Elia Pulvirenti

Increased use of percutaneous technique for totally implantable venous access devices. Is it real progress? A 27-year comprehensive review on early complications.

BackgroundFirst implantation of a totally implantable venous access device (TIVAD) was performed in 1982 with surgical technique. Since then, these devices have permitted infusion of total parenteral nutrition, antibiotics, blood products, and, above all, they have definitively changed the quality of life of patients with cancer. However, with the increase of percutaneous procedures, we have assisted with a concomitant raise of immediate postprocedural life-threatening complications. The aim of this study was to review the literature during a 27-year period, with regard to the changes of incidence of immediate complications after percutaneous or surgical cutdown for TIVAD’s implant.Materials and MethodsAn extensive search of relevant literature was carried out by using MEDLINE (PubMed) and Google Scholar. We gathered articles from 1982 to 2009 that quoted patient’s number, type of pathology, specialist involved, number of devices implanted, site and technique of implantation (surgical cutdown or percutaneous technique), and immediate complications occurrence.ResultsA total of 952 reports were screened, and finally only 45 articles addressing all inclusion criteria were used for the present study. A total of 11,430 TIVADs implanted in 11,381 patients were analyzed. Pneumothorax, hemothorax, arterial puncture, and hemoptysis developed only after percutaneous procedures. Atrial fibrillation, hematomas, and malpositioning were more frequent after percutaneous approach. The total amount of immediate complications in patients submitted to percutaneous implant was 4.5%, compared with 0.9% subsequent to cutdown technique.ConclusionsDespite the increased use of percutaneous technique for TIVADs’ implantation, surgical cutdown, because of its safety, remains the best approach to avoid possible fatal immediate complications.

Health-related quality of life in patients with hepatocellular carcinoma after hepatic resection, transcatheter arterial chemoembolization, radiofrequency ablation or no treatment

BACKGROUND Aim of this work was to compare quality of life (QoL) of patients affected by HCC and submitted to hepatic resection (HR), transarterial chemoembolization (TACE), radiofrequency ablation (RFA), or no treatment (NT). METHODS Patients affected by HCC between 2001 and 2009 were considered for this study. Gender, diabetes, hepatitis status, Child grade, tumor size, and recurrence were analyzed. QoL was assessed before treatment and 3, 6, 12, and 24 months after, using a FACT-Hep questionnaire. P value was considered significant if <0.01 and highly significant if <0.001. RESULTS Fourteen patients (27.45%) were treated with HR, 15 patients (29.41%) underwent TACE, RFA was performed in 9 patients (17.65%), and 13 patients (25.49%) were not treated. Physical well-being, social/family well-being, emotional well-being, functional well-being and additional concerns 24 months after HR were significantly higher compared to all other treatments. CONCLUSIONS Hepatic resection provides the best QoL at 24 months. RFA provides a worse QoL compared to HR, but a higher QoL compared to TACE or NT.

Could antibiotic prophylaxis be not necessary to implant totally implantable venous access devices? Randomized prospective study

BACKGROUND The growing use of totally implantable venous access devices (TIVAD) has caused the simultaneous increase of various complications. Among these, one of the most encountered is the infection of the subcutaneous pocket in which the device is positioned, or the infection of TIVAD itself. The aim of this study is to evaluate the role of the antibiotic in the prevention of the infection of both the surgical site and the TIVAD within 30 days after the implant. METHODS The authors enrolled one hundred eight consecutive patients divided into two randomized arms each of 54 patients: group A (antibiotic), group B (no antibiotic). All patients were affected by solid tumors needing chemotherapy continuously. TIVADs were implanted surgically in cephalic vein. On the first, third, and seventh postoperative days, the following manifestations were considered as signs or symptoms of infection: pain, localized swelling, redness, and heat; white blood cell count was performed in the in-hospital laboratory. Body temperatures were checked twice a day for 7 days. A statistical analysis of the results was performed. RESULTS No sign of infection was recorded in both groups. Body temperatures and white blood cell counts remained within normal limits in both groups. One month after the procedure no patients recorded any sign of skin infection or body temperature increase. CONCLUSIONS The study suggests that, following strict methods of pre- and postoperative care, TIVADs in patients with solid tumors may be surgically implanted without any antibiotic prophylaxis.

A New Technique for Spleen Autotransplantation

Purpose. Although the efficacy of spleen autotransplantation is debated, this approach remains the only possibility for preserving splenic function after traumatic splenectomy. This report describes an alternative method for splenic autotransplantation in case of splenic trauma. Methods. After splenectomy, the organ was weighed and the undamaged part was cut transversely to prepare a segment of approximately 4 × 3 × 2 cm in size and of 35 g of weight to be transplanted. The greater omentum was pedunculated in its left lateral portion, and the previously prepared splenic tissue was implanted in a pouch created at the lower edge of the omentum. The omental peduncle containing the splenic tissue was fixed to the parietal peritoneum of posterior left upper quadrant of the abdomen where the native spleen was previously located. Results. This technique was performed in 4 patients after informed consent had been obtained. The functionality of the splenic implant was assessed after 3 months by abdominal computed tomography and scintigraphy. These exams showed the functioning of the trasplanted splenic tissue in all patients. Conclusion. This new technique needs further evaluation, but it appears to be an easy and safe alternative for spleen autotransplantation.

Sacroplasty in a patient with bone metastases from hepatocellular carcinoma. A case report

Bone metastases account for 10% to 30% of secondary tumors in all cancer types. In patients with primary hepatocellular carcinoma (HCC), bone metastases are usually treated by nonoperative procedures including pain medication, radiotherapy, hormone therapy, chemotherapy, and bisphosphonates. Surgical treatments include vertebrectomy, reconstruction with a cage or polymethylmethacrylate bone cement, and stabilization with pedicle screws. Sacroplasty to treat bone metastases from HCC has been rarely reported in the literature. We describe the case of a patient with vertebral metastases of HCC treated by this approach. A 65-year-old man had undergone a hepatic segmentectomy in 2004. In May 2008, after several weeks of back pain and bed rest, the patient underwent computed tomography and magnetic resonance imaging of the abdominal and pelvic spine, which revealed metastatic lesions in S1-S5 on the right and S1-S2 on the left. Sacroplasty was performed on all lesions without complications. The patient was discharged from the hospital the same day of the procedure. Two months later, he reported pain relief and improvement in walking. Due to the technical feasibility, low complication rate, and immediate relief of symptoms, sacroplasty for HCC metastases of the sacrum may be considered a valid therapeutic option.

Use of dissecting sealer may affect the early outcome in patients submitted to hepatic resection

BACKGROUND Many technological devices have been used to avoid intraoperative bleeding during hepatic parenchymal transection and to avoid morbidity and mortality, but until now none is complete. The aim of this work is to prospectively analyze hepatic resection patients treated with a water-cooled high frequency monopolar device in order to evaluate its effectiveness. PATIENTS AND METHODS All consecutive patients who underwent liver resection by use of this device, between January 2003 until December 2007, were analyzed prospectively. The following variables were considered: age, sex, kind of disease, kind of liver resection, number of major/minor resections, total operative time and transection time, number and time of clamping, blood loss, time of hospitalization, morbidity, and mortality. RESULTS Between January 2003 and December 2007, 26 patients were analyzed prospectively (69% women, 31% men). Ages ranged from 18 to 84 years. Sixty-five percent of patients had a malignant disease; 35%, a benign disease. The procedures performed were two major hepatectomies (7.6%) and 24 minor hepatectomies (92.4%). Hepatic transection was performed in 35 to 150 min. Total operative time range was 120-480 min. The average blood loss was 325 ml (range 50-600 ml). The mean postoperative stays were nine days for all the patient and six days for non-cirrhotic patients. CONCLUSION The water-cooled high frequency monopolar device is useful for reducing ischemia-reperfusion damage due to the Pringle maneuver and for reducing the risk of morbidity. However, the Kelly forceps remains the only inexpensive instrument really essential for liver surgery.

An update on indications for treatment of solid hepatic neoplasms in noncirrhotic liver

During recent years, we have experienced an increased detection of previously unsuspected liver masses in otherwise asymptomatic patients owing to the widespread application of imaging techniques. Regardless of the malignant or cystic tissues, a remarkable percentage of these masses are represented by benign solid neoplasms. Treatment of benign liver tumors still represents a major concern in the hepatic surgery field. Indications for surgery have remained unchanged for many years, but the laparoscopic approach could determine in some cases a broadening of indications, which may result in overtreatment. In this article, the main surgical indication for hepatic hemangioma, focal nodular hyperplasia and hepatocellular adenoma are discussed with regard to the most recent advancements in literature. In addition, a separate section deals with the role of laparoscopy in the treatment of benign liver neoplasms.

An unusual association of diffuse adenomyomatosis with dysplastic adenoma in chronic calculous cholecystitis: case presentation

BackgroundGallbladder adenomyomatosis is an epithelial proliferation and hypertrophy of the muscularis mucosae of the gallbladder. Rokitansky-Aschoff sinuses are a characteristic of this condition. The segmental adenomyomatosis has a higher risk of developing into gallbladder carcinoma, especially in the fundal region of elderly patients.We report the case of a patient affected by chronic calculous cholecystitis with diffuse adenomyomatosis associated with dysplastic adenoma.Case presentationAn 81-year-old woman presented at our hospital with a 1-year history of intermittent pain localized at the right upper abdominal quadrant, without diffusion to any other body part. On physical examination the abdomen was soft, not distended, and tender to palpation in the right upper quadrant. Murphy sign was negative. Laboratory tests were normal. The patient was scheduled for a laparoscopic cholecystectomy, and neither endoscopic ultrasonographic scan nor magnetic resonance imaging was performed. The operation, performed after obtaining informed consent, was uncomplicated and the intra-operative pathological examination showed no malignancy. The definitive pathological examination of the gallbladder showed: multiple stones of cholesterol origin; diffuse mucosal adenomyomatosis; and a 1.1 cm pedunculated mass localized at the fundus, whose surface was lumpy. This mass was diagnosed as an adenoma with multiple areas of severe dysplasia.ConclusionsThe adenoma of the gallbladder, together with the dysplasia, represents a biological carcinogenetic model. Carcinoma has rarely been reported in adenomyomatosis. Degenerative risk suggests surgery should be mandatory when there is a concomitant presence of large adenoma and adenomyomatosis.

Adenoma or atypical hepatic focal nodular hyperplasia: role of preoperative imaging and laparoscopic treatment.

Differentiation of focal nodular hyperplasia (FNH) and other hypervascular liver lesions, such as hepatocellular adenoma (HCA), is important because of the drastically different therapeutic approach. However, FNH can be well distinguished only if it shows a typical aspect; alternatively, in the case of atypical FNH, imaging findings are not specific enough to provide a secure diagnosis and histologic verification of the lesion is required. In addition, HCA cannot be identified conclusively by any current available imaging technique and it can be at best suspected strongly, and this suspicion may lead to liver resection. Herein we report a case of a patient with an unusual FNH nodule presenting at ultrasonographic scanning as an isoechoic mass arising from hepatic segment 4b; the diagnostic indecision between FNH and HCA was not definitively solved even after computed tomography scan and magnetic resonance imaging and the patient was scheduled for a laparoscopic resection. The pathologic examination diagnosed an atypical FNH nodule. The clinical doubt between FNH and HCA remains a problem affecting the clinicians, and more effort should be made in the direction of a better preoperative differentiation of such different conditions. Surgical resection should not be considered as the failure of the preoperative diagnostic attempt, but as the mainstay for a definitive and sure diagnosis.

Pneumoscrotum Due to Perforated Peptic Ulcer Previously Sutured by Laparoscopy

Pneumoscrotum is a rare condition defined by the presence of gas within the scrotum. Most cases are associated with the pneumoperitoneum; the condition has been described after various diagnostic and therapeutic procedures and disease conditions. In this article, we report a case of a patient admitted to the emergency department for right-upper quadrant abdominal pain. Abdominal X-ray showed free air in the right subdiaphragm; computed tomography (CT) confirmed free air in the abdomen and detected free fluid in the pelvis. The patient underwent laparoscopy, at which time a 1-cm perforation on the anterior wall of the gastric antrum near the pylorus was identified. The perforation was sutured with three detached stitches of reabsorbable material. Approximately 2 days after the surgical procedure, physical examination of the patient showed significant scrotal swelling suspicious for the presence of subcutaneous air. A CT scan confirmed the presence of the pneumoscrotum. The patient returned to the operating room and underwent an exploratory laparotomy. A new perforation was identified beneath the previous one and was sutured with two detached stitches. The patient was discharged uneventfully after 8 days of hospitalization. Pneumoscrotum should be recognized as an early sign of recurrence in patients operated on laparoscopically for peptic ulcer.