Cinzia Nobili

Multivariate Analysis of Risk Factors for Pulmonary Complications After Hepatic Resection

Objective:To generate the first evaluation of risk factors for postoperative pulmonary complications (PPCs) after hepatectomy. Background:Postoperative pulmonary complications (PPCs) after surgery are associated with significant morbidity and have been shown to increase the length of hospital stays. Several studies have been conducted to identify the risk factors for PPCs after abdominal surgery. Methods:Between January 2006 and December 2009, 555 patients underwent elective hepatectomy. We prospectively collected and retrospectively analyzed demographic data, pathological variables, associated pathological conditions, and preoperative, intraoperative, and postoperative variables. The dependent variables studied were the occurrence of PPCs, pleural effusion, pneumonia, and pulmonary embolism. Results:Multivariate analysis identified 5 independent risk factors for global PPCs: prolonged surgery [odds ratio (OR) = 1], presence of a nasogastric tube (OR = 1.6), intraoperative blood transfusion (OR = 1.7), diabetes mellitus (OR = 2.7), and a transverse subcostal bilateral muscle cutting incision (OR = 3.4). There were 4 independent risk factors for pleural effusion: prolonged surgery (OR = 1), surgery on the right lobe of the liver (OR = 1.6), neoadjuvant chemotherapy (OR = 2), and a transverse subcostal bilateral muscle cutting incision (OR = 2.5). There were 3 independent risk factors for pneumonia: intraoperative blood transfusion (OR = 1.9), diabetes mellitus (OR = 2.2), and atrial fibrillation (OR = 3). For pulmonary embolism, history of previous thromboembolic events was identified as the only risk factor (OR = 8.8). Conclusions:The correction of modifiable risk factors among the identified factors could reduce the incidence of PPCs and, as a consequence, improve patient outcomes and reduce the length of hospital stays.

What is a safe future liver remnant size in patients undergoing major hepatectomy for colorectal liver metastases and treated by intensive preoperative chemotherapy

BackgroundA multidisciplinary approach involving preoperative chemotherapy has become common practice in patients with colorectal liver metastases (CLM). The definition of a safe future liver remnant (FLR) volume based on preoperative clinical data in these patients is lacking. Our aim was to identify predictors of postoperative morbidities in patients undergoing major hepatectomy after intensive preoperative chemotherapy for CLM.MethodsBetween January 2000 and August 2010, a total of 101 consecutive patients with CLM underwent major hepatectomy after preoperative chemotherapy (≥6 cycles of oxaliplatin or irinotecan regimen with or without targeted therapies). The FLR ratio was calculated by two formulas: actual FLR (aFLR) ratio, and standardized FLR (sFLR) ratio. Predictors of postoperative overall morbidity, sepsis, and liver failure were identified by univariate and multivariate analyses.ResultsFifty-eight patients (57.4%) had 95 postoperative complications. Sepsis and postoperative liver failure occurred in 23 (22.8%) and 16 patients (15.8%), respectively. On univariate analysis, small aFLR ratio was significantly associated with all complications, and sFLR ratio was associated with sepsis and liver failure. In receiver-operating characteristic analysis, the cutoff of aFLR ratio in predicting overall morbidity, sepsis, and liver failure was 44.8, 43.1, and 37.7%, respectively, and that of sFLR ratio in predicting sepsis and liver failure was 43.6 and 48.5%, respectively. On multivariate analysis, these aFLR and sFLR ratio cutoffs were independent predictors of all complications and of sepsis and liver failure, respectively.ConclusionsThis study provides a cutoff FLR ratio for safe postoperative outcome after major hepatectomy in CLM patients receiving six or more cycles of preoperative chemotherapy.

Risk factors for liver failure and mortality after hepatectomy associated with portal vein resection.

Objective:To report the postoperative outcome of hepatectomy associated with portal vein resection (PVR) and to identify risk factors of clinical value for predicting postoperative liver failure and mortality. Summary Background Data:Resection of the portal vein during hepatectomy allows an increase in the number of patients who may benefit from a potentially curative operation that is, however, technically difficult and may increase postoperative morbidity and mortality. Few data are available about risk factors for liver failure and mortality after such extensive operations. Methods:Between July 1996 and July 2008, a total of 1348 patients were operated on for liver disease in our institution. Among them, 55 patients underwent liver resection associated with PVR. Medical records of these patients were prospectively collected and retrospectively analyzed. Results:Overall mortality for this selected group of patients was 7.2%. Irreversible liver failure was the main cause of death. Overall morbidity was 58.1%. A total of 94% of the patients (n = 52) underwent a major (≥ 3 segments) or an extended >4 segments) right or left hepatectomy. Univariate analysis showed that male gender (P = 0.004), extended liver resection (P = 0.028), and, particularly, extended right hepatectomy (P = 0.015) were significantly associated with an increased risk of postoperative liver failure. Male gender was the single independent risk factor for liver failure. Moreover, the presence of liver steatosis (P = 0.014), an extended right hepatectomy procedure (P = 0.047), and postoperative liver failure (P = 0.046) were significantly associated with an increased rate of postoperative mortality. Conclusion:The present study confirmed that major or extended hepatic resection with PVR can be performed with acceptable overall morbidity and mortality rates. Preoperative selection of the patients should take in consideration the gender and the extent of hepatic resection to avoid irreversible postoperative liver failure. Extended right hepatectomy with PVR should be carefully considered in patients with liver steatosis due to the high risk of postoperative mortality.

Double purse-string telescoped pancreaticogastrostomy: an expedient, safe, and easy technique.

Received October 8, 2012; Revised November 26, 2 November 27, 2012. From Hepato-Pancreato-Biliary Surgery and Liver Transp des Pathologies Digestives, Hepatiques et de la Transplan de Hautepierre-Hopitaux Universitaires de Strasbourg, Uni bourg, Strasbourg, France (Addeo, Rosso, Oussoultzoglou, Jaeck, Bachellier) and the Department of Surgery, The Perm Group, Walnut Creek, CA (Fuchshuber). Correspondence address: Philippe Bachellier, MD, PhD, He Biliary Surgery and Liver Transplantation, Pole des Patholo Hepatiques et de la Transplantation, Hopital de Hautepierre versitaires de Strasbourg, Universite de Strasbourg, 1, Avenue Strasbourg, France. email: philippe.bachellier@chru-strasbou

Safety and outcome of combined liver and pancreatic resections

In Western countries, combined liver and pancreatic resections (CLPR) are performed rarely because of the perceived high morbidity and mortality rates. This study evaluated the safety and outcomes of CLPR at a tertiary European centre for hepatopancreatobiliary surgery.

Robotic central pancreatectomy with stented pancreaticogastrostomy: operative details.

Central pancreatectomy (CP) is increasingly being used to treat selected lesions of the central pancreatic segment. A step‐by‐step technique for robotic CP is described and a literature review provided for this minimally invasive approach.

A safe technique for radical antegrade modular pancreatosplenectomy with venous resection for pancreatic cancer.

Received May 13, 2013; Revised August 9, 2013; Accepted A From Hepato-Pancreato-Biliary Surgery and Liver Transp des Pathologies Digestives, Hepatiques et de la Transplan de Hautepierre-Hopitaux Universitaires de Strasbourg, Uni bourg, Strasbourg, France. Correspondence address: Philippe Bachellier, MD, P Pancreato-Biliary Surgery and Liver Transplantation, Pole Digestives, Hepatiques et de la Transplantation, Hopital d Hopitaux Universitaires de Strasbourg, Universite de Strasbo Moliere, 67098, Strasbourg, France. email: Philip chru-strasbourg.fr

Malignant Rhabdoid Tumour of the Liver in the Young Adult: Report of First Two Cases

Few cases of malignant rhabdoid tumour (MRT) of the liver are reported in literature and always in paediatric patients. We report the first two cases of young adults submitted to hepatic resection for MRT of the liver. A major liver resection was performed in both cases. The histology showed round or fusiform, loosely cohesive cells. The cytoplasm contained abundant eosinophilic inclusions, which caused the nuclei to be located in eccentric locations, giving the characteristic rhabdoid appearance. The immunohistochemical study was performed, and characteristic lack of nuclear INI1 protein expression was found. In a case surgery was associated to chemoradiotherapy. One patient died at 48 months followup for tumour recurrence. The other is still alive at 25 months followup. MRTs are rare tumours of pediatric age with poor prognosis. Hypothetical less malignant behaviour in the young adults could be supposed. Therefore an aggressive surgical and oncological treatment seems justified.

Sarcome primitif du pancréas avec métastases hépatiques : place d’une chirurgie radicale ?

Pancreatic leiomyosarcomas are a rare neoplasm that accounts for 1/1000 of pancreatic cancers. In the literature, 23 cases of pancreatic leiomyosarcoma have been reported and the majority being diagnosed on autopsy. It has never been reported any radical curative surgery in presence of synchronous hepatic metastasis. We reported a case of a patient affected by a primitive pancreatic leiomyosarcoma with bilobar hepatic metastasis, who underwent distal splenopancreatectomy associated with the resection of multiple liver metastases.