Fast-track anesthesia and outcomes in hepatopancreatic cancer surgery: a retrospective analysis.

AIM: To assess the feasibility of a fast-track anesthesia protocol for hepatopancreatobiliary cancer surgery. METHODS: Retrospective analysis of consecutive sample of patients who underwent hepatopancreatic surgery for cancer for a period of 12 months in a high volume cancer center. Blended anesthesia was performed for most patients who were then observed in a recovery room area until achieving a safety score. RESULTS: Data of 163 patients were examined. Fifty-six and 107 patients underwent surgery for pancreatic cancer and liver surgery for primary tumor or metastases, respectively. Most patients were ASA 3. The mean durations of anesthesia and surgery were 322 min (SD 320) and 296 min (SD 133), respectively. Extubation was performed in the operating room in 125 patients. Post-operatory invasive ventilation was maintained in the recovery room in fifteen patients for a mean duration of 72.7 min (SD148.2). Only one patient was admitted to intensive care for 15 h. NIV was performed in three patients for a mean duration of 73.3 min (SD 15.3). The mean recovery room staying was 79 min (SD 80). The mean hospital postoperative stay was a mean of 8.1 days (SD 5.7). No complications were found in 144 patients. Globally, mortality rate was 3%. CONCLUSION: A program of fast-track anesthesia with a short stay in recovery room allowed to achieve a good outcome, limiting the costs of intensive care admission.

Assessing the learning curve for totally laparoscopic major-complex liver resections: a single hepatobiliary surgeon experience.

BACKGROUND: Encouraging results have been reported in terms of feasibility, safety, and oncologic, outcomes even for major (≥ 3 segments) or complex for location-specific (right posterior segments) laparoscopic liver resections. Despite this, technically challenging issues and advanced laparoscopic skills required to perform it have limited its use in few highly specialized centers. The aim of this study was to assess the learning curve for major-complex totally laparoscopic liver resections (TLLR) performed by a single HPB surgeon. MATERIALS AND METHODS: From October 2008 to February 2012, a total of 70 TLLR were performed; 24 (33.3%) were major-complex resections. This series was divided in 2 groups according to time of operation: group A (12 cases early series) and group B (12 cases late series); perioperative outcomes were retrospectively analyzed and compared. RESULTS: Comparing the 2 groups, a statistically significant improvement was found in terms of operative time (P=0.017), blood loss (P=0.004), number of cases requiring a Pringle maneuver (P=0.006), and blood transfusion (P=0.001) from case number ten onward. CONCLUSIONS: This study shows that a minimum of 10 cases are required to obtain a significant improvement in perioperative outcome for surgeons with specific training on hepatobiliary surgery and advanced laparoscopic surgical procedures. More studies are required to clarify the minimum standard of training to perform safely this kind of advanced laparoscopic liver surgery on a large scale.

One-stage, totally laparoscopic major hepatectomy and colectomy for colorectal neoplasm with synchronous liver metastasis: safety, feasibility and short-term outcome.

BACKGROUND: Simultaneous surgery for primary colorectal tumor with synchronous liver metastasis has been showed to be safe and effective. One-stage, totally laparoscopic colorectal and minor liver resections have been reported, but there are no data regarding patients requiring simultaneous major hepatectomies and colorectal surgery. We aimed to evaluate the safety, feasibility and short-term outcomes of a small cohort of highly selected patients treated by 1-stage, totally laparoscopic major hepatectomy and colorectal resection. METHODS: From January 2009 to July 2011, 5 patients (3 women and 2 men) with primary colorectal neoplasm and synchronous monolobar liver metastasis requiring a major hepatectomy underwent attempt of 1-stage, totally laparoscopic approach after neoadjuvant chemotherapy. A retrospective analysis of prospective collected data was performed. RESULTS: There were no conversions to open procedures. All the patients but 1 underwent a 1-stage laparoscopic resection. Among these, liver procedures were 3 right and 1 left hepatectomy; colonic procedures were 3 sigmoidectomies and 1 anterior resection of the rectum. Median operative time was 495 minutes, and duration of hospital stay, 6 days. Median estimated blood loss was 475 mL (range, 300-630) with no mortality observed. An R0 resection was always achieved. Median follow-up was 14 months (range, 7-20) with 1 recurrence observed in the liver. CONCLUSION: In highly selected patients, a totally laparoscopic approach is a feasible and safe option to treat primary colorectal neoplasm with synchronous liver metastasis requiring major hepatectomies. These results need to be validated by larger, prospective, randomized studies.

Totally laparoscopic liver resections for primary and metastatic cancer in the elderly: safety, feasibility and short-term outcomes.

BACKGROUND: Standard oncologic liver resections performed on elderly patients (≥70 years old) have been shown to be safe and effective. The aim of this study was to analyze operative and oncologic short-term outcomes of totally laparoscopic liver resections (TLLR) performed on elderly patients for malignancies. METHODS: We performed a retrospective statistical analysis of prospectively recorded data of TLLR performed from October 2008 to February 2012 by a single hepato-pancreato-biliary (HPB) surgeon. Patients were divided into two groups according to age (<70 vs. ≥ 70 years old) and perioperative outcomes were compared. RESULT: A total of 60 TLLR for malignancies were identified of which 25 patients (42 %) were aged ≥ 70 years (Group A) and 35 (58 %) were aged <70 years (Group B). There was no difference in operative time (170 vs. 180 min, p = 0.267), median blood loss (200 vs. 250 ml, p = 0.183), number and time of Pringle maneuver (p = 0.563 and p = 0.180), blood transfusion rate (4 vs. 17 %, p = 0.222), conversion rate (4 vs. 9 %, p = 0.443), morbidity rate (12 vs. 20 %, p = 0.797), and perioperative mortality rate (0 vs. 3 %, p = 0.688). An R0 resection was achieved in 92 (Group A) versus 83 % (Group B) (p = 0.265). At a median follow-up of 18 months, 12 % of patients in Group A experienced a disease recurrence with a related mortality rate similar to that of Group B (8 vs. 12 %, p = 0.375). CONCLUSION: This retrospective comparative study shows that TLLR performed on elderly for liver neoplasm are feasible and safe and lead to short-term outcomes similar to those of younger patients.

Laparoscopic staged adjustable gastric banding and liver resection in morbidly obese patient.

We report the case of a 34-year old morbidly obese female, with a history of polycystic ovarian syndrome and birth control pill therapy, who underwent laparoscopic gastric banding. On laparoscopic exploration, a 4-cm liver neoplasm that was missed by preoperative ultrasound was incidentally found. The intraoperative biopsy was suggestive for a benign lesion of hepatocellular origin but could not make the differential diagnosis between focal nodular hyperplasia and adenoma. The neoplasm had atypical features on postoperative magnetic resonance imaging and was suggestive of liver adenoma. Six months after laparoscopic gastric banding, the patient presented with a weight loss of 24 kg and consented to liver resection. A laparoscopic resection of liver segment 3 was performed. Atypical liver neoplasms are subject to potential degeneration, rupture, and bleeding; therefore, they should be treated surgically to allow final diagnosis and potential cure of the disease. In this case, a staged approach was effective in obtaining substantial weight loss and a lesser degree of liver steatosis to enable the performance of a laparoscopic liver resection.

Critical use of extended criteria donor liver grafts in adult-to-adult whole liver transplantation: a single-center experience.

This study presents our experience with the use of extended criteria donor (ECD) liver grafts. One hundred fifteen liver transplants were divided into 2 groups: standard (S) and nonstandard (NS). Fifty-eight patients in group S received a liver procured from an ideal donor, whereas 57 patients in group NS received an organ from an ECD. On the basis of the number of risk factors, patients were divided into 3 subgroups: the S group with 58 receiving a standard graft, the NS1 group with 44 receiving a graft with 1 or 2 risk factors, and the NS2 group with 13 receiving a graft with 3 to 4 risk factors. Patient survival was not different at 6, 12, and 24 months (P > 0.05), whereas graft survival was different (P = 0.0079). Both patient survival and graft survival were influenced by the cumulative number of risk factors. The univariate analysis of the donor risk factors detected hemodynamic factors as predictive of graft failure (P = 0.024) and death (P = 0.018). In the multivariate analysis, which was adjusted for recipient age and donor and recipient gender, hemodynamic risk factors and Model for End-Stage Liver. Disease score in the recipient were the only variables independently associated with graft failure (P = 0.006, P = 0.012, negatively). Finally, we observed a reduction of dropout from the list to 9% from 14.1% (P = 0.04) and of mortality on the list to 32.55% from 41.01% (P = 0.11). Critical use of ECD liver grafts allowed recipients in the waiting list to have a greater chance of being transplanted.

Successful treatment of small-for-size syndrome in adult-to-adult living-related liver transplantation: single center series.

The portal hyperperfusion, or small-for-size syndrome (SFSS), is a widely recognized clinical complication that may occur after segmental liver transplantation. Several surgical strategies have been proposed to reduce portal blood inflow and portal pressure after partial liver transplantation. In particular, splenic artery ligation and splenectomy have been used without a firm hemodynamic basis for these procedures. Our group recently demonstrated that, in patients with cirrhosis and portal hypertension, the occlusion of the splenic artery causes a significant reduction in the portal pressure gradient, which is directly related to the spleen volume and indirectly related to the liver volume. This concept is at the center of our strategy for performing early splenic artery embolization (SAE) for the treatment of SFSS after living-related liver transplantation (LRLT). Six patients developed small-for-size syndrome, defined as: onset within the first week after LRLT of progressive hyperbilirubinemia without mechanical cause; marked cholestasis; centrilobular sinusoidal dilatation and hepatocyte atrophy at liver biopsy; and refractory ascites in the absence of vascular complications. All six patients who underwent SAE rapidly improved their clinical condition, with an evident decrease in the value of bilirubin in the serum, in the production of ascites, and improvement in condition of pancytopenia. Coagulopathy expressed by the international normalized ratio value (INR) was not a reliable early marker of SFSS in this series; in fact a slight improvement in the result of this test was already present immediately after LRLT and before SAE. Because splenic flow clearly contributes to portal hyperperfusion, an early SAE can relieve the partial graft from the deleterious effect of this portal overflow.

Sequential preoperative ipsilateral portal and arterial embolization in patients with colorectal liver metastases.

BACKGROUND: Preoperative portal vein embolization (PVE) induces ipsilateral atrophy of the hepatic parenchyma to be resected, as well as contralateral compensatory hypertrophy of the residual liver. However, there are two potential problems with this technique: inadequate contralateral hypertrophy and tumor progression while waiting for the non-embolized liver to hypertrophy. We devised a strategy to deal with these two problems by performing an ipsilateral hepatic artery embolization 6 weeks after an unsatisfactory PVE in an effort to accelerate the hypertrophy of the remnant liver. MATERIALS AND METHODS: Two patients with colorectal liver metastases underwent to this sequential preoperative treatment in order to achieve resectability of their metastatic disease. RESULTS: Both patients successfully underwent major hepatic resection. CONCLUSIONS: In our experience sequential ipsilateral portal vein and hepatic artery embolization extended the indications for liver resection for metastatic colorectal cancer.

Fulminant hepatic failure bridged to liver transplantation with a molecular adsorbent recirculating system: a single-center experience.

We herein describe the clinical course of a consecutive series of fulminant hepatic failure patients treated with a molecular adsorbent recirculating system (MARS), a cell-free albumin dialysis technique. From November 2000 to September 2002, seven adult patients ages 22-61 (median, 41), one male (14.2%) and six females (85.7%), affected by fulminant hepatic failure underwent seven courses (one to five sessions each, 6 hr in duration) of extracorporeal support using the MARS technique. Pre- and posttreatment blood glucose, liver function tests, ammonia, arterial lactate, electrolytes, hemodynamic parameters, arterial blood gases, liver histology, Glasgow Coma Scale, and coagulation studies were reviewed. No adverse side effects such as generalized bleeding on noncardiogenic pulmonary edema, often seen during MARS treatment, occurred in the patients included in this study. Six patients (85.7%) are currently alive and well, and one (14.2%) died. Four patients (57%) were successfully bridged (two patients in 1 day and two other patients in 4 days) to liver transplantation, while two (5%) recovered fully without transplantation. All the measured variables stabilized after commencement of the MARS. No differences were noted between the pre- and the post-MARS histology. We conclude that the MARS is a safe, temporary life support mechanism for patients awaiting liver transplantation or recovering from fulminant hepatic failure.

Thromboelastography used to assess coagulation during treatment with molecular adsorbent recirculating system.

Coagulopathy is a life-threatening complication of liver cirrhosis. We describe the effect of molecular adsorbent recirculating system (MARS), a cell-free dialysis technique, on the blood coagulation of cirrhotic patients. From February 2002 to July 2002, nine patients--five males (55.5%) and four females (44.4%), age 47-70 yr (median 56)--underwent 12 courses (4-7 sessions each) of MARS. Patients were treated for the following indications: six (66.6%) acute-on-chronic hepatic failure, three (33.3%) intractable pruritus. Platelet count, prothrombin time (PT), international standardized ratio and thromboelastography were measured before and after each MARS session. Coagulation factors II, V, VII, VIII, IX, X, XI, XII, XIII, von Willebrand, lupus anticoagulant, protein C, protein S, antithrombin III, plasminogen, alpha 2 antiplasmin, D-dimer, fibrin monomers, complement, and C(1) inactivator were measured before and at the end of each MARS treatment. We found a statistically significant difference (p < 0.05) in the platelet count, PT, all the thromboelastograph variables (reaction and constant time, alpha angle, and maximal amplitude), factor VIII, von Willebrand, and D-dimer, when measured before and after MARS. Previous reports have shown amelioration of blood coagulation following MARS treatments. However, we document that MARS induces coagulopathy through a platelet-mediated mechanism, whereby platelet may be mechanically destroyed during the passage of blood through the filters and lines. An alternative postulated mechanism is an immune-mediated platelet disruption - coagulopathy.

New technique in hepatic parenchymal transection for living related liver donor and liver neoplasms.

BACKGROUND: Many different surgical techniques have been described for hepatic parenchymal transection. A retrospective analysis of perioperative mortality, length of hospitalization and blood transfused during operation in two patient groups undergoing liver resection was carried out. In group A, we developed a new technique to resect hepatic parenchyma, using an ultrasonic surgical aspirator with monopolar floating ball cautery, while in group B the crushing clamp technique was used. METHODS: In all, 42 patients with liver resection were enrolled in group A and 107 resections in group B. All patients had hepatic neoplasms except for seven living transplant donors. In group A 43% of resections involved >or=3 segments and 57% involved or=3 segments and 63.6% consisted of

Noncardiogenic pulmonary edema induced by a molecular adsorbent recirculating system: case report.

Noncardiogenic pulmonary edema is a well-recognized manifestation of acute lung injury which has been related, among others, to blood or blood-product transfusion, intravenous contrast injection, air embolism, and drug ingestion. We describe two cases of noncardiogenic pulmonary edema after use of a molecular adsorbent recirculating system, a cell-free dialysis technique. Patients in this series presented at our institution to be evaluated for liver transplantation. Subsequently, they developed an indication for the molecular adsorbent recirculating system. Two patients of 30 (6.6%) treated with the molecular adsorbent recirculating system for acute-on-chronic liver failure and intractable pruritus had normal chest X-rays before treatment and developed severe pulmonary edema, in the absence of cardiogenic causes, following use of the molecular adsorbent recirculating system. For each patient we reviewed the history of blood or blood-product transfusion, echocardiograms if available, daily chest X-rays, and when available pre- and postmolecular adsorbent recirculating systemic blood pressure, central venous pressure, pulmonary arterial pressures, cardiac output, cardiac index, systemic vascular resistance index, and arterial blood gas. Our data suggest that the molecular adsorbent recirculating system may cause noncardiogenic pulmonary edema, possibly by an immune-mediated mechanism.

Effect of molecular adsorbent recirculating system in hepatitis C virus-related intractable pruritus.

Intractable pruritus is more common in cholestatic liver diseases and may be the presenting symptom and/or major complaint of hepatitis C and/or hepatitic C virus-related cirrhosis. From September 2000 to May 2002, three patients affected by intractable pruritus secondary to hepatitis C cirrhosis that failed medical treatment were treated with a molecular adsorbent recirculating system (MARS). MARS is an artificial liver support system that aims to clear the blood of metabolic waste products normally metabolized by the liver. Each patient underwent seven MARS sessions. Liver function tests, the 36-Item Short Form quality-of-life test, visual analog scale for itching, and bile acid measurement in the serum, albumin circuit and ultrafiltrate were performed before and after each MARS session. Moreover, at hospital admission, each patient underwent a psychological workup and abdominal imaging study. Subjective improvement in pruritus and quality of life, along with a decrease in serum bile acid concentration, was observed in every patient; no patient underwent retreatment and/or liver transplantation up to a 9-month follow-up. One patient died 201 days after MARS treatment. Although we observed a decreased level of serum bile acids, one cannot conclude that this was the mechanism of action for the reduction in pruritus intensity in patients in our series. Different toxins and/or a placebo effect might have had a role in this setting.