION NUMBER: NCT01090284).

To treat or not to treat basilic vein aneurysms? A clinical dilemma.

Superficial venous aneurysms are a very uncommon disease probably associated with thrombosis and recurrent pulmonary thromboembolisms. Surgical treatment is safe and is performed in symptomatic cases. Surgical repair of superficial venous aneurysms is a recommended treatment, and no postoperative complications usually occur. The aim of this study is to report our experience treating superficial venous aneurysms, because they can cause devastating consequences. Obviously, they should be surgically treated if they are symptomatic, but there exists the possibility of complications such as thromboembolic events; however, they are unpredictable. Thus, the only solution to remove the potential risk of developing pulmonary or other embolic events is prophylactic surgery and anticoagulant therapy, also in low-risk patients.