Fabio Uggeri

Hepatic Surgery Using the Ligasure Vessel Sealing System

Blood loss, a well-known risk factor for morbidity and mortality during liver resection, occurs during parenchymal transection, so many approaches and devices have been developed to limit bleeding. Surgical technique is an important factor in preventing intraoperative and postoperative complications. The aim of the present study was to determine whether the bipolar vessel sealing device allows a safe and careful liver transection, achieving a satisfactory hemostasis thus reducing blood loss and related complications.A total of 30 consecutive patients (18 male, 12 female with a mean age of 63 years) underwent major and minor hepatic resection in which the bipolar vessel sealing device was used without routine inflow occlusion. A crush technique followed by energy application was used to perform the parenchymal transection. No other devices were applied to achieve hemostasis. The bipolar vessel sealing device was effective in 27 cases of hepatic resection. It failed to achieve hemostasis in three patients, all of whom had a cirrhotic liver. Median blood loss was 250 ml (range: 100-1600 ml), and intraoperative blood transfusions were required in five patients (17%). Mean operative time was 200 minutes (range: 140-360 minutes). There was no clinical evidence of postoperative hemorrhage, bile leak, or intraabdorninal abscess.The postoperative complication rate was 17%. The bipolar vessel sealing device is a useful tool in standard liver resection in patients with a normal liver parenchyma, but its use should be avoided in cirrhotic livers.

Surgical treatment of liver metastases of gastric cancer: is local treatment in a systemic disease worthwhile?

OBJECTIVES The prognosis of patients with liver metastases of gastric cancer (LMGC) is dismal, but little is known about prognostic factors in these patients; thus justification for surgical resection is still controversial. The purpose of this study was to review recent outcomes of hepatectomy for LMGC and to determine which patients represent suitable candidates for surgery by assessing surgical results and clinicopathologic features. METHODS Outcomes in 21 patients with LMGC who underwent hepatectomy between 1998 and 2007 were assessed. Isolated metastases and potential to perform a curative resection were requisite indi-cations for surgery. Surgical outcome and clinicopathologic features of the hepatic metastases were analysed. RESULTS Overall 1-, 3- and 5-year survival rates after hepatic resection were 68%, 31% and 19%, respectively; three patients survived for >5 years without recurrence. Univariate analysis revealed a solitary metastasis, negative margin (R0) resection and the presence of a peritumoral fibrous capsule as significant favourable prognostic factors. These characteristics were present in all of the three patients who survived for >5 years. CONCLUSIONS Solitary metastases from gastric cancer should be treated surgically and confer a better prognosis. Surgical resection should provide microscopically negative margins (R0). A new prognostic factor, the presence of a pseudocapsule, may be associated with improved prognosis.

Bleeding in Hepatic Surgery: Sorting through Methods to Prevent It

Liver resections are demanding operations which can have life threatening complications although they are performed by experienced liver surgeons. The parameter “Blood Loss” has a central role in liver surgery, and different strategies to minimize it are a key to improve results. Moreover, recently, new technologies are applied in the field of liver surgery, having one goal: safer and easier liver operations. The aim of this paper is to review the different principal solutions to the problem of blood loss in hepatic surgery, focusing on technical aspects of new devices.

Colorectal cancer with neuroendocrine differentiation in a child

Colorectal cancer is extremely rare in children and presents with a poor prognosis because of the delay in diagnosis and lack of histological differentiation. We report a case of a sigmoid colon carcinoma with areas of neuroendocrine cells in a 12-year-old patient without familial occurrence of colorectal cancer. Symptoms at presentation were anaemia, anorexia, abdominal pain and weight loss. The patient was treated with radical resection and adjuvant chemotherapy. One year later, a local recurrence and hepatic metastases were diagnosed and she underwent chemotherapy and surgical resection. Twenty-six months from initial diagnosis she is alive with evidence of disease. The clinical presentation, diagnosis and treatment of the previously reported cases of colorectal cancer in children are also reviewed.

Systematic review and meta-analysis of sutures coated with triclosan for the prevention of surgical site infection after elective colorectal surgery according to the PRISMA statement.

Background:Several randomized clinical trials (RCTs) conducted to evaluate the effect of triclosan-coated suture on surgical site infection (SSI) yield to controversial results. The primary purpose of this systematic review and meta-analysis was to analyze the available RCTs, comparing the effect of triclosan-coated suture with uncoated suture on the incidence of SSI after elective colorectal operations. As secondary endpoint of the analysis, we considered length of hospital stay after surgery. Methods:We performed a systematic literature review through Medline, Embase, Pubmed, Scopus, Ovid, ISI Web of Science, and the Cochrane Controlled Trials Register searching for RCTs published from 1990 to 2015. To conduct these meta-analyses, we followed the guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Study inclusion criteria were as follows: parallel-group RCTs in adult populations reporting the closure of the abdominal wall after elective colorectal operation with triclosan-coated suture or noncoated suture, and reporting the outcomes considered in the meta-analysis. Results:Six trials including 2168 patients (1102 treated and 1066 controls) provided data on SSIs. The overall rate was 11.7% (129/1102) in the triclosan group and 13.4% (143/1066) in the control group (odds ratio 0.81, 95% confidence interval [CI] 0.58–1.13, P = 0.220). Heterogeneity among studies was moderate (I2 = 44.9%). No evidence of publication bias was detectable. Five RCTs (1783 patients; 914 treated and 689 controls) described hospital length of stay with no significant effect (mean difference: −0.02, 95% CI −0.11 to −0.07, P = 0.668). The I2 test for heterogeneity was 0% (P = 0.836). Moderator analyses showed no significant differences were detected in analyses comparing the suture materials (polydioxanone vs polyglactin). In open-label trials, the odds ratio for SSI risk was 0.62 (95% CI 0.20–1.93, P = 0.413), 0.77 in single-blind (95% CI 0.31–1.95, P = 0.583) and 0.85 in double-blind trials (95% CI 0.46–1.54, P = 0.582). Conclusions:Our findings failed to demonstrate a significant protective effect of triclosan-coated sutures on the occurrence of SSI after elective colorectal resections. Further large RCTs are needed before introducing this technology into clinical practice.

Consecutive concomitant laparoscopic splenectomy and cholecystectomy: an Italian experience of 30 patients and proposition of a technique.

INTRODUCTION With recent advancements in the field of minimally invasive surgery, combined laparoscopic procedure is now being performed for treating coexisting abdominal pathologies during the same surgery. In some patients, spleen disorders are associated with gallbladder stones. Conventional surgery requires a wide upper abdominal incision for correct exposure of both organs. The aim of this study was to assess the feasibility and outcomes of concomitant laparoscopic treatment for coexisting spleen and gallbladder diseases. MATERIALS AND METHODS Thirty consecutive laparoscopic splenectomy (LS) plus laparoscopic cholecystectomy (LC) have been performed in our department between January 2000 and December 2009 (24% of 125 LS performed in this period). There were 11 female patients and 19 male patients, with a median age of 16.2 years (range: 4-55). Indications were hereditary spherocytosis for 22 cases, idiopathic thrombocytopenic purpura for 3 cases, thalassemia for 4 cases, and sickle cell disease for 1 case. Patients were operated on using right semilateral position, tilting the table from right to left, using a five-trocar technique in 25 cases and a four-trocar technique in the last 5 cases. Cholecystectomy was performed first, then splenectomy was achieved, and spleen was removed in an Endobag. RESULTS One patient required conversion to open procedure (3.3%) because of splenomegaly. Average operative time was 150 minutes (range: 90-240). Average length of stay was 3.5 days (range: 3-11). Mean blood loss was 60  mL (range: 30-500). Transfusion rate was 3.3%. Mean spleen size and weight were, respectively, 16.5  cm and 410  g. No perioperative mortality occurred in the series. We reported 3 cases of hemoperitoneum, of which one managed conservatively. The results using four trocars were comparable to those with five trocars. CONCLUSION With increasing institutional experience, concomitant laparoscopic splenectomy and cholecystectomy is a safe and feasible procedure and may be considered for coexisting spleen and gallbladder diseases. The four-trocar technique guarantees good results.

CYSTIC LIVER METASTASES FROM LUNG ADENOCARCINOMA: A CASE REPORT

Cystic hepatic metastases arising from lung cancer are rare. We herein describe a case of a 71-year-old women admitted to our hospital for abdominal pain 6 months after the resection of a lung adenocarcinoma. Two cystic lesions of the liver were discovered at abdominal ultrasonography and computerized tomography scan. An ERCP excluded a biliary adenoma or adenocarcinoma, and an ultrasound-guided liver biopsy was negative for malignant cells. For persistence of symptoms and lack of a diagnosis, the patient underwent an exploratory laparotomy, a surgical biopsy with a diagnosis of adenocarcinoma, and a consequent right hepatectomy. After 2 years of follow-up, the patient is well and disease free. Although cystic liver metastasis are rare and a differential diagnosis difficult, the malignant nature should always be considered in the differential diagnosis of hepatic cysts to offer the patient the best treatment.

Effect of oral mesalamine on inflammatory response in acute uncomplicated diverticulitis

AIM To evaluate the impact of mesalamine administration on inflammatory response in acute uncomplicated diverticulitis. METHODS We conducted a single centre retrospective cohort study on patients admitted to our surgical department between January 2012 and May 2014 with a computed tomography -confirmed diagnosis of acute uncomplicated diverticulitis. A total of 50 patients were included in the analysis, 20 (study group) had received 3.2 g/d of mesalamine starting from the day of admission in addition to the usual standard treatment, 30 (control group) had received standard therapy alone. Data was retrieved from a prospective database. Our primary study endpoints were: C reactive protein mean levels over time and their variation from baseline (ΔCRP) over the first three days of treatment. Secondary end points included: mean white blood cell and neutrophile count over time, time before regaining of regular bowel movements (passing of stools), time before reintroduction of food intake, intensity of lower abdominal pain over time, analgesic consumption and length of hospital stay. RESULTS Patients characteristics and inflammatory parameters were similar at baseline in the two groups. The evaluation of CRP levels over time showed, in treated patients, a distinct trend towards a faster decrease compared to controls. This difference approached statistical significance on day 2 (mean CRP 6.0 +/- 4.2 mg/dL and 10.0 +/- 6.7 mg/dL respectively in study group vs controls, P = 0.055). ΔCRP evaluation evidenced a significantly greater increment of this inflammatory marker in the control group on day 1 (P = 0.03). A similar trend towards a faster resolution of inflammation was observed evaluating the total white blood cell count. Neutrophile levels were significantly lower in treated patients on day 2 and on day 3 (P < 0.05 for both comparisons). Mesalamine administration was also associated with an earlier reintroduction of food intake (median 1.5 d and 3 d, study group vs controls respectively, P < 0.001) and with a shorter hospital stay (median 5 d and 5.5 d, study group vs controls respectively, P = 0.03). CONCLUSION Despite its limitations, this study suggests that mesalamine may allow for a faster recovery and for a reduction of inflammatory response in acute uncomplicated diverticulitis.

Impact of Pre-Storage and Bedside Filtered Leukocyte-Depleted Blood Transfusions on Infective Morbidity after Colorectal Resection: A Single-Center Analysis of 437 Patients

BACKGROUND Leukocyte-depleted blood transfusions were introduced to reduce transfusion-associated immunomodulation, but the clinical effects of different types of leukocyte depletion have been analyzed rarely. The aim of this survey was to analyze the clinical impact of pre-storage leukocyte-depleted blood transfusions (considered as pre-storage or bedside-filtered) on post-operative complications in patients undergoing elective or urgent colorectal resection. METHODS Data were collected retrospectively from the medical records of 437 consecutive patients who underwent colorectal resection from 2005 to 2010. All patients requiring transfusion received pre-storage or bedside-filtered leukocyte-depleted red blood cell concentrates according to availability at the blood bank. The outcomes were measured by the analysis of post-operative morbidity in patients receiving the different types of transfusions or having other potentially predictive risk factors. RESULTS The overall morbidity rate, infective morbidity rate, and non-infective morbidity rate were, respectively, 35.6%, 28.1%, and 21.0%. Two hundred five patients (46.9%) received peri-operative transfusions. On multivariable analysis, leukocyte-depleted transfusion (odds ratio [OR] 3.33; 95% confidence interval [CI] 2.14-5.20; p<0.001) and both pre-storage (OR 2.82; 95% CI 1.73-4.59; p<0.001) and bedside-filtered (OR 4.69; 95% CI 2.54-8.67; p<0.001) transfusions were independent factors for post-operative morbidity. Prolonged operation (p=0.035), American Society of Anesthesiologists score≥3 points (p=0.023), diagnosis of cancer rather than benign disease (p=0.022), and urgent operation (p=0.020) were other independent predictors of post-operative complications. Patients transfused with bedside-filtered blood showed significantly higher rates of infective complications (51.4% vs. 31.8%; p=0.006), but not non-infectious complications (35.7% vs. 32.6; p=0.654) than patients who received pre-storage transfusions. CONCLUSIONS Leukocyte-depleted blood transfusions and, in particular, bedside-filtered blood have a significant negative effect on infectious complications after colorectal resection.

Prognostic Factors Affecting Long-Term Survival after Resection for Noncolorectal, Nonneuroendocrine, and Nonsarcoma Liver Metastases

Aim To evaluate feasibility and long-term outcome after hepatic resection for noncolorectal, nonneuroendocrine, and nonsarcoma (NCNNNS) liver metastases in a single center. Methods We retrospectively reviewed our experience on patients who underwent surgery for NCNNNS liver metastases from 1995 to 2015. Patient baseline characteristics, tumor features, treatment options, and postoperative outcome were retrieved. Results We included 47 patients. The overall 5-year survival (OS) rate after hepatectomy was 27.6%, with a median survival of 21 months. Overall survival was significantly longer for patients operated for nongastrointestinal liver metastases when compared with gastrointestinal (41 versus 10 months; p = 0.027). OS was significantly worse in patients with synchronous metastases than in those with metachronous disease (10 versus 22 months; p = 0.021). The occurrence of major postoperative complication negatively affected long-term prognosis (OS 23.5 versus 9.0 months; p = 0.028). Preoperative tumor characteristics (number and size of the lesions), intraoperative features (extension of resection, need for transfusions, and Pringles maneuver), and R0 at pathology were not associated with differences in overall survival. Conclusion Liver resection represents a possible curative option for patients with NCNNNS metastases. The origin of the primary tumor and the timing of metastases presentation may help clinicians to better select which patients could take advantages from surgical intervention.