Biliary Sepsis Due to Recurrent Acute Calculus Cholecystitis (ACC) in a High Surgical-Risk Elderly Patient: An Unexpected Complication.

Acute calculus cholecystitis (ACC) is increasing in frequency within an ageing population, in which biliary tract infection, including cholecystitis and cholangitis, is the second most common cause of sepsis, with higher morbidity and mortality rates. Patient's critical conditions, such as septic shock or anaesthesiology contraindication, may be reasons to avoid laparoscopic cholecystectomy-the first-line treatment of ACC-preferring gallbladder drainage. It can aid in patient's stabilization with also the benefit of identifying the causative organism to establish a targeted antibiotic therapy, especially in patients at high risk for antimicrobial resistance such as healthcare-associated infection. Nevertheless, a recent randomized clinical trial showed that laparoscopic cholecystectomy can reduce the rate of major complications compared with percutaneous catheter drainage in critically ill patients too. On the other hand, among the possibilities to control biliary sepsis in non-operative management of ACC, according to recent meta-analysis, endoscopic gallbladder drainage showed better clinical success rate, and it is gaining popularity because of the potential advantage of allowing gallstones clearance to reduce recurrences of ACC. However, complications that may arise, although rare, can worsen an already weak clinical condition, as happened to the high surgical-risk elderly patient taken into account in our case report.

Immunosuppression Modifications Based on an Immune Response Assay: Results of a Randomized, Controlled Trial.

BACKGROUND: An immune function assay shows promise for identifying solid organ recipients at risk for infection or rejection. The following randomized prospective study was designed to assess the clinical benefits of adjusting immunosuppressive therapy in liver recipients based on immune function assay results. METHODS: Adult liver recipients were randomized to standard practice (control group; n = 102) or serial immune function testing (interventional group; n = 100) performed with a commercially available in vitro diagnostic assay (ImmuKnow; Viracor-IBT Laboratories, Lee's Summit, MO) before transplantation, immediately after surgery and at day 1, weeks 1 to 4, 6, and 8, and months 3 to 6, 9, and 12. The assay was repeated within 7 days of suspected/confirmed rejection/infection and within 1 week after event resolution. RESULTS: Based on immune function values, tacrolimus doses were reduced 25% when values were less than 130 ng/mL adenosine triphosphate (low immune cell response) and increased 25% when values were greater than 450 ng/mL adenosine triphosphate (strong immune cell response). The 1-year patient survival was significantly higher in the interventional arm (95% vs 82%; P < 0.01) and the incidence of infections longer than 14 days after transplantation was significantly lower among patients in the interventional arm (42.0% vs. 54.9%, P < 0.05). The difference in infection rates was because of lower bacterial (32% vs 46%; P < 0.05) and fungal infection (2% vs 11%; P < 0.05). Among recipients without adverse events, the study group had lower tacrolimus dosages and blood levels. CONCLUSIONS: Immune function testing provided additional data which helped optimize immunosuppression and improve patient outcomes.

Cure model survival analysis after hepatic resection for colorectal liver metastases.

BACKGROUND: Statistical cure is achieved when a patient population has the same mortality as cancer-free individuals; however, data regarding the probability of cure after hepatectomy of colorectal liver metastases (CLM) have never been provided. We aimed to assess the probability of being statistically cured from CLM by hepatic resection. METHODS: Data from 1,012 consecutive patients undergoing curative resection for CLM (2001-2012) were used to fit a nonmixture cure model to compare mortality after surgery to that expected for the general population matched by sex and age. RESULTS: The 5- and 10-year disease-free survival was 18.9 and 15.8 %; the corresponding overall survival was 44.3 and 32.7 %. In the entire study population, the probability of being cured from CLM was 20 % (95 % confidence interval 16.5-23.5). After the first year, the mortality excess of resected patients, in comparison to the general population, starts to decline until it approaches zero 6 years after surgery. After 6.48 years, patients alive without tumor recurrence can be considered cured with 99 % certainty. Multivariate analysis showed that cure probabilities range from 40.9 % in patients with node-negative primary tumors and metachronous presentation of a single lesion <3 cm, to 1.5 % in patients with node positivity, and synchronous presentation of multiple, large CLMs. A model for the calculation of a cure fraction for each possible clinical scenario is provided. CONCLUSIONS: Using a cure model, the present results indicate that statistical cure of CLM is possible after hepatectomy; providing this information can help clinicians give more precise answer to patients' questions.

A partnership model between high- and low-volume hospitals to improve results in hepatobiliary pancreatic surgery.

OBJECTIVE: To optimize the results of low-volume (LV) centers for hepatopancreaticobiliary (HPB) surgery. BACKGROUND: High-volume (HV) centers for HPB surgery have lower mortality than LV. Strategies for collaboration between HV and LV centers are not well investigated. METHODS: Postoperative outcomes of patients undergoing curative HPB resection were evaluated at an LV hospital before (2006-2008) and during the collaboration (2009-2012) and at 2 hospitals with HV for either liver or pancreatic resection (2009-2012). Itinerant tutor surgeons from the HV centers were involved in the pre-, intra- and postoperative course of HPB patients at the LV hospital. RESULTS: HPB cases at the LV center increased from 18 to 40 patients per year from 2006 to 2012, whereas 6-month postoperative mortality decreased from 17.8% (2006-2008) to 6% (2009-2012), P<0.05 (liver: 10.3% vs 4.7% and pancreas: 29.4% vs 7.9%). During the collaborative study period, outcomes for hepatectomy were similar for LV and HV (85 vs 507 cases): postoperative Clavien-Dindo scores 4 and 5 were 2% and 0.2% for HV versus 2.4% and 1.2% for LV, respectively. Outcomes for pancreatic procedures (LV 63 vs HV 269 cases) showed better postoperative Clavien-Dindo scores 4 and 5 in the HV (0.7% score 4 and 1.5% score 5 for HV vs 3.2% and 6.3%, respectively, for LV) but the difference disappeared in the last 2 years (2011-2012) and matching the cases. CONCLUSIONS: Our partnership model helped improve postoperative outcomes at the LV center. Results at the LV hospital were comparable with the HV centers, although 2 years of partnership were required to achieve this in pancreatic surgery.

Liver transplantation for hepatic tumors: a systematic review.

Improvements in the medical and pharmacological management of liver transplantation (LT) recipients have led to a better long-term outcome and extension of the indications for this procedure. Liver tumors are relevant to LT; however, the use of LT to treat malignancies remains a debated issue because the high risk of recurrence. In this review we considered LT for hepatocellular carcinoma (HCC), cholangiocarcinoma (CCA), liver metastases (LM) and other rare tumors. We reviewed the literature, focusing on the past 10 years. The highly selected Milan criteria of LT for HCC (single nodule < 5 cm or up to 3 nodules < 3 cm) have been recently extended by a group from the University of S. Francisco (1 lesion < 6.5 cm or up to 3 lesions < 4.5 cm) with satisfying results in terms of recurrence-free survival and the "up-to-seven criteria". Moreover, using these criteria, other transplant groups have recently developed downstaging protocols, including surgical or loco-regional treatments of HCC, which have increased the post-operative survival of recipients. CCA may be treated by LT in patients who cannot undergo liver resection because of underlying liver disease or for anatomical technical challenges. A well-defined protocol of chemoirradiation and staging laparotomy before LT has been developed by the Mayo Clinic, which has resulted in long term disease-free survival comparable to other indications. LT for LM has also been investigated by multicenter studies. It offers a real benefit for metastases from neuroendocrine tumors that are well differentiated and when a major extrahepatic resection is not required. If LT is an option in these selected cases, liver metastases from colorectal cancer is still a borderline indication because data concerning the disease-free survival are still lacking. Hepatoblastoma and hemangioendothelioma represent rare primary tumors for which LT is often the only possible and effective cure because of the frequent multifocal, intrahepatic nature of the disease. LT is a very promising procedure for both primary and secondary liver malignancies; however, it needs an accurate evaluation of the costs and benefits for each indication to balance the chances of cure with actual organ availability.