Filippo Pierangeli

CONTINUOUS VERSUS INTERMITTENT PORTAL TRIAD CLAMPING FOR LIVER RESECTION: A CONTROLLED STUDY

OBJECTIVE The authors compared the intra- and postoperative course of patients undergoing liver resections under continuous pedicular clamping (CPC) or intermittent pedicular clamping (IPC). SUMMARY BACKGROUND DATA Reduced blood loss during liver resection is achieved by pedicular clamping. There is controversy about the benefits of IPC over CPC in humans in terms of hepatocellular injury and blood loss control in normal and abnormal liver parenchyma. METHODS Eighty-six patients undergoing liver resections were included in a prospective randomized study comparing the intra- and postoperative course under CPC (n = 42) or IPC (n = 44) with periods of 15 minutes of clamping and 5 minutes of unclamping. The data were further analyzed according to the presence (steatosis >20% and chronic liver disease) or absence of abnormal liver parenchyma. RESULTS The two groups of patients were similar in terms of age, sex, nature of the liver tumors, results of preoperative assessment, proportion of patients undergoing major or minor hepatectomy, and nature of nontumorous liver parenchyma. Intraoperative blood loss during liver transsection was significantly higher in the IPC group. In the CPC group, postoperative liver enzymes and serum bilirubin levels were significantly higher in the subgroup of patients with abnormal liver parenchyma. Major postoperative deterioration of liver function occurred in four patients with abnormal liver parenchyma, with two postoperative deaths. All of them were in the CPC group. CONCLUSIONS This clinical controlled study clearly demonstrated the better parenchymal tolerance to IPC over CPC, especially in patients with abnormal liver parenchyma.

Improved Results of Liver Resection for Hepatocellular Carcinoma on Cirrhosis Give the Procedure Added Value

ObjectiveTo review a single-center experience to update the performance indexes of liver resection (LR). Summary Background DataSeveral therapies have been proposed in the treatment of hepatocellular carcinoma (HCC) on cirrhosis, although LR was the first to be widely applied. MethodsOf 408 patients with cirrhosis admitted for HCC in the period 1983 to 1998, 264 had a LR. Patient selection, surgical technique, 30-day deaths, long-term survival, recurrence rate, and recurrence treatment were reviewed after stratifying patients according to the year of surgery. Mean follow-up was 34.5 ± 29.1 months. ResultsThe number of Child A patients who underwent surgery after the discovery of the tumor at routine evaluation increased significantly from 64.5% to 87.9% during the study period. Procedures carried out without blood transfusions increased from 31.4% to 76.9%. The overall operative death rate was 4.9%. Actuarial survival rates were 63.1% and 41.1% after 3 and 5 years, respectively; actuarial tumor-free survival rates were 49.3% and 27.9% at the same intervals. After 1992, surgical deaths decreased from 9.3% to 1.3%. Actuarial survival rates increased from 52.9% and 32.3% to 71.7% and 49.4% after 3 and 5 years, respectively. There was no difference in the actuarial recurrence rate between the two periods, but the chance to treat recurrence increased over time from 22.4% to 53.7% with a concomitant, significant improvement in survival. ConclusionsLR represents a well-established therapy for HCC on cirrhosis. It remains one of the fundamentals in the multidisciplinary approach to this tumor and should be considered as the first option for patients with preserved hepatic function and limited disease. Today, LR should offer a surgical death rate of less than 1.5%, a 5-year survival rate of approximately 50%, and a 5-year tumor-free survival rate of 28% when performed in specialized centers.

Piggy‐back versus conventional technique in liver transplantation: report of a randomized trial

Abstract Liver transplantation with preservation of the recipient vena cava (the “piggy-back” technique) has been proposed as an alternative to the traditional method. We performed a randomized study on 39 cirrhotic patients, 20 who underwent the piggy-back technique (group 1) and 19 the traditional method using venovenous bypass (group 2) to evaluate the feasibility and true advantages of the piggy-back technique compared to the traditional method. Two patients were switched to the conventional technique due to the presence of a caudate lobe embracing the vena cava in one patient and a caval lesion in the other. Statistically significant differences between the two groups were only found for the warm ischemia time (48.5 ± 13 min for piggy-back vs 60 ± 12 min for the conventional method) and for renal failure (zero cases in group 1 vs four cases in group 2). We therefore believe that liver transplantation with the piggy-back technique can easily be performed in almost all cases, and that only a few, specific situations, such as a very enlarged caudate lobe, do not justify its routine use.

Surgical outcome and long-term follow up after laparoscopic rectosigmoid resection in women with deep infiltrating endometriosis

The aim of this study was to assess the long‐term outcome of treating severely symptomatic women with deep infiltrating intestinal endometriosis by laparoscopic segmental rectosigmoid resection. Detailed intraoperative and postoperative records and questionnaires (preoperatively, 1 month postoperatively and every 6 months for 3 years) were collected from 22 women. The estimated blood loss during surgery was 290 ± 162 ml (range 180–600), and average hospital stay was 8 days (range 6–19). One woman required blood transfusion after surgery. Two cases were converted to laparotomy. One woman had early dehiscence of the anastomosis. Six months after surgery, there was a significant reduction of symptom scores (greater than 50% for most types of pain) related to intestinal localisation of endometriosis (P < 0.05). Score improvements were maintained during the whole period of follow up. Noncyclic pelvic pain scores showed significant reductions (P < 0.05) after 6 and 12 months, but there was a high recurrence rate later. Dysmenorrhoea and dyspareunia improved in 18/21 and 14/18 women with preoperative symptoms, respectively. Constipation, diarrhoea and rectal bleeding improved in all affected women for the whole period of follow up. Laparoscopic segmental rectosigmoid resection seems safe and effective in women with deep infiltrating colorectal endometriosis resulting in significant reductions in painful and dysfunctional symptoms associated with deep bowel involvement.

Oral budesonide in the treatment of chronic refractory pouchitis

Background  Pouchitis is the major long‐term complication after ileal‐pouch nal anastomosis for ulcerative colitis. Ten to 15% of patients develop a chronic pouchitis, either treatment responsive or treatment refractory.

Local Injection of Infliximab for the Treatment of Perianal Crohn’s Disease

PURPOSEPerianal disease is a serious complication of Crohn’s disease and its surgical management is still controversial. It has been suggested that the local injection of infliximab has resulted in some potential benefit. This pilot study analyzed the feasibility and safety of such therapy in selected patients with severe perianal Crohn’s disease.METHODSThe study included 15 patients with complex perianal Crohn’s disease in which sepsis was not controllable using surgical and medical therapy. Among them, four had previously undergone intravenous infusion of infliximab with no significant response, nine had contraindications for intravenous infusion, and two had associated stenosing ileitis and severe coloproctitis. The injection of 15 to 21 mg of infliximab, associated with surgical treatment, was performed at the internal and external orifices and along the fistula tract. Efficacy was measured by a complete morphologic evaluation using a personal score.RESULTSNo major adverse effects were reported. Ten of 15 patients healed after 3 to 12 infusions.CONCLUSIONSLocal injection of infliximab adjacent to the fistula tract of perianal Crohn’s disease is safe and may help in fistula healing. A controlled, randomized trial is required to prove the value.

Short‐term treatment with infliximab in chronic refractory pouchitis and ileitis

Background  Chronic refractory pouchitis is a long‐term complication after ileal pouch‐anal anastomosis and it may be associated with ileal inflammation.

A Revised Consideration on the Use of Very Aged Donors for Liver Transplantation

The upper age limit for organ donation for liver transplantation has increased over the past few years. A retrospective case control study was carried out to evaluate the outcome of 36 liver transplants (group A) performed with grafts procured from donors over 70 years old in the period 1996 to April 2000, matched with 36 transplants (group B) chronologically performed thereafter with organs procured from donors below the age of 40 yr. The groups were comparable as regards main clinical characteristics. Mean follow‐up was 14.5 months. Clinical and laboratory parameters of the donors, cold ischemia period, intraoperative blood transfusions, 30‐d mortality, incidence of primary graft nonfunction, acute rejection episodes, arterial complications and long‐term survival of recipients were considered. The main postoperative biochemical parameters were also collected and compared. A liver biopsy was obtained in 20/36 old donors, revealing less than 25% of steatosis in all but one, which showed steatosis involving 70% of the hepatocytes. There were two postoperative deaths (5.6%) in group A and one (2.8%) in group B (p = NS). Seven postoperative arterial complications (19.4%) occurred in group A, leading to the patients death because of rupture of the hepatic artery in one case, to successful surgical revascularization in three cases and to retransplantation in three cases. Only one patient in group B (2.8%) experienced hepatic artery thrombosis (p = 0.055). One‐year patient survival rates were 77.4% for group A and 88.8% for group B (p = NS); 1‐yr graft survival rates were 73.3% for group A and 85.7% for group B (p = NS). In conclusion, donors over 70 should not be excluded a priori for liver transplantation in elective settings. Great attention should be paid to the pathological conditions of arterial vessels caused by atherosclerosis, i.e. the presence of calcified plaques on the hepatic artery, which might represent the source of severe complications.

Indication and type of surgery in Crohn's disease

The large majority of patients affected by Crohns disease require surgery during their clinical history. Radical resection originally advocated for Crohns disease does not decrease the recurrence rate, and repeated resections predispose patients to the development of short‐bowel syndrome. Over the last few years, conservative surgery has become accepted by many authors as a safe means of treating obstructive Crohns disease. In this review article we analyse the efficacy and safety of conservative techniques, in comparison with resective surgery. Indications, advantages and technical aspects of resective and conservative surgery are reported.

Local injection of adalimumab for perianal Crohn's disease: Better than infliximab?†

To the Editor: In our experience, local injection of infliximab, after surgical drainage of the sepsis for treatment of complex perianal Crohn’s disease, is effective and associated with a low risk of recurrent abscesses. In fact, more than 70% of patients who underwent the treatment for the presence of contraindications to systemic infusion, such as fibrostenosing disease, had their fistulas finally closed with scar tissue, tested with probe examination and confirmed by pelvic magnetic resonance imaging (MRI). Less encouraging results were obtained in patients with different indications, such as failure of previous intravenous infusion of infliximab and/or associated severe proctocolitis. Therefore, we decided to evaluate the efficacy of local injection of adalimumab as a rescue therapy in patients who did not respond to infliximab local injection. The structural features of adalimumab, in fact, theoretically present the ideal prerequisites to work in a very effective way when injected in the mucosa surrounding the internal orifice of the fistula. In addition, it should be effective even in those patients who did not respond to infliximab since they had already developed antibodies to its murine protein. Finally, the close frequency of administrations could play a primary role in its successful power. Based on all those assumptions, we used the same procedure as infliximab injection, with 40 mg of adalimumab injected every 15 days in outpatient treatment. The procedure was well tolerated and no adverse events have been registered. The preliminary results are, so far, encouraging. Out of 16 patients with complex fistulas, 2 healed after 2 injections and 3 after 4. The remaining patients are still in treatment, with 1 patient not healed after 6 injections and all the others waiting for the second or third injection. Our feeling is that injection of adalimumab results in anal fibrosis but, even in the presence of scar tissue, which makes the anal tissues less flexible, it seems not to result in the same evolution toward stiffness that we observed after treatment with infliximab. Even considering the limit of the small number of patients treated so far, combined treatment with surgical sanitization of the sepsis and local injection of adalimumab seems to be a promising alternative treatment for those patients who do not respond to infliximab, either systemic or locally administered. However, our feeling is that it could be considered a first-line therapy in selected patients. Welldesigned controlled randomized trials are required to confirm the data and define the role of such cure in the treatment algorithm of complex perianal Crohn’s disease. Finally, concerning the dose finding, we think that half the dose we are actually using could be adequate to obtain the same good results, so that it is conceivable to require the companies to produce dedicated doses for local injection, with even lower related costs.