Long-term outcome after laparoscopic fenestration of simple liver cysts.

BACKGROUND: Simple liver cysts (LCs) represent the most common benign liver disease, with a prevalence of 3-5%. Laparoscopic fenestration is considered the best treatment for symptomatic LCs, but few studies have analyzed the rate or type of recurrence during a long-term follow-up period (>5 years). METHODS: Between January 2000 and December 2010, 47 patients underwent laparoscopic fenestration for simple LCs. The indications were symptoms for 42 patients and an uncertain diagnosis for five patients. The follow-up assessment consisted of regular patient evaluations, with results of laboratory data and liver ultrasound. RESULTS: Conversion to laparotomy was not necessary in any case. The postoperative mortality and morbidity rates were nil. The mean follow-up period was 67 months (range 12-142 months), and 26 patients (55.3%) had a follow-up period longer than 5 years. During the follow-up period, 40 patients (85.1%) did not present with any type of recurrence. The overall recurrence rate was 14.9% (seven patients) based on five patients (10.6%) with radiologic asymptomatic recurrences detected by ultrasound or computed tomography (CT) scan and two patients (4.3%) with clinicoradiologic symptomatic recurrences. Both symptomatic recurrences involved LCs located in the right posterior segments. CONCLUSIONS: Laparoscopic fenestration provided complete relief of symptoms for about 95% of patients with simple LCs. Recurrence after surgery was experienced by 14.9% of the patients, but only in 4.3% (two patients) was this recurrence symptomatic requiring a second treatment. The site of recurrence was more frequently in the right posterior segments. Laparoscopic fenestration of symptomatic LCs can be considered a safe and effective procedure that can yield good long-term results.

Bile duct injury after cholecystectomy: timing of surgical repair should be based on clinical presentation. The experience of a tertiary referral center with Hepp-Couinaud hepatico-jejunostomy.

Impact of timing of repair on outcomes of patients repaired with Hepp-Couinaud hepatico-jejunostomy (HC-HJ) after bile duct injury (BDI) during cholecystectomy remains debated. This is an observational retrospective study at a tertiary referral hepato-biliary center. HC-HJ was always performed in patients without sepsis or bile leak and with dilated bile ducts. Timing of repair was classified as: early (≤ 2 weeks), intermediate (> 2 weeks, ≤ 6 weeks), and delayed (> 6 weeks). 114 patients underwent HC-HJ between 1994 and 2022: 42.1% underwent previous attempts of repair at referring institutions (Group A) and 57.9% were referred without any attempt of repair before referral (Group B). Overall, a delayed HC-HJ was performed in 78% of patients; intermediate and early repair were performed in 17% and 6%, respectively. In Group B, 10.6% of patients underwent an early, 27.3% an intermediate, and 62.1% a delayed repair. Postoperative mortality was nil. Median follow-up was 106.7 months. Overall primary patency (PP) attainment rate was 94.7%, with a 5- and 10-year actuarial primary patency (APP) of 84.6% and 84%, respectively. Post-repair bile leak was associated with PP loss in the entire population (odds ratio [OR] 9.75, 95% confidence interval [CI] 1.64-57.87, p = 0.012); no correlation of PP loss with timing of repair was noted. Treatment of anastomotic stricture (occurred in 15.3% of patients) was performed with percutaneous treatment, achieving absence of biliary symptoms in 93% and 91% of cases at 5 and 10 years, respectively. BDI can be successfully repaired by HC-HJ regardless of timing when surgery is performed in stable patients with dilated bile ducts and without bile leak.

Computerized correction of blood base excess to full hemoglobin-O2 saturation.

BACKGROUND AND OBJECTIVE: A mathematical procedure was developed to obtain an accurate coefficient (-∆BEB) for the correction of blood base excess to full hemoglobin-O2 saturation taking into account actual 2,3-diphosphoglycerate (2,3-DPG) concentration. METHODS: Previously published laboratory data were carefully processed through regression analysis, by correlating laboratory measurements of -∆BEB with the corresponding values of plasma pH, CO2 tension and 2,3-DPG. RESULTS: Data processing allowed the development of two accurate fits to the original laboratory results for blood with normal 2,3-DPG and for blood depleted of 2,3-DPG (r2 = 0.990 and 0.986, respectively, p < 0.0001 for both), as the main components of a procedure for estimating the correction factor in normal conditions and in moderate-to-extreme illness with extreme acid-base abnormalities. CONCLUSIONS: This regression-derived procedure can easily integrate any computer system to automatically obtain an accurate correction factor on the basis of plasma pH, CO2 tension, and 2,3-DPG concentration if available. It may also allow for the assessment of small stoichiometric quantities involved in O2-linked H+ exchange and equilibrium (Haldane effect) in computer programs dedicated to these types of investigations.

Increased ratio of P[v-a]CO2 to C[a-v]O2 without global hypoxia: the case of metformin-induced lactic acidosis.

The ratio of venoarterial CO2 tension to arteriovenous O2 content difference (P[v-a]CO2/C[a-v]O2) increases when lactic acidosis is due to inadequate oxygen supply (hypoxia); we aimed to verify whether it also increases when lactic acidosis develops because of mitochondrial dysfunction (dysoxia) with constant oxygen delivery. Twelve anaesthetised, mechanically ventilated pigs were intoxicated with IV metformin (4.0 to 6.4 g over 2.5 to 4.0 h). Saline and norepinephrine were used to preserve oxygen delivery. Lactate and P[v-a]CO2/C[a-v]O2 were measured every one or two hours (arterial and mixed venous blood). During metformin intoxication, lactate increased from 0.8 (0.6-0.9) to 8.5 (5.0-10.9) mmol/l (p < 0.001), even if oxygen delivery remained constant (from 352 ± 78 to 343 ± 97 ml/min, p = 0.098). P[v-a]CO2/C[a-v]O2 increased from 1.6 (1.2-1.8) to 2.3 (1.9-3.2) mmHg/ml/dl (p = 0.004). The intraclass correlation coefficient between lactate and P[v-a]CO2/C[a-v]O2 was 0.72 (p < 0.001). We conclude that P[v-a]CO2/C[a-v]O2 increases when lactic acidosis is due to dysoxia. Therefore, a high P[v-a]CO2/C[a-v]O2 may not discriminate hypoxia from dysoxia as the cause of lactic acidosis.

Erratum to "Prognostic Role of Serum Amino Acids in Head and Neck Cancer".

[This corrects the article DOI: 10.1155/2020/2291759.].

Does hepatic pedicle clamping affect disease-free survival following liver resection for colorectal metastases?

OBJECTIVE: To evaluate the impact of liver ischemia from hepatic pedicle clamping (HPC) on long-term outcome after hepatectomy for colorectal liver metastases (CRLM). BACKGROUND: Liver resection offers the only chance of cure for patients with CRLM. Several clinical and pathologic factors have been reported as determinants of poor outcome after hepatectomy for CRLM. A controversial issue is that hepatic ischemia/reperfusion injury from HPC may adversely affect long-term outcome by accelerating the outgrowth of residual hepatic micrometastases. METHODS: Patients undergoing liver resection for CRLM in 2 tertiary referral centers, between 1992 and 2008, were included. Disease-free survival and specific liver-free survival were analyzed according to the use, type, and duration of HPC. RESULTS: Five hundred forty-three patients had primary hepatectomy for CRLM. Hepatic pedicle clamping was performed in 355 patients (65.4%), and intermittently applied in 254 patients (71.5%). Postoperative mortality and morbidity rates were 1.3% and 18.5%, respectively. Hepatic pedicle clamping had a highly significant impact in reducing the risk of blood transfusions and was not correlated with significantly higher postoperative morbidity. Liver recurrence rate was not significantly different according to the use, type, and duration of HPC, in patients resected after preoperative chemotherapy as well. On univariate analysis, HPC did not significantly affect overall and disease-free survival. These results were confirmed on the multivariate analysis where blood transfusions, primary tumor nodal involvement, and the size of CRLM of more than 5 cm prevailed as determinants of poor outcome. CONCLUSIONS: This study confirms the safety and effectiveness of HPC and demonstrates that in the human situation, there is no evidence that HPC may adversely affect long-term outcome after hepatectomy for CRLM.

Prognostic Role of Serum Amino Acids in Head and Neck Cancer.

INTRODUCTION: Serum amino acid (AA) profiles represent a valuable tool in the metabolic assessment of cancer patients; still, information on the AA pattern in head and neck cancer (HNC) patients is insufficient. The aim of the study was to assess whether serum AA levels were associated with the stage of neoplastic disease and prognosis in primary HNC patients. METHODS: Two hundred and two primary HNC patients were included in the study. Thirty-one AAs and derivatives were measured in serum through an ultraperformance liquid chromatography-mass spectrometry (UPLC-MS). The association between AA concentrations and the stage (advanced versus early) of HNC was estimated using a multivariable logistic regression model. A multivariable Cox regression model was used to evaluate the prognostic significance of each AA. RESULTS: At the multivariable logistic regression analysis, increased levels of alpha-aminobutyric acid, aminoadipic acid, histidine, proline, and tryptophan were associated with a reduced risk of advanced stage HNC, while high levels of beta-alanine, beta-aminobutyric acid, ethanolamine, glycine, isoleucine, 4-hydroxyproline, and phenylalanine were associated with an increased risk of advanced stage HNC. Furthermore, at multivariate analysis, increased levels of alpha-aminobutyric acid were associated with increased overall survival (OS), while high levels of arginine, ethanolamine, glycine, histidine, isoleucine, 4-hydroxyproline, leucine, lysine, 3-methylhistidine, phenylalanine, and serine were associated with decreased OS. CONCLUSIONS: Our study suggests that AA levels are associated with the stage of disease and prognosis in patients with HNC. More study is necessary to evaluate if serum AA levels may be considered a hallmark of HNC and prove to be clinically useful markers of disease status and prognosis in HNC patients.

Hypotransferrinemia and changes in plasma lipid and metabolic patterns in sepsis.

This study was performed to obtain a characterization of the changes in plasma transferrin (Tf, g/L) in sepsis. More than four hundred determinations of Tf, and of a large series of simultaneously collected blood and hemodynamic variables, were obtained in 17 patients with post-traumatic sepsis. Tf during sepsis was consistently low (mean +/- SD = 1.46 +/- 0.46) however fluctuated markedly according to changes in metabolic and hemodynamic patterns. Regression analysis showed that decreases in Tf were simultaneously correlated with the plasma lipid pattern (in particular with decreasing cholesterol and increasing triglycerides), with decreases in albumin and peripheral O2 extraction, and with increasing cardiac index (p < 0.001 for all). Decreases in Tf were moderated by increasing the parenteral amino acid dose (p < 0.001). Combinations of these variables in multiple regressions explained nearly 80% of the variability of Tf. There were no similar correlations for other acute phase proteins except ceruloplasmin, which showed opposite changes compared to those of Tf. These results show that within the hypotransferrinemia which characterizes sepsis, Tf may oscillate remaining strongly correlated with changes in metabolic and hemodynamic patterns, which may account for nearly 80% of the variability of Tf.

Role of the surgeon as a variable in long-term survival after liver resection for colorectal metastases.

BACKGROUND AND OBJECTIVES: Survival analyses after hepatectomy for colorectal liver metastases (CRLM) mostly address tumor-related factors; this study has simultaneously evaluated interventional factors which may be influenced by the surgeon. METHODS: Operative and long-term results of 251 consecutive patients undergoing hepatectomy for CRLM between 1992 and 2007 were analyzed. RESULTS: Mortality was 0.8%, morbidity 22.9%, intraoperative blood transfusion rate 23.1% (19.4% with pedicle clamping, 35.0% without clamping, P = 0.01), R0-resection 93.6% (2/3 with tumor-free margin >5 mm). The 3-, 5-, 10-year overall and disease-free survival rates were 55.2%, 38.9%, 24.2%, and 37.1%, 28.2%, 25.4%. Univariate analysis: lower survival was related to transfusion requirement, tumor size >5 cm, tumor-free margin < or =5 mm, major hepatectomy, R1-resection, multiplicity of CRLM, preoperative CEA > or =50 ng/ml. Multivariate analysis: intraoperative transfusion remained the only independent predictor of survival; tumor-free margin < or =5 mm and multiplicity of CRLM remained independent predictors of disease-free survival within 12 months from hepatectomy; intraoperative transfusion became again the prominent predictor for later recurrences. CONCLUSIONS: Two factors may be influenced by the surgeon: bleeding with requirement for blood transfusion (through the protective effect of pedicle clamping) and width of tumor-free surgical margin. These factors have prominent roles on long-term outcomes after hepatectomy for CRLM.

Left hepatectomy for metastatic thrombosis of umbilical vein and left portal vein from renal cell carcinoma.

Renal cell carcinoma is an aggressive tumor which is often advanced at the time of diagnosis; its distant spread can take a lymphatic route or, more often, a vascular route (renal vein and inferior vena cava), but tumor thrombosis of left portal vein extending into the round ligament (the umbilical vein) coming from this tumor, to our knowledge, has never been described. We report the case of a metastatic thrombosis of left portal vein and of the umbilical vein from renal cell carcinoma, developed 13 years after nephrectomy, which was successfully treated with left hepatectomy. The experience with hepatectomy for metastatic renal cell carcinoma has been rarely reported. Nevertheless radical hepatectomy is considered to be the only opportunity for curative treatment for selected patients with metastatic renal cell carcinoma.

[Primary intrahepatic lithiasis: indications and results of liver resection]. / La calcolosi intraepatica primaria: indicazioni e risultati del trattamento chirurgico resettivo.

The aim of this study was to review a series of patients submitted to hepatectomy for primary intrahepatic lithiasis to evaluate early and late results with an assessment of indications, methods and long-term outcomes. From January 1992 to December 2007, 40 patients (25 males and 15 females with a mean age of 51 years) underwent surgery for primary intrahepatic lithiasis in our Hepato-biliary Surgery Unit. Left hepatectomy (20 patients) and left lateral segmentectomy (12 patients) were the most common procedures performed. A cholangiocarcinoma was found in 4 patients (10%) and only two of these underwent liver resection, while an exploratory laparotomy was performed in the remaining two patients for an unresectable tumour, unexpected before surgery. There was no postoperative mortality. The morbidity rate was 22.5% with a prevalence of infectious complications related to bile leakage. Long-term results, assessed in 30 patients with a follow-up longer than 12 months, were good or fair in 28 patients (93.3%). Primary intrahepatic lithiasis is diagnosed increasingly in Western countries as a result of the improvement in imaging techniques. The stones originate inside the liver at the level of dilatations of the bile ducts above congenital strictures of the main hilar ducts. Biliary pain and cholangitis are the most common presenting symptoms, whereas cholangiocarcinoma represents the unfavourable complication of the disease. In the majority of cases, a single liver lobe or segment is involved and liver resection allows definitive treatment of the disease and prevention of cancer.

The impact of R1 resection for colorectal liver metastases on local recurrence and overall survival in the era of modern chemotherapy: An analysis of 1,428 resection areas.

BACKGROUND: It is still unclear whether a positive surgical margin after resection of colorectal liver metastases remains a poor prognostic factor in the era of modern perioperative chemotherapy. The aim of this study was to evaluate whether preoperative chemotherapy has an impact on reducing local recurrence after R1 resection, and the impact of local recurrence on overall survival. METHODS: Between 2000 and 2014, a total of 421 patients underwent resection for colorectal liver metastases at our unit after preoperative chemotherapy. The overall number of analyzed resection areas was 1,428. RESULTS: The local recurrence rate was 12.8%, significantly higher after R1 resection than after R0 (24.5% vs 8.7%; P < .001). These results were also confirmed in patients with response to preoperative chemotherapy (23.1% after R1 vs 11.2% after R0; P < .001). At multivariate analysis, R1 resection was the only independent risk factor for local recurrence (P < .001). At the analysis of the 1,428 resection areas, local recurrence significantly decreased according to the increase of the surgical margin width (from 19.1% in 0 mm margin to 2.4% in ≥10 mm). At multivariable logistic regression analysis for overall survival, the presence of local recurrence showed a significant negative impact on 5-year overall survival (P < .001). CONCLUSION: Surgical margin recurrence after modern preoperative chemotherapy for colorectal liver metastases was still significantly higher after R1 resection than it was after R0 resection. Local recurrence showed a negative prognostic impact on overall survival. R0 resection should be recommended whenever technically achievable, as well as in patients treated by modern preoperative chemotherapy.

External lymphatic fistula after intra-abdominal lymphadenectomy for cancer. Treatment with total parenteral nutrition and somatostatin.

OBJECTIVE: External lymphatic fistula or chyloperitoneum after intra-abdominal lymphadenectomy may present challenging problems. In the absence of definite guidelines the choice of treatment is often empirical, with unpredictable effectiveness, and the reporting of new cases may broaden the available experience. METHODS: We describe two cases. One patient had high-output external fistula (1300 mL/d) after para-aortic lymphadenectomy for metastatic lymph nodes. The fistula became fully evident at postoperative day 4, with resumption of an oral diet, on the basis of a 1300-mL/d output of white milky fluid from an abdominal drainage. Oral feeding was interrupted and total parenteral nutrition was started; this was transiently associated with octreotide administration, subsequently replaced by somatostatin. The second patient had a low-output fistula (350 mL/d) after liver resection and lymphadenectomy for cholangiocarcinoma and underwent treatment with total parenteral nutrition and somatostatin. RESULTS: In the first case the lymphatic fistula healed in just less than 3 wk, with the patient constantly remaining in very good condition, without secondary complications. In the second case the low-output fistula healed more rapidly. CONCLUSION: Interruption of oral feeding with total parenteral nutrition and continuous somatostatin infusion was an effective treatment in both patients with an intra-abdominal lymphatic leak.

Liver resection for primarily unresectable colorectal metastases downsized by chemotherapy.

This study was performed prospectively to assess the effect of systemic chemotherapy (FOLFIRI protocol) in patients with initially unresectable colorectal liver metastases (CRLM) and, after performing liver resection in patients with downsized metastases, to compare the postoperative and long-term results with those of patients with primarily resectable CRLM. Records from a prospective database including all consecutive admissions for CRLM between June 2000 and June 2004 were reviewed. The analysis addressed all patients who underwent hepatectomy for primarily resectable CRLM (Group A), or underwent chemotherapy for primarily unresectable CRLM and among these, particularly the patients who were finally resected after downsizing of CRLM (Group B). There were 60 primarily resected patients (Group A). Forty-two other patients underwent chemotherapy; after an average of nine courses, 18 of them (42.8%) with significantly downsized lesions were explored and 15 (35.7%, Group B) were resected, whereas three had peritoneal metastases. Group B differed from Group A for a significantly higher rate of synchronous CRLM upon diagnosis of colorectal cancer, a larger size of CRLM upon evaluation in our center, and a lower rate of major hepatectomies (20.0% vs. 51.6 %) at surgery. No patient in Group B had positive margins of resection. Operative mortality was nil and morbidity was 20.0% in both groups. In Group B vs. Group A median survival after hepatectomy was 46 vs. 47 months (n.s), 3-year survival rate was 73% vs. 71% (n.s.), disease-free survival rate was 31% vs. 58% (p = 0.04) and, at a median follow-up of 34 months, tumor recurrence rate was 53.3% vs. 28.3% (n.s.). Four out of the eight Group B patients with recurrence underwent a re-resection, and were alive at 9 to 67 months after the first resection. These results show that in about one-third of the patients with primarily unresectable CRLM, downsizing of the lesions by chemotherapy (FOLFIRI protocol) permitted a subsequent curative resection. In these patients, operative risk and survival did not differ from the figures observed in primarily resectable patients and, in spite of a lower disease-free survival with more frequent recurrence, re-resection still represented a valid option to continue treatment.

Hanging maneuver in right hepatectomy for recurrent metastases with diaphragmatic infiltration after radiofrequency ablation: a new indication.

The liver hanging maneuver is a safe technique to prevent bleeding during transection when a right hepatectomy by an anterior approach, without previous mobilization of the liver, is required. This article proposes a new indication for this technique. The liver hanging maneuver may be useful during right hepatectomy for local recurrence of liver metastases previously treated by radiofrequency ablation (RFA). In these cases, necrosis or fibrosis induced by RFA and local recurrence may cause strong adhesions between liver parenchyma and the diaphragm, thus increasing the risk of bleeding during liver mobilization. Between January 2003 and March 2006, seven patients with recurrent colorectal liver metastases of the right hemiliver, after previous treatment by RFA, underwent right hepatectomy. Liver resection was feasible with the proposed technique in all patients. In four cases, a limited diaphragmatic resection was associated. There was no mortality. Postoperative morbidity was 42.8 per cent. An anterior approach with the liver hanging maneuver for recurrent liver metastases after RFA should be recommended when the metastases are located posteriorly, are not detachable from the diaphragm, and the preliminary mobilization of the right liver may be difficult.

Clinical use of plasma chitotriosidase in severe sepsis.

Plasma chitotriosidase activity (ChT) was previously proposed to quantify severity of sepsis. In a complex surgical case, with prolonged sepsis and consistently high ChT, we found that the least increased values occurred in stages of extreme illness, with profound hypocholesterolemia. ChT needs better characterization before becoming a reliable biomarker of septic evolution.