Ettore Marzano

Two-stage hepatectomy for multiple bilobar colorectal liver metastases

As surgical resection of colorectal liver metastases (CLM) remains the only treatment for cure, efforts to extend the surgical indications to include patients with multiple bilobar CLM have been made. This study evaluated the long‐term outcome, safety and efficacy of two‐stage hepatectomy (TSH) for CLM in a large cohort of patients.

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.

Prediction of Mortality Rate After Major Hepatectomy in Patients Without Cirrhosis

OBJECTIVE To assess the ability of preoperative biological parameters to predict a fatal outcome after a major liver resection in patients without cirrhosis. DESIGN Retrospective descriptive cohort study. SETTING Department of Digestive Surgery and Transplantation, University of Strasbourg. PATIENTS From January 1, 2004, through December 31, 2007, 67 consecutive patients underwent resection of at least 4 contiguous liver segments. MAIN OUTCOME MEASURES Perioperative data were prospectively recorded, and predictors of postoperative mortality rate and liver failure were analyzed. RESULTS Five patients (7%) died after a mean (SD) of 32.4 (11.8) postoperative days. The overall morbidity was 73% (49 patients). Univariate analysis revealed that a preoperative alanine aminotransferase blood level greater than 40 U/L (to convert to microkatals per liter, multiply by 0.0167), a preoperative prothrombin ratio less than 70%, a preoperative Indocyanine green retention rate at 15 minutes of greater than 15%, preoperative biliary drainage, and performance of extrahepatic bile duct resection significantly predict the occurrence of in-hospital death. The number of preoperative biological parameters in each patient significantly increased the mortality rate. Indeed, the mortalities were 0%, 3%, and 67% in patients presenting with none, 1, and 2 or more risk factors, respectively. CONCLUSIONS This study shows that preoperative liver tests and function can predict postoperative fatal outcome in patients presenting with biliary carcinomas and requiring a major liver resection. On the basis of these preoperative biological parameters, a decision-making algorithm is provided.

Targeted molecular therapies (cetuximab and bevacizumab) do not induce additional hepatotoxicity: preliminary results of a case-control study.

AIMS To analyse the effects of the preoperative targeted molecular therapy (cetuximab (cetu) or bevacizumab (beva)) on non-tumorous liver parenchyma, and the clinical and biological outcome after liver resection for colorectal liver metastases (CLM). METHODS Between January 2005 and December 2007, 36 patients receiving preoperatively cetu (n = 15) or beva (n = 21) were, respectively, matched to a control group of patients who did not receive targeted molecular therapy. They were matched on the basis of age, gender, body mass index, extent of hepatectomy, and type and number of neoadjuvant chemotherapy. Liver function tests, postoperative outcome and histopathology of the resected liver were compared. RESULTS There was no mortality. Postoperative morbidity and perioperative bleeding rates were similar in both groups. In the beva group, liver function tests showed higher serum bilirubin level on postoperative day (POD) 1 (p = 0.001) and POD 3 (p = 0.01), higher serum aspartate aminotransferase on POD 1 (p = 0.004), and lower prothrombin time on POD 5 (p = 0.02). In both groups, cetu and beva, the postoperative peaks of gamma-glutamyl transpeptidase and alkaline phosphatase were statistically higher than in the control groups. Interestingly, the prevalence of sinusoidal injury and fibrosis was lower in patients receiving cetu (p = 0.04), while the prevalence of steatohepatitis was lower in patients receiving beva (p = 0.04). CONCLUSION The addition of beva or cetu to the neoadjuvant chemotherapy regimens does not appear to increase the morbidity rates after hepatectomy for CLM. The pathological examination did not show additional injury to the non-tumorous liver parenchyma.

Surgical resection of liver metastases from breast cancer

The aim of this review is to define the relevance of surgical resection for liver metastasis of breast cancer. We report the rationale for hepatic surgery of liver metastasis, the survival prognosis factors for these patients, and the influence of liver resection on overall survival. The aim of this surgery is not only the local control, but also general control of the disease by preventing the selection of resistant tumor cell clones. Adjuvant therapies remain necessary for general control of the disease. While preoperative detection of small intra hepatic lesions remains difficult, MRI and preoperative ultrasound may help.

Repeat hepatectomy for liver metastases from colorectal primary cancer: a review of the literature.

INTRODUCTION After hepatectomy for metastases from colorectal cancer (CRC), approximately 50% to 70% of patients develop recurrent hepatic metastases. This recurrence is limited to the liver in about one-third of cases. The purpose of this study is to report a comprehensive review of the literature concerning the results of repeat hepatectomy for recurrent liver metastases from CRC. METHODS An electronic literature search was conducted to identify all medical articles published concerning repeat hepatectomy for liver metastases of colorectal origin during the period January 1990 to December 2010. RESULTS After a second hepatectomy, the mean mortality was 1.4% and the mean morbidity rate was 21.3%. The 5-year survival ranged from 16% to 55%. After a third or fourth hepatectomy, the mean mortality rate was 0% and the mean morbidity rate was 24.5%. After a third hepatectomy, the 5-year survival ranged from 23.8% to 37.9%. After a fourth hepatectomy, the 5-year survival was 9.3% to 36%. CONCLUSION Repeat hepatectomy seems justified, since it may result in prolonged survival with acceptable rates of morbidity and mortality, results similar to those seen after initial hepatectomy.

Robotic resection of duodenal adenoma.

Duodenal sporadic adenomatous polyps are rare findings during upper endoscopy. Resection is indicated due to their malignant potential.

Laparoscopic treatment of biliary peritonitis following nonoperative management of blunt liver trauma

IntroductionNonoperative management (NOM) of hemodynamically stable patients with blunt hepatic injuries is considered the current standard of care. However, it is associated with several in-hospital complications. In selected cases laparoscopy could be proposed as diagnostic and therapeutic means.Case reportA 28 years-old male was admitted in the Emergency Unit following a motor vehicle crash. CT-scan showed an isolated stade II hepatic injury at the level of the segment IV. Firstly a NOM was decided. Laparoscopic exploration was then performed at day 4 due to a biliary peritonitis. Intraoperative trans-cystic duct cholangiography showed a biliary leaks of left hepatic biliary tract, involving sectioral pedicle to segment III. Cholecystectomy, trans-cystic biliary drainage, application of surgical tissue sealing patch and abdominal drainage were performed. Postoperative outcome was uneventful, with fast patient recovery.ConclusionLaparoscopy has gained a role as diagnostic and therapeutic means in treatment of complications following NOM of blunt liver trauma. This approach seems feasible and safety, with satisfactory postoperative outcome.

Nuclear medicine imaging of gastro-entero-pancreatic neuroendocrine tumors. The key role of cellular differentiation and tumor grade: from theory to clinical practice

Abstract Nuclear medicine imaging is a powerful diagnostic tool for the management of patients with gastro-entero-pancreatic neuroendocrine tumors, mainly developed considering some cellular characteristics that are specific to the neuroendocrine phenotype. Hence, overexpression of specific trans membrane receptors as well as the cellular ability to take up, accumulate, and decarboxylate amine precursors have been considered for diagnostic radiotracer development. Moreover, the glycolytic metabolism, which is not a specific energetic pathway of neuroendocrine tumors, has been proposed for radionuclide imaging of neuroendocrine tumors. The results of scintigraphic examinations reflect the pathologic features and tumor metabolic properties, allowing the in vivo characterization of the disease. In this article, the influence of both cellular differentiation and tumor grade in the scintigraphic pattern is reviewed according to the literature data. The relationship between nuclear imaging results and prognosis is also discussed. Despite the existence of a relationship between the results of scintigraphic imaging and cellular differentiation, tumor grade and patient outcome, the mechanism explaining the variability of the results needs further investigation.

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.