Francesco Di Fabio

Laparoscopic right hepatectomy: a challenging, but feasible, safe and efficient procedure

BACKGROUND Few centers are undertaking major laparoscopic liver resections, because of the well-recognized technical difficulties and lack of training opportunities. METHODS The authors describe their technique for laparoscopic right hepatectomy, highlighting relevant details for accomplishing a safe and efficient procedure. Patients were chronologically divided into 2 groups to evaluate the impact of increasing experience on the surgical outcomes. RESULTS Group I included 17 patients and group II 18 patients. The conversion rate to open or hybrid techniques significantly decreased from 36% in group I to 6% in group II (P = .03). The hospital stay decreased from a median of 6 days in group I to a median of 4 days in group II (P = .05). Complications occurred in 4 patients (11%), of whom 3 were in group I. The mortality was zero. CONCLUSIONS Laparoscopic right hepatectomy is a safe and efficient procedure when performed at specialized centers with extensive experience in hepatic surgery. Long-term training is necessary to acquire adequate expertise.

Thromboembolism in Inflammatory Bowel Disease: An Insidious Association Requiring a High Degree of Vigilance

Venous and arterial thromboembolism are both serious extraintestinal manifestations of inflammatory bowel disease (IBD). Acquired risk factors seem to play a more prominent role than congenital in promoting thrombotic events. Prevention of thromboembolism is thus mainly aimed at minimizing the acquired/reversible risk factors (e.g., inflammation, immobility, hospitalization, steroid therapy, central intravenous catheters, smoking, oral contraceptives, and deficiency of B vitamins and folate). The diagnosis of venous and arterial thromboembolism is extremely challenging and requires a high degree of vigilance. Deep vein thrombosis and pulmonary embolism may be clinically silent or manifest with only few specific symptoms. Thrombosis of the portal vein system may occur with nonspecific symptoms such as abdominal pain, nausea/vomiting, abdominal tenderness, ascites, and fever. The diagnosis of arterial thromboembolism may also be challenging, particularly when the splanchnic region is involved. Indeed, arterial thrombosis of the splanchnic region tends to be overlooked and misinterpreted as a clinical exacerbation of IBD. Early diagnosis plays a central role in optimizing the therapeutic intervention and reducing the risk of short-term and long-term thrombosis-associated complications. The decision regarding the duration of systemic anticoagulation must take into account the individual risk of intestinal bleeding.

Intra-Abdominal Venous and Arterial Thromboembolism in Inflammatory Bowel Disease

ABSTRACT: Venous and arterial thromboembolism constitutes a significant cause of morbidity and mortality in patients with inflammatory bowel disease. The most common thrombotic manifestations are lower extremity deep vein thromboses with or without pulmonary embolism. Occasionally, thromboembolic events occur in the main abdominal vessels, such as the portal and superior mesenteric veins, vena cava and hepatic vein, aorta, splanchnic and iliac arteries, or in the limb arteries. The decision-making process for the treatment of these uncommon thromboembolic complications in inflammatory bowel disease may be very challenging for several reasons: 1) no standardized therapies are available; 2) the decision of starting anticoagulant therapy implies the potential risk of intestinal bleeding; 3) thromboembolic events may recur and be life-threatening if inadequately treated. The literature was searched by using MEDLINE, Embase, and the Cochrane library database. Studies published between 1970 and 2007 were reviewed. We discuss the medical and surgical therapeutic options that should be considered to optimize the outcome and reduce the risk of complications in abdominal thromboembolisms associated with inflammatory bowel disease.

Prognostic Variables for Cancer-Related Survival in Node-Negative Colorectal Carcinomas

Background/Aim: The efficacy of adjuvant treatment in node-negative colorectal carcinoma is unproven. The purpose of this study was to analyze the prognostic value of routinely detectable clinicopathological variables in order to identify subgroups of node-negative colorectal cancer patients at a high risk of a recurrence. Methods: Seventy-three patients who did not receive radio- or chemotherapy were selected among 112 node-negative colorectal cancer patients who underwent curative resection. Follow-up was a minimum of 5 years or until death. The influence of 17 demographic, clinical, and pathological variables on the 5-year cancer-related survival was assessed using univariate and multivariate analyses. Results: The compliance with follow-up was 99%. The 5-year survival rate was 81%. Univariate analysis showed that T4 lesions (p < 0.001), age >70 years (p = 0.008), lymphatic invasion (p = 0.001), and neural invasion (p = 0.02) were significantly associated with a decreased survival. T4 stage (hazard ratio 12.75, p < 0.001) and age >70 (hazard ratio 3.08, p = 0.04) significantly affected the cancer-related survival on multivariate analysis. Conclusions: Node-negative colorectal cancer patients with T4 carcinoma or those aged over 70 years have a higher risk of recurrences after resection. They should receive adjuvant or neoadjuvant treatment compatible with their performance status.

Implementation of enhanced recovery programme for laparoscopic distal pancreatectomy: feasibility, safety and cost analysis.

BACKGROUND/OBJECTIVES The adoption of laparoscopy for distal pancreatectomy has proven to substantially improve short-term outcomes. Stress response after major surgery can be further minimized within an enhanced recovery programme (ERP). However, data on the potential benefit of an ERP for laparoscopic distal pancreatectomy are still lacking. The aim was to assess the feasibility, safety and cost of ERP for patients undergoing laparoscopic distal pancreatectomy. METHODS This is a case-control study from a Tertiary University Hospital. Sixty-six consecutive patients who underwent laparoscopic distal pancreatectomy were analyzed. Twenty-two patients were enrolled for the ERP and compared with previous consecutive 44 patients managed traditionally (1:2 ratio). Operative details, post-operative outcome and cost analysis were compared in the two groups. RESULTS Patients enrolled in the ERP had similar intraoperative blood loss (median 165 ml vs. 200 ml; p = 0.176), operation time (225 min vs. 210 min; p = 0.633), time to remove naso-gastric tube (1 vs. 1 day; p = 0.081) but significantly shorter time to mobilization (median 1 vs. 2 days; p = 0.0001), start solid diet (2 vs. 3 days; p = 0004), and pass stools (3 vs. 5 days; p = 0.002) compared to the control group. Median length of stay was significantly shorter in the ERP group (3 vs. 6 days; p < 0.0001). No significant difference in readmission or complication rate was observed. Cost analysis was significantly in favor of the ERP group (p = 0.0004). CONCLUSIONS Implementation of ERP optimizes outcomes for laparoscopic distal pancreatectomy with significant earlier return to normal gut function, reduced length of stay and cost saving.

Surgical management of benign and indeterminate hepatic lesions in the era of laparoscopic liver surgery

Background/Aims: The expansion of the laparoscopic approach for the management of benign liver lesions has raised concerns regarding the risk of widening surgical indications and compromising safety. Large single-centre series focusing on laparoscopic management of benign liver lesions are sporadic. Methods: We reviewed a prospectively collected database of patients undergoing pure laparoscopic liver resection (LLR) for benign liver lesions. All cases were individually discussed at a multidisciplinary team meeting. Results: Forty-six patients underwent 50 LLRs for benign disease. Indications for surgery were: symptomatic lesions, preoperative diagnosis of adenoma or cystadenoma, and lesions with an indeterminate diagnosis. The preoperative diagnosis was uncertain in 11 cases. Of these, histological diagnosis was hepatocellular carcinoma in one (9%) and benign lesion in 10 patients (91%). Thirteen patients (28%) required major hepatectomy. Three patients (7%) developed postoperative complications. Mortality was nil. The median postoperative hospital stay following major and minor hepatectomy was 4 and 3 days, respectively. Conclusion: The laparoscopic approach represents a safe option for the management of benign and indeterminate liver lesions, even when major hepatectomy is required. LLR should be only performed in specialized centres to ensure safety and strict adherence to orthodox surgical indication.

Pure Laparoscopic En Bloc Left Hemihepatectomy and Caudate Lobe Resection in Patients with Intrahepatic Cholangiocarcinoma

INTRODUCTION There is an ongoing debate on whether it is safe to push the boundaries and widen the indications of laparoscopic liver surgery after careful patient selection. We report 2 cases of pure laparoscopic en bloc left hemihepatectomy and caudate lobe resection for intrahepatic cholangiocarcinoma (ICC). METHODS The first patient (a 79-year old) had an ICC affecting segments 2, 3, and 4 of the liver with dilatation of segment 1 ducts at preoperative imaging. The second patient (an 81-year old) had an ICC affecting segments 2, 3 with local invasion of segment 1. Both patients underwent pure laparoscopic left hemihepatectomy and caudate lobe resection. RESULTS The first patients operative time was 360 minutes and blood loss was 390 mL. Postoperative hospital stay was 8 days. The definitive histology was as follows: pT1 ICC (25 mm in maximal diameter), with 20 mm free resection margin. The second patients operative time was 310 minutes and blood loss was 300 mL. Postoperative hospital stay was 4 days. The definitive histology was as follows: T1 ICC (49 mm in maximal diameter) with 10 mm free resection margin. The first patient was disease free 12 months after surgery. The second patient died 11 months after surgery of metastatic disease. CONCLUSION Pure laparoscopic left hemihepatectomy and caudate lobectomy for ICC may be feasible and safe. This is, however, a very complex procedure requiring extensive experience in laparoscopic liver surgery and careful patient selection to optimize surgical outcome. To our knowledge, this is the first systematic description of a pure laparoscopic en bloc left hemihepatectomy and caudate lobe resection for ICC.

Apoptotic phenomena are not a major cause of enteric neuronal loss in constipated patients with dementia.

Chronic constipation is a frequent symptom in patients with dementia, especially in those institutionalized. However, few data are available on the neuropathological aspects of the colon in such patients. We investigated the enteric neuropathology of the colon in two patients with longstanding dementia and intractable constipation, requiring surgery to alleviate symptoms. The results were compared to those obtained in 10 controls. No abnormalities were found at conventional histological examination, except for the presence of melanosis coli. Immunohistochemical evaluation revealed no important difference between patients and controls, except for a decreased number of enteric neurons in patients. However, this neuronal decrease was not associated to apoptotic phenomena, as observed in patients with severe idiopathic constipation. We concluded that in severely constipated patients with dementia the neuropathological abnormalities might be reconducted to a physiological neuronal decrease as a result of aging, and that the pathophysiological aspects of constipation in these subjects differ from those found in idiopathic constipation.

Solitary Microcarcinoid of the Rectal Stump in Ulcerative Colitis

A case of solitary microcarcinoid and chronic ulcerative colitis of the rectal stump is described. The association of intestinal carcinoid with ulcerative colitis has been reported previously in 26 patients. Pathogenic pathways are discussed according to the presence of multifocal carcinoid and/or gut endocrine cell hyperplasia.

Laparoscopic liver resection for hepatocellular adenoma.

AIM To investigate the role of laparoscopy in the surgical management of hepatocellular adenoma (HA). METHODS We reviewed a prospectively collected database of consecutive patients undergoing laparoscopic liver resection for HA. RESULTS Thirteen patients underwent fifteen pure laparoscopic liver resections for HA (male/female: 3/10; median age 42 years, range 22-72 years). Two patients with liver adenomatosis required two different laparoscopic operations for ruptured adenomas. Indications for surgery were: symptoms in 12 cases, need to rule out malignancy in 2 cases and preoperative diagnosis of large HA in one case. Symptoms were related to bleeding in 10 cases, sepsis due to liver abscess following embolization of HA in one case and mass effect in one case (shoulder tip pain). Five cases with ruptured bleeding adenoma required emergency admission and treatment with selective arterial embolization. Laparoscopic liver resection was then semi-electively performed. Eight patients (62%) required major hepatectomy [right hepatectomy (n = 5), left hepatectomy (n = 3)]. No conversion to open surgery occurred. The median operative time for pure laparoscopic procedures was 270 min (range 135-360 min). The median size of the excised lesions was 85 mm (range 25-180 mm). One patient with adenomatosis developed postoperative bleeding requiring embolization. Mortality was nil. The median hospital stay was 4 d (range 1-18 d) with a median high dependency unit stay of 1 d (range 0-7 d). CONCLUSION The laparoscopic approach represents a safe option for the management of HA in a semi-elective setting and when major hepatectomy is required.