Case-matched analysis of totally laparoscopic versus open liver resection for HCC: short and middle term results.

BACKGROUND AND OBJECTIVES: Laparoscopy is gaining acceptance as a safe procedure for resection of liver neoplasms. The aim of this study is to evaluate surgical results and mid-term survival of minor hepatic resection performed for HCC. METHODS: Data of 16 patients with HCC, undergoing laparoscopic hepatectomy from September 2005 to January 2009, were compared to a control group of 16 patients who underwent open resection (OR) during the same period. The two groups were matched in terms of type of resection, tumor size, and severity of cirrhosis. RESULTS: One patient underwent conversion to an open approach. Laparoscopic approach resulted in shorter operating time (150 min, P:0.044) and lower blood loss (258 ml, P:0.008). There was no difference in perioperative morbidity and mortality rate; laparoscopic approach was associated with a shorter hospital stay (6.3 days, P:0.039). After a mean follow up of 32 months, disease free survival and overall survival were 40.2 and 23.3 months for laparoscopic group, and 47.7 and 31.4 months for OR group (P NS). CONCLUSION: Laparoscopic resection of HCC is feasible and safe in selected patients and can result in good surgical results, with similar outcomes in terms of overall and disease-free survival.

Liver resection with portal vein thrombectomy for hepatocellular carcinoma with vascular invasion.

INTRODUCTION: Hepatocellular carcinoma (HCC) tends to invade the intrahepatic vasculature, especially the portal vein. The presence of portal vein tumor thrombus (PVTT) in patients with HCC is one of the most significant factors for a poor prognosis. The presence of macroscopic PVTT in patients with HCC is also a significant factor for poor prognosis, with a median survival of <3 months without treatment. In surgically resected series, in patients with gross PVTT (PVTT in the portal trunk, its first-order branch, or its second-order branch), the 3-year and 5-year survival rates are reportedly 15% to 28% and 0% to 17%, respectively. METHODS: The patient was a 77-year-old woman with well-compensated hepatitis C virus-related cirrhosis (stage A6 according to Child-Pugh classification) who sought care at our department for vague abdominal discomfort. Triphasic spiral computed tomographic scan confirmed HCC 6 cm in diameter in the left lobe of the liver. In addition, portal vein tumor thrombosis of the left branch that extended to the right portal vein was present. RESULTS: The procedure included left hepatectomy and en-bloc portal vein thrombectomy with clamping of both the common portal vein trunk and the right portal vein. The portal vein was incised at the bifurcation of the right and left portal veins, and the thrombus was extracted from the incision in the portal vein. With this procedure, we were able to examine under direct vision the exact extent of the portal vein thrombus, and we identified whether the tumor thrombus was adherent to the venous wall or was freely floating in the venous lumen. Portal clamping and length of operation were 16 and 330 minutes, respectively. Intraoperative blood loss was 550 mL. The patient was discharged on postoperative day 6, and she was free of disease at 15 months after surgery. DISCUSSION: Liver resection should be considered a valid therapeutic option for HCC with PVTT.

Oxidative stress induction by the invasive sponge Paraleucilla magna growing on Peyssonnelia squamaria algae.

The introduction of invasive species can lead to significant adverse effects on the colonized areas. The aim of the present research was to determine if the invasive behavior of Paraleucilla magna could induce the activation of the antioxidant defences in the native red algae, Peyssonnelia squamaria. Individuals of isolated P. squamaria and individuals epiphytized by P. magna, both growing on rocky bottoms, were collected. The activity of the antioxidant enzymes - catalase, superoxide dismutase, glutathione peroxidase and glutathione reductase - and the levels of the malondialdehyde were significantly higher in the algae of the epiphytic group compared to the control group, while the detoxifying enzyme glutathione S-transferase did not show significant differences. The levels of reduced glutathione and total polyphenols were higher in the algae affected by the sponge. In conclusion, the arrival of the species P. magna induces an adaptative antioxidant response in P. squamaria determined by the use of biomarkers.

Results of preoperative hepatic arterial infusion chemotherapy in patients undergoing liver resection for colorectal liver metastases.

BACKGROUND: Although hepatic artery infusion chemotherapy (HAIC) of floxuridine (FUDR) for colorectal liver metastases (CLM) can produce high response rates, data concerning preoperative HAIC are scarce. The aim of this study was to assess the feasibility and results of liver resection after preoperative HAIC with FUDR. METHODS: Between 1995 and 2004, 239 patients with isolated CLM received HAIC in our institution. Fifty of these patients underwent subsequent curative liver resection (HAIC group). Short- and long-term results of the HAIC group were compared with the outcomes of 50 patients who underwent liver resection for CLM without preoperative chemotherapy. RESULTS: Postoperative morbidity rate were comparable between the two groups. Overall disease-free survival at 1 and 3 years after hepatectomy were 77.5% and 57.5% in the HAIC group and 62.9% and 37% in the control group (P = .036). Overall survival from diagnosis of CLM at 1, 3, and 5 years were 97%, 59%, and 49% in the HAIC group versus 94%, 48%, and 35% in the control group (P = .097). When patients were stratified according to clinical-risk scoring (CRS) system, patients with more advanced disease at the time of liver resection (CRS > or = 3) had a median survival of 41 months in the HAIC group (n = 37) and 35 months in the control group (n = 34) (P = .031). CONCLUSIONS: HAIC of FUDR does not negatively affect the outcome of subsequent liver resection. Preoperative HAIC of FUDR may reduce liver recurrence rate and improve long-term survival in patients with more advanced liver disease.

A prospective evaluation of laparoscopic versus open left lateral hepatic sectionectomy.

BACKGROUND: Left lateral sectionectomy is one of the most commonly performed laparoscopic liver resections, but limited clinical data are actually available to support the advantage of laparoscopic versus open-liver surgery. The present study compared the short-term outcomes of laparoscopic versus open surgery in a case-matched analysis. MATERIALS AND METHODS: Surgical outcome of 20 patients who underwent left lateral sectionectomy by laparoscopic approach (LHR group) from September 2005 to January 2007 were compared in a case-control analysis with those of 20 patients who underwent open left lateral sectionectomy (OHR group). Both groups were similar for: tumor size, preoperative laboratory data, presence of cirrhosis, and histology of the lesion. Surgical procedures were performed in both groups combining the ultrasonic dissector and the ultrasonic coagulating cutter without portal clamping. RESULTS: Compared with OHR, the LHR group had a decreased blood loss (165 mL versus 214 mL, P=0.001), and earlier postoperative recovery (4.5 versus 5.8 days, P=0.003). There were no significant differences in terms of surgical margin and operative time. Morbidity was comparable between the two groups, but two cases of postoperative ascites were recorded in two cirrhotic patients in the OHR. Major complications were not observed in either groups. CONCLUSIONS: Laparoscopic resection results in reduced operative blood loss and earlier recovery with oncologic clearance and operative time comparable with open surgery. Laparoscopic liver surgery may be considered the approach of choice for tumors located in the left hepatic lobe.

Laparoscopic liver resection without portal clamping: a prospective evaluation.

BACKGROUND: Previous comparative studies have demonstrated that laparoscopic liver resection is associated with more frequent use and longer duration of portal camping than open liver resection, a fact that may partially explain the improvement in operative blood loss reported by most series of laparoscopic liver resection. The aim of this prospective study was to evaluate the real need for portal clamping in laparoscopic liver surgery. STUDY DESIGN: Surgical outcomes of 40 consecutive patients who underwent laparoscopic liver resection for benign and malignant lesions from September 2005 to August 2007 were evaluate. Portal clamping was not systematically used. RESULTS: No patient required blood transfusion and median blood loss was 160 ml (range 100-340 ml). Mean operating time was 267 min (range 220-370 min) and portal clamping was necessary in only one patient. Surgical complications included two grade I complication, three grade II, and one case of postoperative hemorrhage (grade III). CONCLUSIONS: Laparoscopic liver surgery without clamping can be performed safely with low blood loss.

Microplastic in marine organism: Environmental and toxicological effects.

Microplastics are tiny ubiquitous plastic particles present in marine environments. They are not an individual entity, but constitute a cocktail of polymers and additives that can absorb substances from the surrounding environment, including living substances, nutrients and marine pollutants. Given their small size (< 5 µm), microplastics can be ingested by a wide range of marine organisms with the potential to cause harms. Microplastics are a growing threat for marine biota and ecosystem. For organisms, the risks associated with microplastic ingestion are not only due to the material itself, but also to its ability to absorb and concentrate environmental contaminants in seawater and subsequently transfer them through food chains. Moreover, microplastics could influence ecological processes. Recently, plastic debris are recognized as emerging pollutants and represent a great risk for marine biodiversity worldwide. Here, we summarize the main effects of plastics and microplastics on some marine organisms and ecosystem.

Preoperative methylprednisolone administration maintains coagulation homeostasis in patients undergoing liver resection: importance of inflammatory cytokine modulation.

Alterations in hemostatic parameters are a common finding after major hepatic resection. There is growing evidence that inflammation has a significant role in inducing coagulation disarrangement that follows major surgery. To determine whether preoperative methylprednisolone administration has a protective effect against the development of coagulation disorders, we evaluated the effect of preoperative steroids administration on changes in hemostatic parameters and plasma levels of inflammatory cytokines in patients undergoing liver surgery. Seventy-three patients undergoing liver resection were randomized to a steroid group or to a control group. Patients in the steroid group received 500 mg of methylprednisolone preoperatively. Serum levels of coagulation parameters (prothrombin time, platelets, fibrinogen, plasma fibrin degradation products [D-dimer], antithrombin III) and inflammatory mediators (IL-6 and TNF-alpha) were measured before and immediately after the operation and on postoperative days 1, 2, and 5. Multivariate analysis was performed to identify factors related to the characteristics of the patients and surgery affecting coagulation parameters between the two groups. Decreases in antithrombin III, platelet count and fibrinogen levels, prolongation of prothrombin time, and increases in the plasma fibrin degradation products were significantly suppressed by the administration of methylprednisolone. Cytokines production was also significantly suppressed by the administration of methylprednisolone, and there was significant correlation between plasma levels of cytokines and coagulation alterations. These findings suggest that preoperative methylprednisolone administration inhibits the development of coagulation disarrangements in patients undergoing liver resection, possibly through suppressing the production of inflammatory cytokines.

Omission of radiotherapy in elderly patients with early breast cancer: 15-Year results of a prospective non-randomised trial.

BACKGROUND: Whether radiotherapy (RT) is beneficial in elderly (⩾ 70 years) patients undergoing conservative surgery for early breast cancer has long been controversial. Recent randomised trials show that most elderly patients do not benefit from RT. We started a prospective non-randomised trial to address this issue in 1987 and now present results for the 627 consecutive pT1/2cN0 patients recruited, and treated by conservative surgery (quadrantectomy) and tamoxifen, and assigned non-randomly to RT or no RT. METHODS: We used multivariate competing risks models to estimate 15-crude cumulative incidence (CCI) of ipsilateral breast tumour recurrence (IBTR), distant metastasis and breast cancer mortality. The models incorporated a propensity score as a measure of probability of receiving RT based on baseline characteristics, to account for the lack of randomisation. RESULTS: For pT1 patients, 15-year CCIs of IBTR, distant metastasis and breast cancer death were indistinguishable in the RT and no RT groups. For pT2 patients, 15-year CCI of IBTR was much higher in those not given RT (14.6% versus 0.8%, p = 0.004), although breast cancer mortality and distant metastasis did not differ significantly between RT and no RT. CONCLUSIONS: Consistent with the findings of recent randomised trials, our long-term data indicate that most elderly, ER-positive patients with pT1 cN0 breast cancer treated by quadrantectomy do not benefit from RT. The 14.6% CCI of IBTR in our pT2 patients is an additional finding not presented in the trials and suggests that RT should be administered to elderly patients with pT2 disease.

Laparoscopic hepatic left lateral sectionectomy using the LaparoEndoscopic Single Site approach: evolution of minimally invasive liver surgery.

BACKGROUND/PURPOSE: Laparoscopic liver surgery is attracting wider interest for the treatment of benign and malignant neoplasms. Laparoscopy is a safe and feasible approach for lesions located in the left liver lobe. As the emphasis on minimizing the technique continues, single-port access surgery is quickly evolving. We present our initial experience of single-port laparoscopic liver surgery using a LaparoEndoscopic Single Site (LESS) approach with the TriPort System (ASC; Advanced Surgical Concepts, Bray, Ireland) to perform a left lateral sectionectomy via a single supraumbilical incision. METHODS: The abdomen was approached through a 15 mm supraumbilical incision and a single-port access device was used to perform a left lateral sectionectomy in a patient with a single colorectal metastasis. RESULTS: The total operative time was 145 min, with 50 ml blood loss. Hospital stay was 4 days. CONCLUSIONS: Single-port laparoscopic left lateral sectionectomy is a feasible procedure, when performed by experienced laparoscopic surgeons. It has to be determined whether or not this approach would offer benefit to patients, except in terms of cosmesis, compared to standard laparoscopic liver resection.

Impact of type of liver resection on the outcome of colorectal liver metastases: a case-matched analysis.

BACKGROUND: Wedge resection (WR) for colorectal liver metastases (CLM) has become more common in an attempt to preserve liver parenchyma. However, some investigator have reported that WR is associated with a higher incidence of positive margin and an inferior survival compared with anatomic resection (AR) 1. OBJECTIVES: This study evaluated survival, margin status, and pattern of recurrence of patients with CLM treated with WR or AR. METHODS: We identified 208 consecutive patients, in a single institutional database from 1995 to 2004, who underwent either WR or AR. WR was defined as a nonanatomic resection and AR was defined as single resection of one or two liver segments. Patients with combined WR-AR and patients requiring resection of more than two segments or radiofrequency ablation were excluded from the analysis. RESULTS: One hundred six patients underwent WR and 102 patients had AR. There were no differences in the rate of positive surgical margin (P = 0.146), overall recurrence rates (P = 0.211), and patterns of recurrence between the two groups (P = 0.468). The median survival was 32 months for WR and 42 for AR, with 5-year survival rates of 29% and 27% respectively, with no significant difference (P = 0.308). Morbidity was similar between the two groups. CONCLUSIONS: WR is a safe procedure and does not disadvantage the patients in terms of tumor recurrence and overall survival.

Ultrasonic-mediated laparoscopic liver transection.

Parenchymal liver transection represents a fundamental phase of liver surgery. Several devices have been described for safe and careful dissection of the liver parenchyma during laparoscopic liver surgery, but the ideal technique has not yet been defined. This report describes the combined use of ultrasonic dissector and the ultrasonic coagulating cutter for laparoscopic liver resection. The ultrasonic dissector is used to fracture the parenchyma along the line of proposed division, and the uncovered bridging structures are sealed using the ultrasonic coagulating cutter. The combined use of ultrasonic dissector and harmonic scalpel allows liver resection to be safely performed, with the advantage of minimal surgical complication and low blood losses.