Giovanni Battista Levi Sandri

Alpha-Fetoprotein and Novel Tumor Biomarkers as Predictors of Hepatocellular Carcinoma Recurrence after Surgery: A Brilliant Star Raises Again

Alpha-fetoprotein (AFP), des-γ-carboxy prothrombin (DCP), and lens culinaris agglutinin-reactive fraction of AFP (AFP-L3) have been developed with the intent to detect hepatocellular carcinoma (HCC) and for the surveillance of at-risk patients. However, at present, none of these tests can be recommended to survey cirrhotic patients at risk for HCC development because of their suboptimal ability for routine clinical practice in HCC diagnosis. Starting from these considerations, these markers have been therefore routinely and successfully used as predictors of survival and HCC recurrence in patients treated with curative intent. All these markers have been largely used as predictors in patients treated with hepatic resection or locoregional therapies, mainly in Eastern countries. In recent studies, AFP has been proposed as predictor of recurrence after liver transplantation and as selector of patients in the waiting list. Use of AFP modification during the waiting list for LT is still under investigation, potentially representing a very interesting tool for patient selection. The development of a new predictive model combining radiological and biological features based on biological markers is strongly required. New genetic markers are continuously discovered, but they are not already fully available in the clinical practice.

Laparoscopic and robotic approach for hepatocellular carcinoma-state of the art.

Hepatocellular carcinoma (HCC) is the sixth most common malignant tumor worldwide and the most common primary liver cancer, in over 80% of cases HCC grown on a cirrhotic liver. Laparoscopic liver resection (LLR) is now worldwide accepted considering the excellent results shown. Minimally invasive surgical approach for HCC is increasing continuously and in specialized centers seems to become the first-line approach for those patients. The aim of this review presents and discusses state of the art in the laparoscopic and robotic surgical treatment of HCC. An electronic search was performed to identify all studies dealing with HCC resected with laparoscopy or robotic approach. Indications for laparoscopic resection, robotic assisted and totally robotic resection of HCC will be doubtless increased in future years. LLR and robotic approach for HCC is safe and feasible.

Laparoscopy in Liver Transplantation: The Future Has Arrived

In the last two decades, laparoscopy has revolutionized the field of surgery. Many procedures previously performed with an open access are now routinely carried out with the laparoscopic approach. Several advantages are associated with laparoscopic surgery compared to open procedures: reduced pain due to smaller incisions and hemorrhaging, shorter hospital length of stay, and a lower incidence of wound infections. Liver transplantation (LT) brought a radical change in life expectancy of patients with hepatic end-stage disease. Today, LT represents the standard of care for more than fifty hepatic pathologies, with excellent results in terms of survival. Surely, with laparoscopy and LT being one of the most continuously evolving challenges in medicine, their recent combination has represented an astonishing scientific progress. The intent of the present paper is to underline the current role of diagnostic and therapeutic laparoscopy in patients waiting for LT, in the living donor LT and in LT recipients.

The role of robotics in widening the range of application of minimally invasive surgery for pancreaticoduodenectomy.

Nearly two decades after its appearance, the use of minimallyinvasive techniques in pancreatic surgery is becoming more widespread, mostly due to the increased experience in this field and the availability of new technologies. However, if on one side minimally invasive surgery (MIS) has been associated with significant advantages over conventional open surgery in case of left sided pancreatectomies [1,2], pancreaticoduodenectomy (PD) is still considered a relative limitation to laparoscopic techniques [3e5]. About twenty years ago Gagner and Pomp from the University of Montr eal presented the first case of a laparoscopically performed pylorus-preserving PD for the treatment of chronic pancreatitis [6]. As a consequence, an increasing number of encouraging preliminary experiences coming from other centers followed, progressively expanding the indications from benign conditions to small malignancies of the pancreatic head [7]. Notwithstanding promising initial results and all the potential advantages connected with laparoscopy over conventional surgery, the intervening years have seen minimally invasive PD failing to obtain wide acceptance in real clinical practice worldwide [3,4]. Indeed, laparoscopic PD is regarded as a technically highdemanding procedure, mostly due to the deep, retroperitoneal location of the gland, its close relationship with major vascular structures and the complex reconstruction phase that requires at least three anastomoses. Several crucial maneuvers require angulated or curved lines of section and rigid laparoscopic instruments, with their restricted freedom of movement, can lead to significant technical difficulties [5,7]. In this regard, we do believe that PD represents one of the procedureswhichmay greatly benefit from robotics. A number of technical issues connected with conventional laparoscopy has been overcome, at least partially, by robotic platforms, which permit magnified 3-dimensional intraoperative view and enhanced surgical dexterity that, thanks to the endowristed maneuverability, affords optimal control on fine dissections. These features enable not only easier resecting and suturing, thus permitting more accurate anastomoses, but also facilitate the management of possible intraoperative complications such as major bleedings [8,9]. As a result, robot-assisted surgery has significantly increased the possibility of application of minimally invasive pancreatic surgery worldwide, particularly in the context of PD. This becomes evident if one notes the growing use of robotic surgery in PD over the last few years. By investigating the relevant scientific evidence, a significant difference of development and application of minimally invasive PD can be noted between the robotic and conventional

Liver resection for hepatocellular carcinoma ≥5 cm.

BACKGROUND Management of hepatocellular carcinoma (HCC) larger than 5 cm is still debated. The aim of our study was to compare morbidity and mortality after the surgical resection of HCC according to the nodule size. METHODS Since 2001, 429 liver resections for HCC were performed in our institution. We divided the cohort into two groups, 88 patients in group 1 patients with HCC diameter from 5 to 10 cm and 39 patients in group 2 with HCC diameter ≥10 cm. RESULTS In 30.7% of cases in the first group and in 35.9% of cases in the second group the HCC grew into a healthy liver. A major liver resection was performed in 36.3% of cases in group 1 vs. 66.6% in group 2 (P=0.001). In two cases for the first group and in ten cases in the second group a laparoscopic approach was performed. Median operative time was higher in group 2 (P=0.001). The median post-operative hospital stay was similar in the two groups (P=0.897). The post-operative morbidity was not different between the two groups (P=0.595). CONCLUSIONS The tumour size does not contraindicate a surgical resection of HCC even in patient with HCC ≥10 cm.

The use of robotic surgery in abdominal organ transplantation: A literature review

Minimally invasive surgical approaches in transplantation are gaining increasing interest, and many centers are reporting their, mainly laparoscopic, experiences. Robotic surgery (RS) has some hypothetical advantages over traditional laparoscopy and has been successfully applied, although infrequently to organ transplantation. Our goal was to review and critique the publications reporting RS use in organ transplantation. Most of the RS experience has been with living renal donor organ procurement and, to a lesser extent, with RS procedures in the transplant recipient. The available literature suggests that RS appears to be a safe surgical alternative to standard open procedures. RS in living liver donor surgery remains limited, and more experience is required before commenting on RS‐related outcomes RS in pancreatic transplantation is exceedingly rare. The enhanced precision and ergonomics of RS may expand its applicability to liver living donation and pancreas transplantation at some point in the future.

Liver splenosis mimicking hepatocellular carcinoma in cirrhotic liver.

Hepatocellular carcinoma (HCC) is the sixth most common cancer and the third cause of cancer-related death (1). Approximately 90% of HCCs are associated with an underlying risk factor, including chronic viral hepatitis (types B and C) (2). Splenosis is a heterotopic implantation of splenic fragments into exposed vascularised peritoneal and intrathoracic surfaces, following splenic injury or elective splenectomy (3). We present a case of a 54-year-old Caucasian man admitted in our unit with the diagnosis of suspect HCC developed on HBV-related cirrhosis. At the age of 29, the patient has been already operated, undergoing an urgent spenectomy owing to blunt trauma after a traffic accident. A computed tomography (CT) scan reported a lesion located at the level of segment III, with the typical radiological characteristics of HCC (Fig. 1A,B). Atypical hepatic resection of the lesion was performed, and patient was discharged after an uneventful post-operative course at day 7. Histopathology showed a 4.5 9 3.5 9 1.5-cm brownish mass with the microscopical aspects of a capsulated spleen (Fig. 2A,B). Autotransplant of splenic tissue may occur anywhere in the body, but is most commonly observed in the peritoneal cavity. Splenosis is easily misinterpreted as a tumour condition. There are few previous reports of hepatic splenosis mimicking hepatocellular carcinoma. Treatment usually requires surgery and confirmation by pathology. In case of patients waiting for liver transplantation, particular attention must be paid in patients with a history of accidental splenectomy.

Comparison of Image Quality and Diagnostic Performance of Cone-Beam CT during Drug-Eluting Embolic Transarterial Chemoembolization and Multidetector CT in the Detection of Hepatocellular Carcinoma

PURPOSE To compare image quality and diagnostic performance of cone-beam computed tomography (CT) and multidetector CT in the detection of hypervascular hepatocellular carcinoma (HCC) in patients with cirrhosis undergoing transarterial chemoembolization with drug-eluting embolic agents. MATERIALS AND METHODS Fifty-five consecutive patients referred for chemoembolization of hypervascular HCC were prospectively enrolled. Imaging included preprocedural multidetector CT within 1 month before planned treatment, intraprocedural cone-beam CT, and 1-month follow-up multidetector CT. Analysis of image quality was performed with calculations of lesion-to-liver contrast-to-noise ratio (LLCNR) and lesion-to-liver signal-to-noise-ratio (LLSNR). One-month follow-up multidetector CT was considered the reference standard for the detection of HCC nodules. RESULTS Median LLCNR values were 3.94 (95% confidence interval [CI], 3.06-5.05) for preprocedural multidetector CT and 6.90 (95% CI, 5.17-7.77) for intraprocedural cone-beam CT (P < .0001). Median LLSNR values were 11.53 (95% CI, 9.51-12.44) for preprocedural multidetector CT and 9.36 (95% CI, 8.12-10.39) for intraprocedural cone-beam CT (P < .0104). Preprocedural multidetector CT detected 115 hypervascular nodules with typical HCC behavior, and cone-beam CT detected 15 additional hypervascular nodules that were also visible on 1-month follow-up multidetector CT. CONCLUSIONS Cone-beam CT has a significantly higher diagnostic performance compared with preprocedural multidetector CT in the detection of HCCs and can influence management of patients with cirrhosis by identifying particularly aggressive tumors.

Hepatocellular carcinoma with macrovascular invasion treated with yttrium-90 radioembolization prior to transplantation

BACKGROUND Yttrium-90 microspheres radioembolization (Y90-RE) has shown to be an effective and safe treatment of primary liver tumors. According to the staging system of the Barcelona Clinic Liver Cancer (BCLC), patients with macrovascular invasion are staged as BCLC-C. This paper comprises a presentation of the results following application of the procedure. METHODS From January 2002 to December 2015, 367 patients were transplanted at the San Camillo Hospital Center. One hundred and forty-three patients were transplanted for hepatocellular carcinoma (HCC) and in 22 cases patients were treated with Y90-RE before liver transplantation (LT), of them 4 with macrovascular invasion were included in this study. RESULTS The four patients had a complete response for the thrombosis, and were included in the waiting list within the Milan criteria. Means interval time between Y90-RE and LT was 15.86 months. No patient death was observed at Y90-RE procedure or at LT. We obtain a free-survival of 39.1 (range, 6-76) months. In all four cases the complete thrombosis regression was observed. CONCLUSIONS We reported a short series of patients transplanted after Y90-RE in patients with BCLC stage C. In our experience we achieved acceptable overall and disease-free survival. Eventually, Y90-RE seems to have a place in the downstaging strategy for LT candidates.

Minimally invasive surgery for the treatment of pilonidal disease. The Gips procedure on 2347 patients

BACKGROUND Pilonidal disease is a quite common chronic inflammatory disease that causes discomfort, embarrassment and absence from work or school. In line with its acquired pathogenesis, a number of surgical alternatives to conventional en bloc excision have been proposed over the last decades, yielding encouraging results. We reviewed our experience with minimally invasive sinusectomy to evaluate its safety and efficacy. METHODS this study was a review of a prospectively maintained database of consecutive patients over a 7-year period. From November 2009 to December 2015, 2347 patients with pilonidal disease were operated on using the Gips procedure. Patients received surgery as a day-case procedure under local anesthesia. Operative and perioperative data were examined. RESULTS there were 1714 men (73%) and 633 women (27%) in the study; the median age was 19 years. Recurrent diseases in patients who had previously undergone surgery elsewhere composed 61% of cases. Globally, 102 cases of clinically relevant postoperative complication occurred (4.3%). At a median follow up of 16 months, the recurrence rate was 5.8%. The treatment of recurrent disease did not correlate to increased recurrence rate following sinusectomy. Recurrent patients were more likely to be male and have delayed wound healing. CONCLUSIONS the Gips procedure for the treatment of pilonidal disease is safe and feasible. It has a low complication and recurrence rate, early return to daily activities and offers a good cosmetic result.