Resective surgery for liver tumor: a multivariate analysis of causes and risk factors linked to postoperative complications

BACKGROUND: In spite of accurate selection of patients eligible for resection, and although advances in surgical techniques and perioperative management have greatly contributed to reducing the rate of perioperative deaths, stress must be placed on reducing the postoperative complication rates reported to be still as high as 50%. This study was designed to analyze the causes and foreseeable risk factors linked to postoperative morbidity on the grounds of data derived from a single-center surgical population. METHODS: From September 1989 to March 2005, 287 consecutive patients, affected either with HCC or liver metastasis, had liver resection at our department. Among the HCC series we recorded 98 patients (73.2%) in Child- Pugh class A, 32 (23.8%) in class B and 4 in class C (3%). In 104 colorectal metastases, 71% were due to colon cancer, 25% rectal, 3% sigmoid, and 1% anorectal. In 49 non-colorectal metastases, 22.4% were derived from breast cancer, 63.2% gastrointestinal tumors (excluding colon) and 14.4% other cancers. We performed 80 wedge resections, 77 bisegmentectomies and/or left lobectomies, 74 segmentectomies, 22 major hepatectomies, 20 left hepatectomies, and 14 trisegmentectomies. RESULTS: The in-hospital mortality rate in this series was 4.5%, and the morbidity rate was 47.7%, because of pleural effusion (30%), hepatic abscess (25%), hepatic insufficiency (19%), ascites (10%), hemoperitoneum (10%), or biliary fistula (6%). The variables associated with the technical aspects of the surgical procedure thatwere responsible for the complications were: a Pringle maneuver length more than 20 minutes (P=0.001); the type of liver resection procedure, including major hepatectomy (P=0.02), left hepatectomy (P=0.04), trisegmentectomy (P=0.04), bisegmentectomy and/or left lobectomy (P=0,04); and a blood transfusion of more than 600 ml (P=0.04). CONCLUSION: The evaluation of causes and foreseeable risk factors linked to postoperative morbidity during the planning of surgical treatment should play the same role as other factors weighed in the selection of patients eligible for liver resection.

Combined approach for spontaneous rupture of hepatocellular carcinoma

Ruptured hepatocellular carcinoma is a rare,emergency occurrence in western countries with high mortality risk.A number of hypotheses have been formulated in order to explain the precise mechanism that leads to hepatocellular carcinoma(HCC) rupture:sub-capsular location,dimensions,portal hypertension,tumour necrosis,local increase of venous pressure due to the outflow reduction caused by neoplastic invasion,and the presence of a previous vascular injury which might predispose to HCC rupture.There is still a debate in the literature concerning the best approach in cases of HCC rupture.Surgery is the first option for treatment of acute abdominal bleeding.However the advent of endovascular treatments widens the range of possible therapies for acute bleeding control and subsequent ablation purposes.We report a case of hemoperitoneum from spontaneous rupture of undiagnosed HCC,that was treated successfully by emergency surgical resection followed by transarterial chemo-embolizationfor local recurrence.

Role for contrast-enhanced ultrasound in assessing complications after kidney transplant

Kidney transplantation(KT)is an effective treatment for end-stage renal disease.Despite their rate has reduced over time,post-transplant complications still represent a major clinical problem because of the associated risk of graft failure and loss.Thus,post-KT complications should be diagnosed and treated promptly.Imaging plays a pivotal role in this setting.Grayscale ultrasound(US)with color Doppler analysis is the first-line imaging modality for assessing complications,although many findings lack specificity.When performed by experienced operators,contrast-enhanced US(CEUS)has been advocated as a safe and fast tool to improve the accuracy of US.Also,when performing CEUS there is potentially no need for further imaging,such as contrast-enhanced computed tomography or magnetic resonance imaging,which are often contraindicated in recipients with impaired renal function.This technique is also portable to patients’bedside,thus having the potential of maximizing the cost-effectiveness of the whole diagnostic process.Finally,the use of blood-pool contrast agents allows translating information on graft microvasculature into time-intensity curves,and in turn quantitative perfusion indexes.Quantitative analysis is under evaluation as a tool to diagnose rejection or other causes of graft dysfunction.In this paper,we review and illustrate the indications to CEUS in the post-KT setting,as well as the main CEUS findings that can help establishing the diagnosis and planning the most adequate treatment.

Non-erosive and uncomplicated erosive reflux diseases:Difference in physiopathological and symptom pattern

AIM:To investigate differences in the physiopathological findings(manometry and pH monitoring) and symptoms between cases of non-erosive reflux disease(NERD) and erosive reflux disease(ERD) found positive at 24 h pH monitoring. METHODS:For a total of 670 patients who underwent 24 h pH monitoring,esophageal manometry and upper endoscopy were retrospectively evaluated,assessing the reflux symptoms,manometric characteristics of the lower esophageal sphincter(LES) and esophageal body and the presence or absence of esophagitis and hiatal hernia. Typical and atypical symptoms were also evaluated. For inclusion in the study,patients had to have NERD or ERD and be found positive on pH monitoring(NERD+) . Patients with Gastroesophageal reflux disease(GERD) complicated by stenosis,ulcers or Barrett's esophagus were ruled out. RESULTS:214 patients were involved in the study,i.e. 107 cases of NERD+ and 107 of ERD. There were no significant gender-or age-related differences between the two groups. The ERD group had more cases of hiatal hernia(P = 0.02) and more acid reflux,both in terms of number of reflux episodes(P = 0.01) and as a percentage of the total time with a pH < 4(P = 0.00) ,when upright(P = 0.007) and supine(P = 0.00) . The NERD+ cases had more reflux episodes while upright(P = 0.02) and the ERD cases while supine(P = 0.01) . The LES pressure was higher in cases of NERD+(P = 0.03) while the amplitude and duration of their esophageal peristaltic waves tended to be better than in the ERD group(P >0.05) . The NERD+ patients presented more often with atypical symptoms(P = 0.01) . CONCLUSION:The NERD+ patients' fewer reflux episodes and the fact that they occurred mainly while in the upright position(unlike the cases of ERD) may be two factors that do not favor the onset of esophagitis. The frequently atypical symptoms seen in patients with NERD+ need to be accurately evaluated for therapeutic purposes because patients with GERD and atypical symptoms generally respond only partially to medical and surgical treatments.

Pros and cons of liver transplantation in human immunodeficiency virus infected recipients

Before the introduction of combined highly antiretroviral therapy,a positive human immunodeficiency virus(HIV)serological status represented an absolute contraindication for solid organ transplant(SOT).The advent of highly effective combined antiretroviral therapy in 1996 largely contributed to the increased demand for SOT in HIV-positive individuals due to increased patients’life expectancy associated with the increasing prevalence of end-stage liver disease(ESLD).Nowadays,liver failure represents a frequent cause of mortality in the HIV-infected population mainly due to coinfection with hepatitis viruses sharing the same way of transmission.Thus,liver transplantation(LT)represents a reasonable approach in HIV patients with stable infection and ESLD.Available data presently supports with good evidence the practice of LT in the HIV-positive population.Thus,the issue is no longer"whether it is correct to transplant HIV-infected patients",but"who are the patients who can be safely transplanted"and"when is the best time to perform LT".Indeed,the benefits of LT in HIV-infected patients,especially in terms of mid-and long-term patient and graft survivals,are strictly related to the patients’selection and to the correct timing for transplantation,especially when hepatitis C virus coinfection is present.Aim of this article is to review the pros and cons of LT in the cohort of HIV infected recipients.