Eleonora Guzzetti

Case-matched analysis of totally laparoscopic versus open liver resection for HCC: short and middle term results.

Laparoscopy is gaining acceptance as a safe procedure for resection of liver neoplasms. The aim of this study is to evaluate surgical results and mid‐term survival of minor hepatic resection performed for HCC.

Laparoscopic liver resection without portal clamping: a prospective evaluation

BackgroundPrevious comparative studies have demonstrated that laparoscopic liver resection is associated with more frequent use and longer duration of portal camping than open liver resection, a fact that may partially explain the improvement in operative blood loss reported by most series of laparoscopic liver resection. The aim of this prospective study was to evaluate the real need for portal clamping in laparoscopic liver surgery.Study designSurgical outcomes of 40 consecutive patients who underwent laparoscopic liver resection for benign and malignant lesions from September 2005 to August 2007 were evaluate. Portal clamping was not systematically used.ResultsNo patient required blood transfusion and median blood loss was 160 ml (range 100–340 ml). Mean operating time was 267 min (range 220–370 min) and portal clamping was necessary in only one patient. Surgical complications included two grade I complication, three grade II, and one case of postoperative hemorrhage (grade III).ConclusionsLaparoscopic liver surgery without clamping can be performed safely with low blood loss.

Impact of type of liver resection on the outcome of colorectal liver metastases: A case-matched analysis†

Wedge resection (WR) for colorectal liver metastases (CLM) has become more common in an attempt to preserve liver parenchyma. However, some investigator have reported that WR is associated with a higher incidence of positive margin and an inferior survival compared with anatomic resection (AR) 1 .

Preoperative methylprednisolone administration maintains coagulation homeostasis in patients undergoing liver resection: importance of inflammatory cytokine modulation.

Alterations in hemostatic parameters are a common finding after major hepatic resection. There is growing evidence that inflammation has a significant role in inducing coagulation disarrangement that follows major surgery. To determine whether preoperative methylprednisolone administration has a protective effect against the development of coagulation disorders, we evaluated the effect of preoperative steroids administration on changes in hemostatic parameters and plasma levels of inflammatory cytokines in patients undergoing liver surgery. Seventy-three patients undergoing liver resection were randomized to a steroid group or to a control group. Patients in the steroid group received 500 mg of methylprednisolone preoperatively. Serum levels of coagulation parameters (prothrombin time, platelets, fibrinogen, plasma fibrin degradation products [D-dimer], antithrombin III) and inflammatory mediators (IL-6 and TNF-&agr;) were measured before and immediately after the operation and on postoperative days 1, 2, and 5. Multivariate analysis was performed to identify factors related to the characteristics of the patients and surgery affecting coagulation parameters between the two groups. Decreases in antithrombin III, platelet count and fibrinogen levels, prolongation of prothrombin time, and increases in the plasma fibrin degradation products were significantly suppressed by the administration of methylprednisolone. Cytokines production was also significantly suppressed by the administration of methylprednisolone, and there was significant correlation between plasma levels of cytokines and coagulation alterations. These findings suggest that preoperative methylprednisolone administration inhibits the development of coagulation disarrangements in patients undergoing liver resection, possibly through suppressing the production of inflammatory cytokines.

Liver Resection with Portal Vein Thrombectomy for Hepatocellular Carcinoma With Vascular Invasion

IntroductionHepatocellular carcinoma (HCC) tends to invade the intrahepatic vasculature, especially the portal vein.1 The presence of portal vein tumor thrombus (PVTT) in patients with HCC is one of the most significant factors for a poor prognosis.2–5 The presence of macroscopic PVTT in patients with HCC is also a significant factor for poor prognosis, with a median survival of <3 months without treatment.1 In surgically resected series, in patients with gross PVTT (PVTT in the portal trunk, its first-order branch, or its second-order branch), the 3-year and 5-year survival rates are reportedly 15% to 28% and 0% to 17%, respectively.2–5MethodsThe patient was a 77-year-old woman with well-compensated hepatitis C virus–related cirrhosis (stage A6 according to Child-Pugh classification) who sought care at our department for vague abdominal discomfort. Triphasic spiral computed tomographic scan confirmed HCC 6 cm in diameter in the left lobe of the liver. In addition, portal vein tumor thrombosis of the left branch that extended to the right portal vein was present.ResultsThe procedure included left hepatectomy and en-bloc portal vein thrombectomy with clamping of both the common portal vein trunk and the right portal vein. The portal vein was incised at the bifurcation of the right and left portal veins, and the thrombus was extracted from the incision in the portal vein. With this procedure, we were able to examine under direct vision the exact extent of the portal vein thrombus, and we identified whether the tumor thrombus was adherent to the venous wall or was freely floating in the venous lumen.Portal clamping and length of operation were 16 and 330 minutes, respectively. Intraoperative blood loss was 550 mL. The patient was discharged on postoperative day 6, and she was free of disease at 15 months after surgery.DiscussionLiver resection should be considered a valid therapeutic option for HCC with PVTT.

In defense of the administration of perioperative steroids in liver transplantation

The article by Iwasaki et al. presents further evidence of the risk of adrenal failure in liver transplant patients with steroid-free protocols. A growing trend is emerging for limiting or even abolishing the use of steroids in liver transplantation (LT) because of the well-known complications associated with the chronic administration of steroids. However, beside their immunosuppressive effects, short-term administration of steroids may have several benefits. Hepatic injury secondary to ischemia-reperfusion (I/R) injury, organ dysfunction, and alterations in hemostatic parameters are often unavoidable events after LT. The release of inflammatory mediators is believed to play a significant role in the genesis of these events. Therefore, increased attention has been paid to modulating potentially deleterious inflammatory responses. Several trials have investigated the benefits of administering corticosteroids as a modulator of cytokine response in patients undergoing elective cardiothoracic or gastrointestinal surgery and in cases of septic shock, suggesting that several aspects of the surgical stress responses, organ dysfunction, and postoperative recovery are improved by administration of perioperative steroids. In addition, these trials have demonstrated that the administration of perioperative steroids is not associated with adverse effects of chronic steroid use. Turner et al. investigated the effect of preoperative methylprednisolone (MP) as a modifier of injury of distant organs consequent to liver I/R during LT and on graft function. Thirty-four patients undergoing elective LT were randomly allocated to receive either saline or 10 mg/kg MP at induction of anesthesia. The authors found that MP administration positively modified markers of kidney function and hepatic dysfunction. In addition, the incidence of postoperative complications in the steroid group was significantly lower than that in the control group. Our group has also investigated the clinical benefits on I/R injury and systemic responses of preoperatively administered MP in patients undergoing liver surgery. Seventy-six patients undergoing liver resection with portal clamping were randomized either to a steroid group or to a control group. Postoperative markers of liver injury, recovery, and postoperative morbidity were significantly improved by the preoperative administration of MP. Hepatic dysfunction after I/R injury and heavy hemorrhage upset the coagulation balance because of impaired synthesis of clotting factors and regulatory proteins and production of inflammatory mediators. We have demonstrated that a preoperative MP pulse may contribute to maintaining coagulation homeostasis by attenuating the inflammatory cytokine response. Even though the exact molecular-biologic mechanisms of steroid action on hepatic I/R injury remain partially unknown, several pieces of experimental and clinical evidence support the hypothesis that preoperative administration of MP may preserve liver function following warm and cold hepatic I/R and has no apparent negative effects on hepatic regeneration. Although most data seem to support the beneficial effects of MP on hepatic I/R, it has been reported that dexamethasone may inhibit early regenerative response and enhance hepatic I/R injury after cold preservation and transplantation. However, different steroids (such as hydrocortisone, dexamethasone, or MP) have different anti-inflammatory and antiproliferative properties, and this makes an appropriate comparison more difficult. As reported by Iwasaki et al. and other authors, a factor to consider regarding steroid-free protocols is the risk of adrenal failure in liver transplant patients. Marik et al. conducted a clinical study including 119 patients who underwent LT under steroid-free immunosuppression and reported that 92% of the patients were diagnosed with mild adrenal insufficiency. The former routine pairing of steroids with immunosuppressants may have had a role in preventing adrenal insufficiency in many liver transplant recipients. As previously suggested by Perkins, short administration of steroids might be recommended for reducing the risk of adrenal failure. We believe that there are several reasons to maintain a short course of steroids in patients undergoing LT and that the clinical potential of perioperative steroid treat-