Andreas Bakoyiannis

Model for end-stage liver disease (MELD) score, as a prognostic factor for post-operative morbidity and mortality in cirrhotic patients, undergoing hepatectomy for hepatocellular carcinoma.

BACKGROUND/AIMS To evaluate the ability of the model for end-stage liver disease (MELD) in predicting the post-hepatectomy outcome for hepatocellular carcinoma (HCC). METHODS Between 2001 and 2004, 69 cirrhotic patients with HCC underwent hepatectomy and the results were retrospectively analysed. MELD score was associated with post-operative mortality and morbidity, hospital stay and 3-year survival. RESULTS Seventeen major and 52 minor resections were performed. Thirty-day mortality rate was 7.2%. MELD < or = 9 was associated with no peri-operative mortality vs. 19% when MELD > 9 (P < 0.02). Overall morbidity rate was 36.23%; 48% when MELD > 9 vs. 25% when MELD < or = 9 (P < 0.02). Median hospital stay was 12 days [8.8 days, when MELD < or = 9 and 15.6 days when MELD > 9 (P = 0.037)]. Three-year survival reached 49% (66% when MELD < or = 9; 32% when MELD > 9 (P < 0.01). In multivariate analysis, MELD > 9 (P < 0.01), clinical tumour symptoms (P < 0.05) and American Society of Anesthesiologists (ASA) score (P < 0.05) were independent predictors of peri-operative mortality; MELD > 9 (P < 0.01), tumour size >5 cm (P < 0.01), high tumour grade (P = 0.01) and absence of tumour capsule (P < 0.01) were independent predictors of decreased long-term survival. CONCLUSION MELD score seems to predict outcome of cirrhotic patients with HCC, after hepatectomy.

Intrahepatic biliary cystadenoma: a need for radical resection.

Background Intrahepatic biliary cystadenoma (IBC) is a rare liver tumour, which has strong tendency to recur and malignant potential as it can progress to cystadenocarcinoma (IBCa). Methods From June 2003 to December 2006, four patients diagnosed with hepatic cystadenoma were operated on our Liver Surgical Unit. All patients were females with median age of 51 years (range 45–63 years). Liver resections included three left and one right hepatectomies. In two patients, IBC was diagnosed by abdominal imaging and serum tumour markers but the rest of the patients were initially misdiagnosed as simple cysts, treated by laparoscopic fenestration and referred to our unit after cyst recurrence. Results In all cases, the pathology report was consistent with liver cystadenomas. The postoperative course was uneventful and the median hospital stay was 8 days (range 5–12 days). In a median 18-month follow-up (range 2–40 months), all patients are alive and free of recurrence. Conclusion Liver cystadenomas can be easily misdiagnosed with other hepatic cystic lesions. An aggressive surgical approach is recommended, due to their malignant potential and high recurrence rate after fenestration.

Hepatic resection for hepatocellular carcinoma exceeding Milan criteria

BACKGROUND Many hepatocellular carcinomas (HCCs) are discovered at an advanced stage. The efficacy of transplantation for such tumors is doubtable. The aim of this retrospective study was to determine liver resection efficacy in patients with large HCC regarding long term and disease- free survival. METHODS Between 2002 and 2008, sixty six patients with large HCC (>5cm) underwent hepatectomy. Fifty nine patients had background cirrhosis due to hepatitis B, C or other reason and preserved liver function (Child A). Liver function was assessed by both Childs-Pugh grading and MELD score. Conventional approach of liver resection was performed in most cases. RESULTS The 5-year overall survival was 32% with a median follow up of 33 months. The three year disease-free survival was 33% in our cohort. On multivariate analysis, only tumor size and grade remained independent predictors of adverse long term outcome. Multivariate analysis identified size of the primary tumour and degree of differentiation as risk factors for recurrence. Median blood loss was 540ml and median transfusion requirements were two units of pack red blood cells. Morbidity included pleural effusion (n=18), biliary fistula (n=4), peri-hepatic abscess (n=4), hyperbilirubinemia (n=3), pneumonia (n=5) and wound infection (n=6). No peri-operative mortality was reported in our study. CONCLUSION Partial hepatectomy is safe in selective patients with large HCC. Surgical resection if feasible is suggested in patients with large HCC because it prolongs both overall and disease-free survival with low morbidity.

Rare cystic liver lesions: A diagnostic and managing challenge

Cystic formations within the liver are a frequent finding among populations. Besides the common cystic lesions, like simple liver cysts, rare cystic liver lesions like cystadenocarcinoma should also be considered in the differential diagnosis. Thorough knowledge of each entitys nature and course are key elements to successful treatment. Detailed search in PubMed, Cochrane Database, and international published literature regarding rare cystic liver lesions was carried out. In our research are included not only primary rare lesions like cystadenoma, hydatid cyst, and polycystic liver disease, but also secondary ones like metastasis from gastrointestinal stromal tumors lesions. Up-to date knowledge regarding diagnosis and management of rare cystic liver lesions is provided. A diagnostic and therapeutic algorithm is also proposed. The need for a multidisciplinary approach by a team including radiologists and surgeons familiar with liver cystic entities, diagnostic tools, and treatment modalities is stressed. Patients with cystic liver lesions must be carefully evaluated by a multidisciplinary team, in order to receive the most appropriate treatment, since many cystic liver lesions have a malignant potential and evolution.

Clamp–crush technique vs. radiofrequency‐assisted liver resection for primary and metastatic liver neoplasms

BACKGROUND Several techniques for liver resection have been developed. We compared radiofrequency-assisted (RF) and clamp-crush (CC) liver resection (LR) in terms of blood loss, operating time and short-term outcomes in primary and metastatic tumour resection. METHODS From 2002 to 2007, 196 consecutive patients with primary or metastatic hepatic tumours underwent RF-LR (n= 109; group 1) or CC-LR (n= 87; group 2) in our unit. Primary endpoints were intraoperative blood loss (and blood transfusion requirements) and total operative time. Secondary endpoints included postoperative complications, mortality and intensive care unit (ICU) and hospital stay. Data were collected retrospectively on all patients with primary or secondary liver lesions. RESULTS Blood loss was similar (P= 0.09) between the two groups of patients with the exception of high MELD score (>9) cirrhotic patients, in whom blood loss was lower when RF-LR was used (P < 0.001). Total operative time and transection time were shorter in the CC-LR group (P= 0.04 and P= 0.01, respectively), except for high MELD score (>9) cirrhotic patients, in whom total operation and transection times were shorter when RF-LR was used (P= 0.04). Rates of bile leak and abdominal abscess formation were higher after RF-LR (P= 0.04 for both). CONCLUSIONS Clamp-crush LR is reliable and results in the same amount of blood loss and a shorter operating time compared with RF-LR. Radiofrequency-assisted LR is a unique, simple and safe method of resection, which may be indicated in cirrhotic patients with high MELD scores.

Hepatic parenchyma resection using stapling devices: peri-operative and long-term outcome

BACKGROUND Stapler-assisted hepatectomy has not been well established, as a routine procedure, although few reports exist in the literature. This analysis assesses the safety and outcome of the method based on peri-operative data. MATERIALS AND METHODS From February 2005 to December 2006, endo GIA vascular staplers were used for parenchymal liver transection in 62 consecutive cases in our department. There were 18 (29%) patients with hepatocellular carcinoma (HCC), 31 (50%) with metastatic lesions and 13 (21%) with benign lesions [adenoma, focal nodular hyperplasia (FNH), simple cysts]. Twenty-one patients underwent major resections (33.9%) (i.e. removal of three segments or more) and 41 (66.1%) minor hepatic resections. RESULTS Median blood loss was 260 ml. The median total operative time was 150 min and median transection time was 35 min. No patient required more than 2 days of intensive care unit (ICU) treatment. The median hospital stay was 8 days. Surgical complications included two (3%) cases of bile leak, two (3%) cases of pneumonia, two (3%) cases with wound infection and two (3%) cases with pleural effusion. The peri-operative mortality was zero. In a 30-month median follow-up, all patients with benign lesions were alive and free of disease. The 3-year disease-free survival for patients with HCC was 61% (57% for patients with colorectal metastases) and the 3-year survival 72% (68% for patients with colorectal metastases). CONCLUSION Stapler-assisted liver resection is feasible with a low incidence of surgical complications. It can be used as an alternative for parenchyma transection especially in demanding hepatectomies for elimination of the operating time and control of bleeding.

Hepatic resection for large hepatocellular carcinoma in the era of UCSF criteria

BACKGROUND Treating patients with hepatocellular carcinoma (HCC) remains a challenge, especially when the disease presents at an advanced stage. The aim of this retrospective study was to determine the efficacy of liver resection in patients who fulfil or exceed University of California San Francisco (UCSF) criteria by assessing longterm outcome. METHODS Between 2002 and 2008, 59 patients with large HCC (>5 cm) underwent hepatectomy. Thirty-two of these patients fulfilled UCSF criteria for transplantation (group A) and 27 did not (group B). Disease-free survival and overall survival rates were compared between the two groups after resection and were critically evaluated with regard to patient eligibility for transplant. RESULTS In all patients major or extended hepatectomies were performed. There was no perioperative mortality. Morbidity consisted of biliary fistula, abscess, pleural effusion and pneumonia and was significantly higher in patient group B. Disease-free survival rates at 1, 3 and 5 years were 66%, 37% and 34% in group A and 56%, 29% and 26% in group B, respectively (P < 0.01). Survival rates at 1, 3 and 5 years were 73%, 39% and 35% in group A and 64%, 35% and 29% in group B, respectively (P= 0.04). The recurrence rate was higher in group B (P= 0.002). CONCLUSIONS Surgical resection, if feasible, is suggested in patients with large HCC and can be performed with acceptable overall and disease-free survival and morbidity rates. In patients eligible for transplantation, resection may also have a place in the management strategy when waiting list time is prolonged for reasons of organ shortage or when the candidate has low priority as a result of a low MELD (model for end-stage liver disease) score.

Pathophysiology of Acute and Infected Pancreatitis

Two key pathologic acinar cell responses of acute pancreatitis are vacuole accumulation and trypsinogen activation. Degradation of long-lived proteins, a measure of autophagic efficiency, is markedly inhibited in pancreatitis. Further, processing of the lysosomal proteases cathepsin L (CatL) and CatB into their fully active, mature forms is reduced in pancreatitis, as are their activities in the lysosome-enriched subcellular fraction. These findings indicate that autophagy is retarded in pancreatitis due to deficient lysosomal degradation caused by impaired cathepsin processing. Trypsinogen activation occurred in pancreatitis and is prevented by inhibiting autophagy. A marker of trypsinogen activation partially localized to autophagic vacuoles, and pharmacologic inhibition of CatL increased the amount of active trypsin in acinar cells. The results suggest that retarded autophagy is associated with an imbalance between CatL, which degrades trypsinogen and trypsin, and CatB, which converts trypsinogen into trypsin, resulting in intra-acinar accumulation of active trypsin in pancreatitis. Thus, deficient lysosomal degradation may be a dominant mechanism for increased intra-acinar trypsin in pancreatitis. Proinflammatory cytokines and oxidative stress play a pivotal role in the early pathophysiological events of the disease. Cytokines such as interleukin 1beta and tumor necrosis factor alpha initiate and propagate almost all consequences of the systemic inflammatory response syndrome. On the other hand, depletion of pancreatic glutathione is an early hallmark of acute pancreatitis and reactive oxygen species are also associated with the inflammatory process. Changes in thiol homeostasis and redox signaling decisively contribute to amplification of the inflammatory cascade through mitogen activated protein kinase (MAP kinase) pathways.

Leiomyosarcoma of the infrarenal portion of the inferior vena cava in a cirrhotic patient with hepatitis C.

Leiomyosarcoma of the inferior vena cava is a rare primary tumor. We present a case of a 65-year-old man with the history of cirrhosis and non-specific symptoms. The patient underwent computed tomography and magnetic resonance imaging that revealed a leiomyosarcoma of the infrarenal portion of inferior vena cava. Clinical and imaging features, as well as the surgical technique of resection are discussed.

Rare Localizations of the Hydatid Disease. Experience from a Single Center

Hydatid disease is a rare entity that mostly affects the liver and lung, but almost any organ, forming cysts. Although diagnosis is confirmed by serology and imaging studies, a high index of suspicion is required based on the epidemiological background of the patient. However, rare locations of the cysts remain a diagnostic and therapeutic dilemma. Surgical exploration with special attention to avoid parasite spillage is justified in these situations because diagnostic puncture is usually contraindicated. Pericystectomy or fenestration and omentoplasty is strongly recommended, along with the excision of involved organs when feasible.