Does the margin width influence recurrence rate in liver surgery for hepatocellular carcinoma smaller than 5 cm?

OBJECTIVE: Liver surgery is considered a curative treatment for hepatocellular carcinoma (HCC) but the importance of resection margin width remains controversial. The aim of this study is to clarify the role of 5-10 mm surgical margin width on post-operative recurrence and overall survival after resection. PATIENTS AND METHODS: We analyzed recurrence rate and overall survival rate of 72 patients who underwent curative hepatic resection for HCC smaller than 5 cm with 5-10 mm surgical margin width between January 2005 and December 2014. RESULTS: The mean follow-up period was 36 months. Among the seventy-two patients, thirty-one (31/72; 43%) developed recurrence but only eleven (11/31; 15.3%) along the resection margin. The disease-free survival was 77.2%, 50%, 41.4% at 1, 3 and 5 years respectively, and the overall survival was 89.9%, 78.8%, 60% at 1, 3 and 5 years respectively. CONCLUSIONS: 5-10 mm surgical resection margin for HCC smaller than 5 cm seems to be safe as a wider surgical margin because does not increase the risk of marginal recurrence and does not decrease overall survival rate. Further prospective and randomized studies are required to definitively clarify the importance of surgical margin width in hepatic resection for HCC.

The Aquamantys® system as alternative for parenchymal division and hemostasis in liver resection for hepatocellular carcinoma: a preliminary study.

OBJECTIVE: To evaluate the clinical feasibility and safety of a new technique for liver resection using a new saline-coupled bipolar sealing device (Aquamantys®) that has shown high performance in the animal setting. PATIENTS AND METHODS: Twelve Child-Pugh A cirrhotic patients with hepatocellular carcinoma underwent partial hepatectomies using Aquamantys®. Our primary end-point was to observe occurrence of early specific surgical complications as bleeding, biliary leakage and abscess development. Our secondary end-point was to evaluate local recurrence along resection margin after a minimum follow-up of 1 year. RESULTS: One bisegmentectomy, five monosegmentectomies and six atypical resections were performed. Mean resection time was 45 minutes (range, 30-100 min). Mean blood loss was 20 mL (range 5-80 mL). Mean post-operative stay was 6 days (range 5-16 days). All specimens presented negative margins (R0) at pathological examination. No blood transfusion were required both intra-operatively and post-operatively. No mortality was observed within 30-days post-operatively. One fluid collection occurred after  6-7 bisegmentectomy and was successfully treated by ultrasound-guided percutaneous drainage. At 1 year follow-up two patients died: one because of new lesions into the liver and one because of distant metastases and multifocal new liver disease. Ten patient are alive disease free at 1 year follow-up. CONCLUSIONS: Liver resection using Aquamantys® is feasible and safe and allows to achieve almost bloodless parenchymal division with minimal necrosis and negative margins even in atipycal resection. Comparative trials are needed to confirm our preliminary results.

[Radio-guided parathyroidectomy]. / La paratiroidectomia radioguidata.

The Authors, after a careful review of literature about the instrumental diagnostic techniques (with particular attention to the nuclear-medical ones) and the surgical therapy of parathyroid diseases, report their experience on the use of the radio-guided mininvasive surgery with MIBI and gamma-probe for intraoperative localization of pathological glands. Once exposed their experience, the Authors conclude asserting that this technique is fast, slightly invasive and expensive, and certainly useful for the detection of pathological or ectopic glands. It can be widely employed because, in comparison to its numerous advantages, such as the reduction of the operating time and of the hospital-stay, the greater radicality and the possibility to use mininvasive techniques, it does not present significant technical limitations and/or radio-protectionistic problems.

Laparoscopic cholecystectomy in cirrhotic patients.

BACKGROUND: This study aimed to evaluate the safety of laparoscopic cholecystectomy for patients with cirrhosis. METHODS: The records of 22 laparoscopic cholecystectomies performed in patients with cirrhosis Child-Pugh A and B, from January 1995 to July 2001 were retrospectively reviewed. RESULTS: No deaths occurred. Conversion to open cholecystectomy was necessary in two cases. The average operative time was 115 min, which was significantly shorter than that for patients undergoing open cholecystectomy. None of the patients required blood transfusion. Intraoperative problems occurred in two patients who experienced liver bed bleeding. Postoperative morbidity occurred in 36% of the patients and included hemorrhage, wound complications, intraabdominal collections, and cardiopulmonary complications, but all were controlled. The patients were dismissed after an average of 4 days. CONCLUSION: The authors believe laparoscopic cholecystectomy can be performed safely in selected patients with cirrhosis Child-Pugh A and B who manifest indication for surgery. Laparoscopic cholecystectomy offers several advantages over open cholecystectomy: lower morbidity, shorter operative time, and reduced hospital stay.

[Intraperitoneal neoplastic dissemination of incidental gallbladder carcinoma after laparoscopic surgery]. / La disseminazione neoplastica intraperitoneale da carcinoma incidentale della colecisti dopo chirurgia laparoscopica.

BACKGROUND: Several laboratory and clinical studies have raised the concern that laparoscopic procedures might worsen the prognosis of patient with malignant disease due to premature intraperitoneal cancer cell dissemination. The aim of the study was to examine the risk of the dissemination in patients with unsuspected gallbladder cancer diagnosed after laparoscopic cholecystectomy (LC). METHODS: A retrospective clinicopathologic study was performed on 5 patients with unsuspected gallbladder cancer without preoperatively diagnosis among 1280 patients that underwent LC in the period 1993-2002. The possible neoplastic dissemination was compared to that reported in 8 patients affected from unsuspected gallbladder cancer diagnosed after open cholecystectomy. RESULTS: Two patients with unsuspected gallbladder cancer (T1a-T2) presented a port-site recurrence after respectively six and four months. There was not statistically significant difference between types of cholecystectomy (LC or OC). Survival rate did not change according to whether the operation was carried out using LC or OC. CONCLUSION: After an accurate checking of the factors indicated to explain the early neoplastic dissemination frequently observed in the patients undergone LC and an analysis of their own experience the Authors conclude that LC does not worsen the prognosis of unsuspected gallbladder cancer.

[Endoscopy in non-neoplastic cholestasis]. / L'endoscopia nella colestasi non neoplastica.

The role of endoscopic treatment of cholestasis is well codified as an alternative or adjuvant therapy to surgery, particularly in those cases where non malignant cause has been identified. Non-neoplastic cholestasis therefore benefits very substantially from endoscopic treatment in a context where the traditional surgical approach presents limitations in terms of morbidity and mortality. It should be borne in mind, however, that the two approaches are strictly complementary for the correct management of these patients.

Pre and intra-operative methods of staging gastric cancer.

The aim of this paper was to examine the indications and limits of pre- and intra-operative instrumental diagnosis of gastric cancer. In order to achieve this effectively, the authors emphasized the importance of proper staging methods and obtained a detailed description of tumor diffusion. The most important diagnostic instruments considered were magnetic resonance, endosonography, intra-operative echography, pre- and intra-operative immunoscintography and a cytological examination of peritoneal lavage fluid. The authors concluded that pre- and intra-operative staging of gastric cancer is important for two major reasons: it results in the most accurate definition possible of disease evolution, enabling a proper therapeutic program; and it involves a combination of three complementary metasurgical treatments.

[Surgical problems in the aged patients]. / Problemi chirurgici nel paziente anziano.

Authors, considering the increasing of the middle duration of life and the increasing of geriatric population, examine various surgical problems in the elderly. They took in consideration not only the age, but all the other markers of surgical risk related to the surgical illness, to the associate illness and to the type of operation. After reporting their experience in the treatment of geriatric patients, they conclude that a scrupulous surgical preparation, a correct indication to the operation and an accurate overseeing after surgery are necessary to do that the elderly patient faces surgical intervention with the same capability of success of the young.

[Miles operation in rectal carcinoma: history and current status]. / L'intervento di Miles nella chirurgia del carcinoma del retto: la sua storia, il suo presente.

The Authors confirm how the advent of mechanical suture has directed the management of rectal carcinoma to an increasingly conservative attitude. In reporting their experience--which consists of about twenty years (222 patients) they specify how not only an increased incidence of recurrence has not appeared, but they have also observed a reduction of theirs (-5.2%). They then attempt to outline basic moments which have characterized the history of rectal carcinoma surgery and they state how today, 80 years since it was conceived, Miles' intervention maintains its validity, even if with more restrictive indications.

[The use of synthetic prosthesis in the treatment of hernia]. / L'impiego di protesi sintetiche nel trattamento dei laparoceli.

The authors report their experience on synthetic prosthesis used in 36 patients with abdominal hernias. Thirty six cases of incisional hernias have been analyzed by Institute of General Surgery of Messina University from 1992 to 1998. Among the 33 cases with median parietal defect, in 7 cases concerning great incisional hernias group a PTEF-e prosthesis, which was positioned in an intraperitoneal site, was employed. In 21 cases of medium size incisional hernias they used a polypropylene prosthesis, which was positioned in an intraparietal or preperitoneal site. In 5 cases of small size incisional hernias, polypropylene prosthesis was placed in a superfascial site. In the 3 cases of medium size lateral laparocele++, polypropylene prosthesis was positioned in a intraparietal site. There was no operative mortality. Among postoperative complications, 4 seromas, 1 parietal and 1 subcutaneous haematoma and 2 haematomas in retroperitoneal site appeared. Clinical-instrumental controls, which have continued until two or three years after the operation were performed which pointed out a recurrence in just one case where the prosthesis was positioned in a superfascial site. To conclude, we consider that nowadays the use of synthetic prosthesis lets us face and solve problems concerning surgical treatment of incisional hernias with confidence.

[Aorto-esophageal fistula caused by foreign body]. / La fistola aorto-esofagea da corpo estraneo.

Aortoesophageal fistula is a rare but fatal cause of upper gastrointestinal bleeding. AEF develop progressively from the esophageal perforation caused by foreign body. Clinically, there is a medial chest pain, followed by hematemesis and finally terminal exsanguination. Diagnosis must be achieved during the free intervals in this triad of often rapidly succeeding signs.

[Surgical management of hereditary medullary carcinoma of the thyroid in patients with "RET" proto-oncogene mutation]. / Strategia chirurgica nel carcinoma midollare della tiroide ereditario in portatori di mutazione del proto-oncogene "RET".

The authors report their results in 64 individuals belonging to 11 families with MEN 2 and familial medullary carcinoma of thyroid (CMT) syndromes. They show amplification and restriction techniques, type, site and incidence of genetic alteration in the observed cases; besides they illustrate the adopted surgical management related to the mutation. They stress the concept that genetic test allows to detect the population with altered gene before laboratory or clinical evidence, with the great advantage to indicate an early surgical approach. If it is shown a multi-organ disease, as in one patient with CMT associated with bilateral pheocromocytoma, the two diseases must be treated during the same operative time.

[US or CT-guided percutaneous drainage of pancreatic pseudocyst]. / Il drenaggio percutaneo Eco o T.C. guidato delle pseudocisti pancreatiche.

Authors, after illustrating the pathogenesis of Pancreatic Pseudocysts (PPC) and classifying them into secondary to acute pancreatitis and arising in course of chronic pancreatitis, underline that the use of Ultrasound (US), CT-scan, Magnetic Resonance, Endoscopic Retrograde CholangioPancreatography and, above all, percutaneous drainage of the cysts has modified the therapeutic approach to this pathology. They describe indications and technique of US or CT-guided percutaneous drainage, and report their experience about 12 cases of PPC secondary to acute pancreatitis and 4 of PPC arising during chronic pancreatitis. They analyze the limits of this technique (risk of infections, recurrences, fistulas), and conclude that Percutaneous Drainage of Pancreatic Pseudocysts is a useful therapeutic approach in the treatment of PPC secondary to acute pancreatitis, while its use is complementary to surgery in the treatment of PPC due to chronic pancreatitis.

[Nuclear risk and thyroid neoplasms in infancy]. / Rischio nucleare e carcinoma tiroideo nell'infanzia.

Thyroid carcinoma is a disease with low incidence in adult and rare in child. The authors give oncogenic risk factors of the disease and underline environment factors as iodine deficiency and radiation pollution that, as shown in certain world areas, has a strong effect in the epidemiology of this disease. Eventually radiation's are the most important oncogenic risk factors but and adequate iodine prophylactic program can be considered a valid shield to prevent this disease.

[Alpha-glucosidase and alanine-amino-peptidase in the early diagnosis of renal failure in obstructive jaundice]. / Il ruolo dell'alfa-glucosidasi e dell'alanina-amino-peptidasi nella diagnosi precoce dell'insufficienza renale in corso di ittero ostruttivo.

Renal failure is a serious complication of obstructive jaundice. Early diagnosis and prevention of spontaneous evolution of the disease can improve prognosis, otherwise very poor in many cases. The Authors, on the basis of experimental researches from literature, expose their clinical experience about the validity of the determination of Alpha-Glucosidase and Alanine-Amino-Peptidase for early diagnosis and differentiation between organic or functional forms of renal failure. They conclude that determination of urinary levels of AGS and AAP is a valid aid for the evaluation of renal function in patients with obstructive jaundice.

[Changes in serum levels of folic acid after total gastrectomy]. / Le modificazioni dei livelli sierici di acido folico dopo gastrectomia totale.

The Authors, in consideration that Folic Acid is assimilated in the upper alimentary tract, effected a comparative study between its seric levels in normal patients and in patients submitted to gastrectomy for gastric cancer, at different times from the operation. In the patients of the first group, Folic Acid levels were not correlated with sex, but to age, decreasing with the increasing of it. In gastrectomized patients, serum levels, also if acceptable, were always lower than in control cases, and gradually decreasing with the increasing of the age. The Authors conclude that, obviously, intestinal assimilation and endogenous reserves are able to counterbalance for enough long time the insufficient alimentary absorption.

[Subclavicular localization of Castleman's disease]. / La malattia di Castelman a localizzazione sottoclaveare.

Castelman disease is a rare disease of lymph nodes. There are 2 pathological types: hyalo-vascular asymptomatic form and plasmacytic symptomatic form. Authors report a case of Castelman disease of a subclavicular lymph nodes that underwent surgical operation. Ethiopathogenesis and treatment of the disease are reported.

[Primary adenocarcinoma of the duodenum]. / L'adenocarcinoma primitivo del duodeno.

Adenocarcinoma of the duodenum represents a rare neoplasia characterized by an indefinite symptomatology, at least early, and deceitful, that, therefore, arrives at surgeon, almost always, in advanced stage. The Authors, taking from a clinical case, recently observed, as a starting point, review the literature, referring the etiopathogenetic hypothesis that explain the relative rarity of this neoplasia. They therefore report the diagnostic and therapeutic procedure to carry out in these patients.

[Ambulatory treatment of inguinal hernia]. / Il trattamento ambulatoriale dell'ernia inguinale.

The Authors report their experience about the inguinal hernioplasty operation by implantation of prostheses in prolene following the Licthenstein technique. Prolene mesh strengthens the inguinal canal wall, with no suture tension point. The technique is performed under local anesthesia, in day-hospital system, consenting the patient a rapid reinstatement in the social-working ambit.