Francesco Ardito

Long term effectiveness of resection and radiofrequency ablation for single hepatocellular carcinoma <= 3 cm. Results of a multicenter Italian survey.

BACKGROUND & AIMS The aim of this study was to compare liver resection and radiofrequency ablation in patients with single hepatocellular carcinoma ≤3 cm and compensated cirrhosis. METHODS The study involved 544 Child-Pugh A cirrhotic patients (246 in the resection group and 298 in the radiofrequency group) observed in 15 Italian centers. Overall survival and tumor recurrence rates were analyzed using the Kaplan Meier method before and after propensity score matching. Cox regression models were used to identify factors associated with overall survival and tumor recurrence. RESULTS Two cases of perioperative mortality were observed in the resection group and the rate of major complications was 4.5% in the resection group and 2.0% in the radiofrequency group (p=0.101). Four-year overall survival rates were 74.4% in the resection group and 66.2% in the radiofrequency group (p=0.353). Four-year cumulative HCC recurrence rates were 56% in the resection group and 57.1% in the radiofrequency group (p=0.765). Local tumor progression was detected in 20.5% of ablated patients and in one resected patient (p<0.001). After propensity score matching, both survival and tumor recurrence were still not significantly different although a trend towards lower recurrence was observed in resected patients. Older age and higher alpha-fetoprotein levels were independent predictors of poor overall survival while older age and higher alanine-aminotransferase levels resulted to be independent factors associated with higher recurrence rate. CONCLUSIONS In spite of a higher rate of local tumor progression, radiofrequency ablation can provide results comparable to liver resection in the treatment of single hepatocellular carcinoma ≤3 cm occurring in compensated cirrhosis.

Pedicle clamping with ischemic preconditioning in liver resection

Hepatic pedicle clamping (HPC) is widely used to control intraoperative bleeding during hepatectomy; intermittent HPC is better tolerated but is associated with blood loss during each period of reperfusion. Recently, it has been shown that ischemic preconditioning (IP) reduces the ischemia‐reperfusion damage for up to 30 minutes of continuous clamping in healthy liver. We evaluated the safety of IP for more prolonged periods of continuous clamping in 42 consecutive patients with healthy liver submitted to hepatectomy. IP was used in 21 patients (group A); mean ± SD of liver ischemia was 54 ± 19 minutes (range, 27‐110; in 7 cases >60 minutes). In the other 21 patients, continuous clamping alone was used (Group B); liver ischemia lasted 36 ± 14minutes (range, 13‐70; in 2 cases >60 minutes). Two patients in Group A (9.5%) and 3 in Group B (14.2%) received blood transfusions. In spite of the longer duration of ischemia (P = .001), patients with IP had lower aspartate aminotransferase (AST; P = .03) and alanine aminotransferase (ALT; P = not significant) at postoperative day 1, with a similar trend at postoperative day 3. This was reconfirmed by multiple regression analysis, which showed that although postoperative transaminases increased with increasing duration of ischemia and of the operation in both groups, the increases were significantly smaller (P < .001) with the use of preconditioning. In conclusion, the present study confirms that IP is safe and effective for liver resection in healthy liver and is also better tolerated than continuous clamping alone for prolonged periods of ischemia. This technique should be preferred to continuous clamping alone in healthy liver. Additional studies are needed to assess the role of IP in cirrhotic liver and to compare IP with intermittent clamping. (Liver Transpl 2004;10:S53–S57.)

bacterial Pneumonia in Hiv-infected Patients : analysis of Risk Factors and Prognostic Indicators

This case control study assessed risk factors and prognostic indicators of 350 episodes of bacterial pneumonia in 285 HIV-infected patients. On univariate analysis, intravenous drug abuse (i.v.DA; p < .001 versus controls), regular cigarette smoking (p < .001), cirrhosis (p = .04), and history of a previous episode of pneumonia (p = .04) were risk factors for community-acquired episodes of bacterial pneumonia, whereas length of hospitalization (p = .01) was a risk factor only for nosocomial bacterial pneumonia. The small amount of circulating T CD4+ cells (<100/ mm3) was a risk factor in both groups of pneumonia (p < .05). Stepwise logistic regression analysis revealed that i.v.DA in community-acquired episodes and low levels of circulating T CD4+ cells, both in community-acquired and hospital-acquired episodes, were independent risk factors for the development of bacterial pneumonia. The case-fatality rate observed in our study was 27%. On stepwise logistic regression analysis, T CD4+ cell counts < or = 100/mm3 (p = .02), neutropenia (p = .04), PO2 arterial level < or = 70 mm Hg (p = .01), and Karnofsky score < or = 50 (p = .04) were independent indicators of mortality. According to a personally developed prognostic score, 211 episodes of pneumonia (60%) were classified as mild, 63 (18%) as moderate, and 76 (22%) as severe. Clinicians must carefully evaluate those variables that can influence the prognosis of bacterial pneumonia to make early identification of affected patients and to promptly establish the most appropriate therapeutic strategy in each case.

Advantages of multidisciplinary management of bile duct injuries occurring during cholecystectomy

BACKGROUND The aim of the present study was to highlight the advantages of treatment of bile duct injury (BDI) occurring during cholecystectomy on the basis of a multidisciplinary cooperation of expert surgeons, radiologists, and endoscopists. METHODS Sixty-six patients had major BDIs or short- or long-term failures of repair. BDI was diagnosed intraoperatively in 27 patients (40.9%) and postoperatively in 39 (59.1%) patients. Among referred patients, 30 had complications from bile leak, 15 from obstructive jaundice, and 20 from recurrent cholangitis. Two patients died from sepsis after delayed referral before repair was attempted. Eleven additional patients had minor BDIs with bile leak both with and without choleperitoneum. RESULTS Of patients with major BDI, surgical repair was performed in 41 (64.1%). Postsurgical morbidity rate was 15.8%, and there was no mortality. The rate of excellent or good results after surgical repair was 78.0% (32 of 41 patients), and this increased to 87.8% (36 of 41 patients) by continuing treatment with stenting in postsurgical strictures. Biliary stenting alone was performed in 23 patients (35.9%), with excellent or good results in 17 (73.9%). More than 200 endoscopic and percutaneous procedures were performed for initial assessment, treatment of sepsis, nonsurgical repair, contribution to repair, and follow-up. Patients with minor BDIs underwent various combinations of surgical and endoscopic or percutaneous treatments, always with good results. CONCLUSIONS A multidisciplinary approach was of paramount importance in many phases of treatment of BDI: initial assessment, treatment of secondary complications, resolution of sepsis, percutaneous stenting before surgical repair, dilatation of strictures after repair, final treatment in patients not repaired surgically, and follow-up.

Role of the surgeon as a variable in long-term survival after liver resection for colorectal metastases

Survival analyses after hepatectomy for colorectal liver metastases (CRLM) mostly address tumor‐related factors; this study has simultaneously evaluated interventional factors which may be influenced by the surgeon.

Does hepatic pedicle clamping affect disease-free survival following liver resection for colorectal metastases?

Objective: To evaluate the impact of liver ischemia from hepatic pedicle clamping (HPC) on long-term outcome after hepatectomy for colorectal liver metastases (CRLM). Background: Liver resection offers the only chance of cure for patients with CRLM. Several clinical and pathologic factors have been reported as determinants of poor outcome after hepatectomy for CRLM. A controversial issue is that hepatic ischemia/reperfusion injury from HPC may adversely affect long-term outcome by accelerating the outgrowth of residual hepatic micrometastases. Methods: Patients undergoing liver resection for CRLM in 2 tertiary referral centers, between 1992 and 2008, were included. Disease-free survival and specific liver-free survival were analyzed according to the use, type, and duration of HPC. Results: Five hundred forty-three patients had primary hepatectomy for CRLM. Hepatic pedicle clamping was performed in 355 patients (65.4%), and intermittently applied in 254 patients (71.5%). Postoperative mortality and morbidity rates were 1.3% and 18.5%, respectively. Hepatic pedicle clamping had a highly significant impact in reducing the risk of blood transfusions and was not correlated with significantly higher postoperative morbidity. Liver recurrence rate was not significantly different according to the use, type, and duration of HPC, in patients resected after preoperative chemotherapy as well. On univariate analysis, HPC did not significantly affect overall and disease-free survival. These results were confirmed on the multivariate analysis where blood transfusions, primary tumor nodal involvement, and the size of CRLM of more than 5 cm prevailed as determinants of poor outcome. Conclusions: This study confirms the safety and effectiveness of HPC and demonstrates that in the human situation, there is no evidence that HPC may adversely affect long-term outcome after hepatectomy for CRLM.

Aggressive papillary thyroid microcarcinoma: prognostic factors and therapeutic strategy.

Background and Aim Papillary thyroid carcinomas smaller than 1 cm are classified as papillary microcarcinomas (PMCs). Papillary microcarcinomas are usually considered low-risk tumors; however in some cases, PMCs behave aggressively and metastasize early, giving rise to clinically metastatic disease. Debate exists in the literature about prognostic factors and therapeutic management to PMC. We report here the long-term experience of our referral center for malignant thyroid disease. Methods We retrospectively analyzed 149 consecutive patients with PMC who underwent surgery at our institution between 2000 and 2005; 49 of them (33% of cases) were treated also with radioiodine therapy. Clinical and histopathological parameters potentially predicting patient outcome and recurrent disease were statistically investigated, after a minimum follow-up of 5 years. Results After a median follow-up of 5.4 years (range, 5–11 years), 28 (19%) of 149 patients experienced recurrent disease. All of them were reoperated on and newly treated with radioiodine administration. Of these 28 patients, 27 are living without disease, whereas 1 patient died due to metastatic thyroid cancer to lungs. The multivariate statistical analysis identified extrathyroid invasion (odds ratio [OR], 58.54; P = 0.013), the solid pattern (OR, 25.77; P < 0.001), the tumor multifocality (OR, 15.80; P = 0.005), and the absence of tumor capsule (OR, 9.74; P = 0.015) as significant and independent risk factors for the appearance of PMC recurrences. Of note, in most patients who experienced recurrent disease, the PMC had been diagnosed preoperatively and often for the presence of cervical clinically evident lymphadenopathy. On the other hand, none of the PMC “incidentally” discovered at histopathological examination alone experienced recurrent disease during follow-up. Conclusions Although most PMCs have an indolent course, there is a fraction (19% in our series) of patients with PMC and aggressive behavior strongly correlated with some histopathological features (extrathyroid invasion, solid pattern, tumor multifocality, and absence of a capsule) who need to be individualized and for whom a radical therapeutic approach is recommended based on total thyroidectomy and lymphadenectomy followed by radioiodine administration.

Severe hypocholesterolemia in surgical patients, sepsis, and critical illness

After surgery, in sepsis and various critical illnesses, factors such as severity of the acute phase response, liver dysfunction, and hemodilution from blood loss have cumulative impacts in decreasing cholesterol; therefore, degree of hypocholesterolemia often reflects severity of illness. The direct correlation between cholesterol and several plasma proteins is mediated by the parallel impact of commonly shared determinants. Cholestasis is associated with a moderation of the degree of hypocholesterolemia. In human sepsis, the poor implications of hypocholesterolemia seem to be aggravated by the simultaneous development of hypertriglyceridemia. Cholesterol and triglyceride levels reflect altered lipoprotein patterns, and the issue is too complex and too poorly understood to be reduced to simple concepts; nevertheless, these simple measurements often represent helpful adjunctive clinical tools.

Reappraisal of surgical indications and approach for liver hemangioma: single-center experience on 74 patients

BACKGROUND Liver hemangiomas are rarely large, symptomatic, or presenting atypical imaging patterns. Surgery is rarely needed; indications and choice of the best technique remain not precisely defined. METHODS Features of hemangiomas and surgical indications were assessed in 74 patients (mean follow-up 63.2 months). In 40 operated patients, the results of liver resection versus enucleation were compared. RESULTS Most hemangiomas (60/74, 81.1%) showed no size increment. In 40 operated patients (40/74, 54.1%) the mean tumor size (11.9 cm, range 2.6-46.0) was larger than in nonoperated patients (11.9 vs 6.0 cm, P = .0002). Surgical indications were specific symptoms, tumor enlargement, Kasabach-Merritt syndrome, and uncertain diagnosis. Mortality (nil), morbidity (10.0%), and transfusion rate (15.0%) were similar for 28 liver resections versus 12 enucleations; bleeding was more related to large hemangioma size than to the choice of either technique. Liver ischemia techniques, autotransfusion, and intraoperative blood salvage reduced the risk of transfusion. CONCLUSIONS Surgery is rarely indicated, has a low risk, and has similar results for liver resection versus enucleation. Risk of bleeding is related more to the large size of the hemangioma than to the type of surgery (resection or enucleation). In these patients, management, the need for surgery, and the choice of technique should be carefully individualized.

Evaluation of hilar biliary strictures by using a newly developed forward-viewing therapeutic echoendoscope: preliminary results of an ongoing experience

BACKGROUND Obtaining a definitive tissue diagnosis in patients with hilar biliary strictures (HBS) is often difficult. OBJECTIVE To describe our experience using a newly developed forward-viewing linear echoendoscope (FVL-EUS) with FNA as a primary diagnostic tool in patients with HBS. DESIGN Case series. SETTING A tertiary care, academic medical center. PATIENTS Four patients with HBS who underwent the procedure. MAIN OUTCOME MEASUREMENTS Performance of FNA with the FVL-EUS. RESULTS Visualization and puncture of the primary lesion with a definitive tissue diagnosis was obtained in all of the 4 cases performed. Metastatic hilar cholangiocarcinoma and recurrent neuroendocrine tumor were diagnosed in 2 patients and followed by placement of a self-expandable metal stent, when possible. In the other 2 patients, a diagnosis of resectable hilar cholangiocarcinoma and poorly differentiated adenocarcinoma of unclear origin without evidence of vascular involvement was made, and plastic stents were placed before surgery; the first patient was found to have peritoneal metastases, and resection was aborted, and in the second patient, a gallbladder tumor was diagnosed in the surgical specimen. LIMITATION The small number of patients. CONCLUSIONS These preliminary data suggest that FVL-EUS used as a primary tool for the evaluation of patients with HBS may be of value and should be further explored in properly designed studies with a meaningful number of patients.