Bob Saggi

Evaluation of stapler hepatectomy during a laparoscopic liver resection.

METHODS An international database of 1499 laparoscopic liver resections was analysed using multivariate and Kaplan-Meier analysis. RESULTS In total, 764 stapler hepatectomies (SH) were compared with 735 electrosurgical resections (ER). SH was employed in larger tumours (4.5 versus 3.8 cm; P < 0.003) with decreased operative times (2.6 versus 3.1 h; P < 0.001), blood loss (100 versus 200 cc; P < 0.001) and length of stay (3.0 versus 7.0 days; P < 0.001). SH incurred a trend towards higher complications (16% versus 13%; P = 0.057) including bile leaks (26/764, 3.4% versus 16/735, 2.2%: P = 0.091). To address group homogeneity, a subset analysis of lobar resections confirmed the benefits of SH. Kaplan-Meier analysis in non-cirrhotic and cirrhotic patients confirmed equivalent patient (P = 0.290 and 0.118) and disease-free survival (P = 0.120 and 0.268). Multivariate analysis confirmed the parenchymal transection technique did not increase the risk of cancer recurrence, whereas tumour size, the presence of cirrhosis and concomitant operations did. CONCLUSIONS A SH provides several advantages including: diminished blood loss, transfusion requirements and shorter operative times. In spite of the smaller surgical margins in the SH group, equivalent recurrence and survival rates were observed when matched for parenchyma and extent of resection.

Kidney transplantation alone in ESRD patients with hepatitis C cirrhosis.

Background Kidney transplantation (KTx) alone in patients with cirrhosis and renal failure (end-stage renal disease [ESRD]) infected with hepatitis C virus (HCV) is controversial. The aim of this study was to compare outcomes of HCV+ patients with ESRD and cirrhosis (C group) versus HCV+ patients with ESRD but with no cirrhosis (NC group) listed for KTx. Methods Ninety HCV+ patients with ESRD were evaluated for KTx between 2003 and 2010. Listed patients underwent transjugular liver biopsy with hepatic portal venous gradient (HPVG) measurements. Only patients with HPVG less than 10 mm Hg were considered for KTx alone. We analyzed patient demographics, waitlist/liver disease characteristics, and posttransplant outcomes between groups. Results Sixty-four patients listed for KTx alone were studied. Twelve patients (18.75%) showed biopsy-proven cirrhosis. Thirty-seven patients underwent KTx alone (9 from C and 28 from NC). No patients developed decompensation of their liver disease, although one patient for NC group developed metastatic hepatocellular carcinoma 16 months after transplantation. One- and three-year graft survival rates were 75% and 75% versus 92.1% and 75.1% for groups C and NC, respectively (P=0.72). One- and three-year patient survival rates were 88.9% and 88.9% versus 96.3% and 77.9% for groups C and NC, respectively (P=0.76). Only increasing recipient age and decreasing albumin levels were significantly associated with worse graft and patient survival. Conclusions Our study suggests that KTx alone may be safe in patients with compensated HCV, cirrhosis, and ESRD with HPVG less than 10 mm Hg. A simultaneous liver-kidney transplantation may be an unnecessary use of a liver allograft in these patients.

Evaluation of a laparoscopic liver resection in the setting of cirrhosis

INTRODUCTION Patients presenting with cirrhosis and hepatic tumours represent a fragile group that have typically been avoided in early series of laparoscopic liver resection. This study was undertaken to evaluate the results of a laparoscopic hepatectomy in the setting of cirrhosis. METHODS Subgroup analysis of patients with cirrhosis within a series of 327 patients undergoing a laparoscopic resection was performed. Comparisons were made with patients without cirrhosis where appropriate to highlight differences in patient selection and outcomes. Specific variables assessed included operative details and short-term outcomes including length of stay (LOS), morbidity and mortality. Outcomes specific to hepatocellular carcinoma (HCC) were also assessed. RESULTS There were 52 patients with cirrhosis undergoing a laparoscopic hepatic resection. Ninety per cent of patients were Childs class A, with a median model for end-stage liver disease (MELD) score of 8. Hepatitis C was the most common cause of cirrhosis (88.5%), whereas the most common indication for an operation was HCC (71.2%). Resections were generally limited, with the median number of segments resected being 2 (range: 1-4). Complications occurred in 13 (25%) patients, with a 90-day mortality of 5.8%. The median LOS was 3 days. CONCLUSIONS A laparoscopic hepatectomy is safe in the setting of cirrhosis, provided the application of appropriate selection criteria and sufficient experience with the procedure.

Outcomes of laparoscopic and open resection for neuroendocrine liver metastases

BACKGROUND We sought to compare the outcomes in patients with hepatic carcinoid tumor metastases treated with open versus laparoscopic liver resection. METHODS A retrospective analysis of our liver surgery database was performed. All patients who underwent liver resection for hepatic carcinoid tumor metastases were included. Patients were divided into 2 groups depending on the surgical approach. Patients with concomitant primary and metastatic liver lesions underwent open resection. RESULTS Thirty-six patients underwent resection over a 10-year period (21 open and 15 laparoscopic). Both groups were similar in terms of gender, body mass index, tumor size, incidence of carcinoid syndrome, and extent of resection (P > .05). The laparoscopic group had less mean operative time (2.7 vs 5.4 hours), less mean blood loss (158.3 vs 538.9 mL), and a shorter hospital stay (3.2 vs 7.5 days; P < .05 for all). Complications were similar in both groups (20% vs 33%; P = .21). Two laparoscopic cases required conversion. The 3-year disease-free survival for the laparoscopic group was 73.3% compared to 47.6% for the open group (P = .2). CONCLUSION To our knowledge, this is the first reported study comparing laparoscopic versus open liver resection in the treatment of liver metastases from carcinoid tumors. Our series confirms that selective cases can safely be managed laparoscopically.

Robotic liver resection: initial experience with three-arm robotic and single-port robotic technique.

Robotic liver surgery was found to offer advantages not inherent in conventional laparoscopic liver resection.

Cutaneous Metastases from Primary Hepatobiliary Tumors as the First Sign of Tumor Recurrence following Liver Transplantation

Cutaneous metastasis from hepatobiliary tumors is a rare event, especially following liver transplantation. We report our experience with two cases of cutaneous metastases from both hepatocellular carcinoma and mixed hepatocellular/cholangiocarcinoma following liver transplantation, along with a review of the literature.

Thyroid Storm Complicated by Fulminant Hepatic Failure: Case Report and Literature Review

Objectives: Thyroid storm is a presentation of severe thyrotoxicosis that has a mortality rate of up to 20% to 30%. Fulminant hepatic failure (FHF) entails encephalopathy with severe coagulopathy in the setting of liver disease. It carries a high mortality rate, with an approximately 60% rate of overall survival for patients who undergo orthotopic liver transplantation (OLT). Fulminant hepatic failure is a rare but serious complication of thyroid storm. There have been only 6 previously reported cases of FHF with thyroid storm. Methods: We present a patient from our institution with thyroid storm and FHF. A literature review was performed to analyze the outcomes of the 6 additional cases of concomitant thyroid storm and FHF. Results: Our patient underwent thyroidectomy followed by OLT. Her serum levels of thyroid-stimulating hormone, triiodothyronine, thyroxine, and transaminase normalized, and she was ready for discharge within 10 days of surgery. She has survived without complication. There is a 40% mortality rate for the reported patients treated medically with these conditions. Of the 7 total cases of reported FHF and thyroid storm, 2 patients died. Only 2 of the 7 patients underwent thyroidectomy and OLT — Both at our institution. Both patients survived without complications. Conclusions: Thyroid storm and FHF each independently carry high mortality rates, and managing patients with both conditions simultaneously is an extraordinary challenge. These cases should compel clinicians to investigate liver function in hyperthyroid patients and to be wary of its rapid decline in patients who present in thyroid storm with symptoms of liver dysfunction. Patients with rapidly progressing thyroid storm and FHF should be considered for total thyroidectomy and OLT.

Portal vein thrombosis in liver transplantation: radiologic evaluation, risk factors, and occult diagnosis

Aim: Portal vein thrombosis (PVT) in the liver transplant recipient poses many challenges. Unfortunately, the risk factors and effects on outcomes of PVT are not well-defined. Methods: This study analyzed the experience with PVT in liver transplant program from 2007 to 2013. This included the effectiveness of PVT diagnostics and its risk factors using logistical regression. The primary endpoints were Kaplan-Meir patient and graft survival. The secondary endpoints were the length of stay (LOS), transfusion rate, and overall morbidity. Independent predictors of survival were identified using a Cox’s proportional hazards model. Results: Two hundred and sixteen consecutive liver transplant recipients were examined, and 30 (13.8%) had either a total or partial PVT. Two hundred and five patients had imaging within 1 year of liver transplantation with only 7 (23.3%) of the 30 PVTs identified pre-operatively. Calculated sensitivity (4.8-50%) and negative predictive values (10.5-22.2%) were poor. Only, age significantly predicted PVT [P = 0.037/hazard ratio (HR) =0.95]. Ninety-day-patient and graft survival for PVT was similar at 6 months, although 1-year survival was significantly lower. “Occult” PVT was not associated with inferior survival. Model for end-stage liver disease score > 25 (P = 0.001, HR = 0.49/P = 0.004, HR = 0.52) and age > 60 years (P = 0.017, HR = 0.64/P = 0.013, HR = 0.67) were significant predictors of patient and graft survival. Although the transfusion rate was significantly greater with PVT, LOS, and morbidity were not. Conclusion: Older recipients had a greater likelihood of PVT. Diagnostic studies were not effective at excluding PVT, and occult diagnosis did not affect the outcome. PVT was not an independent predictor of mortality or graft loss, but was associated with greater blood loss but not increased LOS or morbidity.

Racial disparity in New Orleans: A faith-based approach to an age-old problem

RECENTLY IN THE UNITED STATES, HEALTH CARE REFORM has become a central focus of heated debate and controversy. Sweeping legislation was introduced and passed by the Obama administration in attempt to achieve universal health care with the intent of providing equal access to care through national policy. Although a laudable goal, this policy does not ensure equivalent quality of care delivered to the most vulnerable communities in our nation. Historically, racial disparity in health care delivery results in delay in diagnosis, and often inferior patient outcomes at a substantial increase in cost of care. In the same stride, strong criticism has turned to the mounting and unsustainable costs of health care on the national budget. Despite the best intentions, current proposed changes in policy and infrastructure development, national health care policy may be woefully inadequate. Health care in certain socioeconomic groups, regions, or individual institutions function well and provide excellent care. Other regions or even individual institutions struggle under their community’s payor mix to provide adequate care. Governmental support in the form of disproportionate share has been applied to decrease this financial disparity. Unfortunately, this gap is often wider than perceived and innercity institutions absorb the sickest and most complex patients with the least primary care associated with the lowest payor mix. This self-fulfilling prophecy leads rise to multiple at-risk populations