Current management of hepatocellular carcinoma

Hepatocellular carcinoma(HCC)is the sixth most common cancer worldwide and leading cause of death among patients with cirrhosis.Treatment guidelines are based according to the Barcelona Clinic Liver Cancer staging system.The choice among therapeutic options that include liver resection,liver transplantation,locoregional,and systemic treatments must be individualized for each patient.The aim of this paper is to review the outcomes that can be achieved in the treatment of HCC with the heterogeneous therapeutic options currently available in clinical practice.

Critical care management and intensive care unit outcomes following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

AIM To study the early postoperative intensive care unit(ICU) management and complications in the first 2 wk of patients undergoing cytoreductive surgery(CRS) and hyperthermic intraperitoneal chemotherapy(HIPEC).METHODS Our study is a retrospective, observational study per-formed at Icahn School of Medicine at Mount Sinai, quaternary care hospital in New York City. All adult patients who underwent CRS and HIPEC between January 1, 2007 and December 31, 2012 and admitted to ICU postoperatively were studied. Fifty-one patients came to the ICU postoperatively out of 170 who underwent CRS and HIPEC therapy during the study period. Data analysis was performed using descriptive statistics.RESULTS Of the 170 patients who underwent CRS and HIPEC therapy, 51(30%) came to the ICU postoperatively. Mean ICU length of stay was 4 d(range 1-60 d) and mean APACHE Ⅱ score was 15(range 7-23). Thirtyone/fifty-one(62%) patients developed postoperative complications. Aggressive intraoperative and postoperative fluid resuscitation is required in most patients. Hypovolemia was seen in all patients and median amount of fluids required in the first 48 h was 6 L(range 1-14 L). Thirteen patients(25%) developed postoperative hypotension with seven requiring vasopressor support. The major cause of sepsis was intraabdominal, with 8(15%) developing anastomotic leaks and 5(10%) developing intraabdominal abscess. The median survival was 14 mo with 30 d mortality of 4%(2/51) and 90 d mortality of 16%(8/51). One year survival was 56.4%(28/51). Preoperative medical co morbidities, extent of surgical debulking, intraoperative blood losses, amount of intra op blood products required and total operative time are the factors to be considered while deciding ICU vs non ICU admission.CONCLUSION Overall, ICU outcomes of this study population are excellent. Triage of these patients should consider preoperative and intraoperative factors. Intensivists should be vigilant to aggressive postop fluid resuscitation, pain control and early detection and management of surgical complications.

Gallbladder volvulus

Background Like colon or stomach,gallbladder can twist,leading to a volvulus;an entity first described by Wendel in 1898(1).Gallbladder volvulus(GV)is a relatively rare disease occurring when the gallbladder rotates on its own axis,along the cystic duct(Figure 1).Different types of rotation have been described:incomplete vs.complete(≤180°vs.>180°)and clockwise vs.anticlockwise(2).As the rotation might involve the cystic artery,blood supply may be compromised,resulting in ischemia and eventually necrosis.GV constitutes an acute abdominal condition associated with poor outcomes,if not diagnosed and treated in time.