Giovanni Ramacciato

Is Portal Hypertension a Contraindication to Hepatic Resection

Background and Aims:The outcome of hepatic resection in cirrhotic patients has improved remarkably in recent years with improved surgical techniques and perioperative care; however, the role of portal hypertension is still uncertain. The aim of this study was to elucidate surgical outcomes of hepatectomy in patients with portal hypertension. Methods:Data from 241 cirrhotic patients who underwent resection for hepatocellular carcinoma were retrospectively collected and analyzed: patients were divided into 2 groups according to the presence (n = 89) or absence (n = 152) of portal hypertension at the time of surgery. To overcome biases owing to the different distribution of covariates throughout the 2 groups, a one-to-one match was created using propensity score analysis: after match, intraoperative, and postoperative course and survival rates were analyzed. Results:Patients with portal hypertension experienced worse preoperative liver function (mean model for end-stage liver disease [MELD] score, 9.5 ± 7.8 vs. 8.4 ± 1.3; P = 0.001) and survival rates (P = 0.008) in comparison to those without portal hypertension: after one-to-one matching, patients with (n = 78) and without portal hypertension (n = 78) had the same preoperative characteristics and showed the same intraoperative course, postoperative occurrence of liver failure, morbidity, length of in-hospital stay and survival rates (P = ns in all cases). The only predictors of postoperative liver failure were MELD score (P = 0.001) and extent of hepatectomy (P = 0.005). Conclusions:Faced with the same MELD score and extent of hepatectomy planning, presence of portal hypertension should not be considered as a contraindication for hepatic resection in cirrhotic patients.

Trends in perioperative outcome after hepatic resection: analysis of 1500 consecutive unselected cases over 20 years.

Objective:To estimate risk factors affecting the early outcome after hepatic resection in a high volume center specialized in hepatobiliary surgery and to analyze the changing of results during 3 different periods of treatment. Design:Retrospective review. Patients:A series of 1500 consecutive patients who underwent hepatic resection. Methods:Postoperative morbidity and mortality were analyzed in relation to indications for surgery, period of operation, patient characteristics, and intraoperative variables. Patients were classified into 4 groups, according to the indication for surgery: primary liver tumors with cirrhosis (group 1, G1); other liver malignancies (group 2, G2); biliary malignancies (group 3, G3); and benign diseases (group 4, G4). Patients were also divided into 3 groups, according to the year of operation (period 1: June 1985 to October 1993; period 2: November 1993 to September 1999; period 3: October 1999 to September 2007). Results:Overall mortality and morbidity were 3% and 22.5%, respectively. Multivariate analysis revealed that blood transfusions, G1, and additional procedures were associated with an increased risk of postoperative complications, whereas blood transfusions, G1, G3, and extended hepatectomy were associated with an increased risk of postoperative mortality. G1 decreased, whereas G3, extended hepatectomies and additional procedures significantly increased between periods 2 and 3 (P < 0.05). The complication rate was significantly lower in period 2 (18.8%) compared with period 1 (23.8%) and period 3 (24.8%). Similarly, there was a significantly lower mortality rate in period 2 (1.6%) compared with period 1 (3.4%) and period 3 (4%). Conclusions:Slightly worse short-term outcomes in liver surgery were observed in recent years, with a concomitant increase of the aggressiveness of operative strategies. Nevertheless, the present results still justify an aggressive approach in liver resections.

The Role of Liver Resections for Noncolorectal, Nonneuroendocrine Metastases: Experience With 142 Observed Cases

BackgroundTo evaluate the role of liver resection for noncolorectal, nonneuroendocrine metastases, indications and results were retrospectively reviewed in 142 observed patients.MethodsA curative liver resection was performed in 83 cases (58.5%), and the remaining 59 patients received palliative treatments. The primary tumor site was gastrointestinal in 18, breast in 21, genitourinary in 15, leiomyosarcoma in 10, and other in 19. The mean number of metastases was 1.4. The mean diameter of the nodules was 5.7 cm. Liver metastases were synchronous in 11 (13.3%) cases and metachronous in the remaining 72 (86.7%).ResultsThere was no operative mortality. Postoperative morbidity was 20.5%. The median postoperative stay was 9.5 days. The 3- and 5-year actuarial survival rate was 49.5% and 34.3% in resected cases, respectively, whereas there were almost no survivors 3 years after diagnosis in unresected cases (P < .05). The 3- and 5-year disease-free survival was 41.4% and 23.8%, respectively. Among the 83 resected cases, the 3- and 5-year actuarial survival was 17.3% and 8.6% for metastases from gastrointestinal tumors, 53.9% and 24.6% from breast cancer, 63.7% and 36.4% from leiomyosarcoma, 50.4% and 37.8% from genitourinary neoplasms, and 55.6% and 42.4% from other sites, respectively. Fifteen patients (18.1%) survived longer than 5 years.ConclusionsLiver resection is an effective treatment for noncolorectal, nonneuroendocrine metastases; it allows satisfactory long-term survival with an acceptable operative risk in selected patients. Hepatic metastases from gastrointestinal carcinoma have the worst prognosis; those from genitourinary tumors show a better outcome. Patient selection is the key to achieving encouraging results.

Liver Transplantation for Recurrent Hepatocellular Carcinoma on Cirrhosis After Liver Resection : University of Bologna Experience

Liver resection (LR) for patients with small hepatocellular carcinoma (HCC) with preserved liver function, employing liver transplantation (LT) as a salvage procedure (SLT) in the event of HCC recurrence, is a debated strategy.

Metaanalysis of trials comparing minimally invasive and open distal pancreatectomies

BackgroundThe current literature suggests that minimally invasive distal pancreatectomy (MIDP) is associated with faster recovery and less morbidity than open surgery. However, most studies have been limited by a small sample size and a single-institution design. To overcome this problem, the first metaanalysis of studies comparing MIDP and open distal pancreatectomy (ODP) has been performed.MethodsA systematic literature review was conducted to identify studies comparing MIDP and ODP. Perioperative outcomes (e.g., morbidity and mortality, pancreatic fistula rates, blood loss) constituted the study end points. Metaanalyses were performed using a random-effects model.ResultsFor the metaanalysis, 10 studies including 349 patients undergoing MIDP and 380 patients undergoing ODP were considered suitable. The patients in the two groups were similar with respect to age, body mass index (BMI), American Society of Anesthesiology (ASA) classification, and indication for surgery. The rate of conversion from full laparoscopy to hand-assisted procedure was 37%, and that from minimally invasive to open procedure was 11%. Patients undergoing MIDP had less blood loss, a shorter time to oral intake, and a shorter postoperative hospital stay. The mortality and reoperative rates did not differ between MIDP and ODP. The MIDP approach had fewer overall complications [odds ratio (OR), 0.49; 95% confidence interval (CI), 0.27–0.89], major complications (OR, 0.57; 95% CI, 0.34–0.96), surgical-site infections (OR, 0.32; 95% CI, 0.19–0.53), and pancreatic fistulas (OR, 0.68; 95% CI, 0.47–0.98).ConclusionsThe MIDP procedure is feasible, safe, and associated with less blood loss and overall complications, shorter time to oral intake, and shorter postoperative hospital stay. Furthermore, the minimally invasive approach reduces the rate of pancreatic leaks and surgical-site infections after ODP.

Hemoperitoneum from a Spontaneous Rupture of a Giant Hemangioma of the Liver: Report of a Case

Hemangioma is the most common benign tumor of the liver and it is often asymptomatic. Spontaneous or traumatic rupture, intratumoral bleeding, consumption coagulopathy, and rapid growth are mandatory surgical indications. We report a case of giant hemangioma of hepatic segments II and III, which presented as hemoperitoneum, and were treated successfully with preoperative transcatheter arterial embolization (TAE) and hepatic bisegmentectomy. A PubMed Medline search has identified up to now 32 cases of spontaneous rupture of hepatic hemangioma in adults (age >14 years) without a history of trauma, including the present case. Twenty-seven out of these were reviewed. Sixteen (84.2%) of 19 tumors of known size were giant hemangiomas (mean diameter 14.8 cm; range 6–25). Twenty-two (95.7%) patients underwent surgery. Thirteen patients (59.1%) had a resection, 5 (22.8%) were sutured, and 4 (18.1%) underwent tamponade. Three (23%) out of the 13 resected patients died. Four patients (30.8%) underwent TAE prior to elective hepatic resection without any operative mortality. Among the 5 sutured patients, 2 (40%) died as well as 3 (75%) out of 4 patients who underwent tamponade. The mortality rate of all surgery patients was 36.4% (8/22).

Is laparoscopic adrenalectomy safe and effective for adrenal masses larger than 7 cm

BackgroundLaparoscopic adrenalectomy (LA) has become the gold standard treatment for small (less than 6 cm) adrenal masses. However, the role of LA for large-volume (more than 6 cm) masses has not been well defined. Our aim was to evaluate, retrospectively, the outcome of LA for adrenal lesions larger than 7 cm.Patients and methods18 consecutive laparoscopic adrenalectomies were performed from 1996 to 2005 on patients with adrenal lesions larger than 7 cm.ResultsThe mean tumor size was 8.3 cm (range 7–13 cm), the mean operative time was 137 min, the mean blood loss was 182 mL (range 100–550 mL), the rate of intraoperative complications was 16%, and in three cases we switched from laparoscopic procedure to open surgery.ConclusionsLA for adrenal masses larger than 7 cm is a safe and feasible technique, offering successful outcome in terms of intraoperative and postoperative morbidity, hospital stay and cosmesis for patients; it seems to replicate open surgical oncological principles demonstrating similar outcomes as survival rate and recurrence rate, when adrenal cortical carcinoma were treated. The main contraindication for this approach is the evidence, radiologically and intraoperatively, of local infiltration of periadrenal tissue.

Outcome of hepatic artery reconstruction in liver transplantation with an iliac arterial interposition graft

Abstract:  Background: In case of anomal hepatic arterial inflow, it can be necessary to perform revascularization of the liver allograft by iliac arterial interposition graft.

Living Donor Liver Transplantation with Left Liver Graft

Small‐for‐size syndrome in LDLT is associated with graft exposure to excessive portal perfusion. Prevention of graft overperfusion in LDLT can be achieved through intraoperative modulation of portal graft inflow. We report a successful LDLT utilising the left lobe with a GV/SLV of only 20%. A 43 year‐old patient underwent to LDLT at our institution. During the anhepatic phase a porto‐systemic shunt utilizing an interposition vein graft anastomosed between the right portal branch and the right hepatic vein was performed. After graft reperfusion splenectomy was also performed. Portal vein pressure, portal vein flow and hepatic artery flow were recorded. A decrease of portal vein pressure and flow was achieved, and the shunt was left in place. The recipient post‐operative course was characterized by good graft function. Small‐for‐size syndrome by graft overperfusion can be successfully prevented by utilizing inflow modulation of the transplanted graft. This strategy can permit the use of left lobe in adult‐to‐adult living donor liver transplantation.

Malnutrition and pancreatic surgery: Prevalence and outcomes†

Pancreatic surgery is associated with severe postoperative morbidity. Identification of patients at high risk may provide a way to allocate resources objectively and focus care on those patients in greater need. The Authors evaluate the prevalence of malnutrition and its effect on the postoperative morbidity of patients undergoing pancreatic surgery for malignant tumors.