Matteo Barabino

Hepatic resection for hepatocellular carcinoma in patients with Child–Pugh's A cirrhosis: is clinical evidence of portal hypertension a contraindication?

BACKGROUND According to international guidelines [European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD)], portal hypertension (PHTN) is considered a contraindication for liver resection for hepatocellular carcinoma (HCC), and patients should be referred for other treatments. However, this statement remains controversial. The aim of this study was to elucidate surgical outcomes of minor hepatectomies in patients with PHTN (defined by the presence of esophageal varices or a platelet count of <100,000 in association with splenomegaly) and well-compensated liver disease. METHODS Between 1997 and 2012, a total of 223 cirrhotic patients [stage A according to the Barcelona Clinic Liver Cancer (BCLC) classification] were eligible for this analysis and were divided into two groups according to the presence (n = 63) or absence (n = 160) of PHTN. The demographic data were comparable in the two patient groups. RESULTS Operative mortality was not different (only one patient died in the PHTN group). However, patients with PHTN had higher liver-related morbidity (29% versus 14%; P = 0.009), without differences in hospital stay (8.8 versus 9.8 days, respectively). The PHTN group showed a worse survival rate only if biochemical signs of liver decompensation existed. Multivariate analysis identified albumin levels as an independent predictive factor for survival. CONCLUSIONS PHTN should not be considered an absolute contraindication to a hepatectomy in cirrhotic patients. Patients with PHTN have short- and long-term results similar to patients with normal portal pressure. A limited hepatic resection for early-stage tumours is an option for Child-Pugh class A5 patients with PHTN.

Impact of intraoperative ultrasonography in laparoscopic liver surgery

BackgroundLaparoscopic surgery has gained growing acceptance, but this does not hold for laparoscopic surgery of the liver. This mainly includes diagnostic procedures, interstitial therapies, and treatment of liver cysts. However, the authors believe there is room for a laparoscopic approach to the liver in selected cases.MethodsA prospective study of laparoscopic liver resections was undertaken with patients who had preoperative diagnoses of benign lesion and hepatocellular carcinoma with compensated cirrhosis. The inclusion criteria required that hepatic involvement be limited and located in the left or peripheral right segments (segments 2–6), and that the tumor be 5 cm or smaller. The location of the tumor and its transection margin were defined by laparoscopic ultrasound (LUS).ResultsFrom December 1996, 17 (5%) of 313 liver resections were included in the study. There were 5 benign lesions and 12 hepatocellular carcinomas in cirrhotic patients. The mean age of the study patients was 59 years (range, 29–79 years). The LUS evaluation identified the presence of new hepatocellular carcinoma nodules in two patients (17%). The resections included 1 bisegmentectomy, 8 segmentectomies, 3 subsegmentectomies, and 3 nonanatomic resections. The mean operative time, including laparoscopic ultrasonography, was 156 ± 50 min (median, 150 min; range, 60–250 min), and the perioperative blood loss was 190 ± 97 ml. There was no mortality. Conversion to laparotomy was necessary for two patients. Postoperative complications were experienced by 3 of 15 patients, all of them cirrhotics. One of the patients had a wall hematoma, and the remaining two patients had bleeding from a trocar access requiring a laparoscopic reexploration. The mean hospital stay for the whole series was 6.9 ± 4.9 days (median, 6 days; range, 2–25 days) and 5.6 ±1.4 days (median, 6 days; range, 2–8 days) for the 15 laparoscopic patients.ConclusionLaparoscopic treatment should be considered for selected patients with benign and malignant lesions in the left lobe or frontal segments of the liver. Evaluation by LUS is indispensable to guarantee precise determination of the segmental tumor location and the relationship of the tumor to adjacent vascular or biliary structures, excluding adjacent or adjunctive new lesions. The evolution of laparoscopic hepatectomies probably will depend on the development of new techniques and instrumentations.

Is there still a role for laparoscopy combined with laparoscopic ultrasonography in the staging of pancreatic cancer

PurposeThis study was designed to compare our laparoscopic ultrasonography (LUS) experience in the resectability evaluation of pancreatic or periampullary cancers (PAC) in two different periods: before and after the introduction of multidetector CT (MDCT).MethodsWe prospectively enrolled 104 CT-resectable patients with PAC. During Step 1 (1995–1999), we performed LUS on all patients, whereas during Step 2 (2002–2007), LUS was performed selectively according to Pisters’ criteria.ResultsLUS was satisfactorily performed in all cases. At Step 1 accuracy of LUS in predicting pancreatic resectability was high (96%) but it was markedly lower in a subgroup of patients with close contact between tumor and portal vein (sensibility of 57%). At Step 2, selective LUS was performed on 9 of 64 patients (14%). LUS confirmed the MDCT finding of unresectability in 8 of 9 cases, and allowed curative resection in 1 case. Only 1 of 55 of the patients who did not undergo LUS would have benefited from the procedure. The yield of LUS decreased from 45% before to 1.8% after MDCT.ConclusionsIn resectable-MDCT patients, routine LUS is unjustified. However, in doubtful MDCT cases, LUS has yet a good yield. In the event of close vascular contact, neither MDCT nor LUS seem to be conclusive, and laparotomy is still the only solution.

Local Anesthesia for Stapled Prolapsectomy in Day Surgery: Results of a Prospective Trial

PURPOSEThis article reports the results of a prospective trial of the feasibility of Longo’s procedure under local anesthesia in day surgery.METHODSFrom April 2002 to May 2003, 66 patients (42 males and 24 females) were enrolled in the study; the mean age was 47.5 (range, 23–65) years. Thirty-six patients (55 percent) had prolapsed third-degree hemorrhoids, while 30 (45 percent) had fourth-degree hemorrhoids. All patients were operated on under local infiltration of the anorectal region by injecting ropivacaine 7.5 mg/dl using a Quadrijet. During the surgical procedure, blood pressure and heart rate were always monitored and the level of pain was checked using a visual analog scale. Hospital discharge was programmed for 6:00 p.m. Any immediate complications, such as bleeding, urinary retention, or pain, were also recorded.RESULTSIt was possible to perform the procedure under local anesthesia in all patients, and the anesthesiologist did not need to intervene at any time. No vagal reaction was observed; the transient reduction of blood pressure and heart rate, which occurred in four patients (6 percent),was controlled with an analgesic drug. In 96 percent of the cases the mean intraoperative visual analog score was not higher than four. Fifty-six patients were discharged at 6:00 p.m., while only 10 percent required an overnight stay.CONCLUSIONSThe stapled prolapsectomy procedure is feasible and can be performed safely under local anesthesia and as day surgery. This procedure provides good pain control and results in a minimal number of complications.

Radio-guided video-assisted parathyroidectomy: A preliminary report

Background: The surgical management of primary hyperparathyroidism is changing both in terms of the extent of cervical exploration and in technique. There are many new mini-invasive procedures for neck surgery. We describe our preliminary experience with a technique that combines two mini-invasive procedures-radio-guided and video-assisted parathyroidectomy. Methods: Six consecutive patients with no recurrent or persistent primary hyperparathyroidism, no previous cervical operations, and no thyroid pathologies were selected to undergo radio-guided video-assisted parathyroidectomy. Results: One case was converted. There was no morbidity or mortality in the postoperative period. Six parathyroids were removed; the histological diagnosis was adenoma in all cases. All patients were discharged on the 1st postoperative day. Calcium serum levels normalized in all cases, with only one case of transient postoperative hypocalcemia. All patients were normocalcemic after 6 months. Conclusion: Radio-guided video-assisted parathyroidectomy is feasible in selected patients. However, longer follow-up and more cases are necessary before this procedure can be applied routinely.

Intraoperative ultrasound for prediction of hepatocellular carcinoma biological behaviour: Prospective comparison with pathology

Preoperative prediction of both microinvasive hepatocellular carcinoma and histological grade of hepatocellular carcinoma is pivotal to treatment planning and prognostication. The aim of this study was to evaluate whether some intraoperative ultrasound features correlate with both the presence of same histological patterns and differentiation grade of hepatocellular carcinoma on the histological features of the primary resected tumour.

Risk Factors for Prolonged Postoperative Ileus In Adult Patients Undergoing Elective Colorectal Surgery: An Observational Cohort Study

PURPOSE Prolonged Postoperative Ileus (PPOI) after abdominal surgery may affect unfavourably the patient recovery. The aim of this study was to estimate the incidence of PPOI in patients elective for colorectal resection and investigate perioperative variables associated with PPOI. METHODS A consecutive series of 428 patients undergoing colorectal resection (median age 72, range 24-92, years; men/women ratio 1.14) were analyzed. Data were extracted retrospectively throughout a five-year period from an electronic prospectively maintained database. PPOI was defined as the need for postoperative insertion of a nasogastric tube in a patient experiencing nausea and two episodes of vomiting and further showing absence of adequate bowel function (absence of flatus/stool) with lack of bowel sounds and abdominal distension. RESULTS Incidence of PPOI was 7% [95% confidence interval (95%CI), 4.8-9.9%]. Mean hospital stay was 8 days longer in patients with PPOI. Male gender, cancer, cardiac and respiratory co-morbidity, rectal resection, open/converted access, duration of operation, stoma formation and body mass index were associated with PPOI at univariate analysis (0.001< P< 0.048). PPOI was independently associated with male gender [adjusted odds ratio (OR), 4.2; 95%CI, 1.5-11.5], stoma formation (OR, 2.8; 95%CI, 1.2-6.8) and obesity (OR of obese vs. normal weight patients, 3.8, 95%CI, 1.2-12.0). CONCLUSION After colorectal resection, PPOI leads to a prolonged hospital stay and slower patients recovery. An international standardized definition of PPOI is strongly needed to make comparable results from researches and to reliably identify patients with increased risk, also to improve the therapeutic preventive policies in these patients.

Non-resection: Radiofrequency Ablation, Cryo, Microwave

The increased diffusion of laparoscopy in the oncologic field promoted the use of laparoscopic ultrasound (LUS). LUS provides a set of information: (a) in staging of operability, LUS extends the surgical exploration by detecting non palpable lesions; (b) LUS supports the planning of the interstitial approach by visualisation of the lesion and guides the needle position. A correct technique can be mastered relatively quickly by a surgeon already familiar with laparoscopic and ultrasound techniques. The learning curve mainly relates to the interpretation of the ultrasonographic images and to the technical tricks of interventional manoeuvres.

Single versus two-operator endoscopic biliary cannulation technique: a multicenter matched-case analysis and a literature review

BACKGROUND The aim of this study was to compare the outcomes of physician-controlled, using both long and short endoscopic-retrograde-cholangiopancreatography wire systems, and assistant-controlled guide-wire biliary cannulation techniques, and to perform a literature review on this topic. METHODS The endoscopic databases of three Endoscopic Centers were reviewed to identify all consecutive patients with an intact papilla who, between July 2013 and December 2014, underwent an endoscopic-retrograde-cholangiopancreatography. A total of 240 patients (80 for each group) were matched 1:1, by gender, age and indications for procedure and were included in the analysis. All articles of physician-controlled vs. assistant-controlled guide-wire biliary cannulation techniques, were extracted up to December 2016, and included in the review. RESULTS There were no statistically significant differences in primary and final (using rescue technique) cannulation rate between the three groups. The mean primary cannulation time and overall cannulation time were shorter in the two groups of physician-controlled guide-wire compared to the assistant-controlled guide-wire group, but the difference was not statistically significant. The total procedure time did not differ significantly between the three groups, but the physician-controlled guide-wire using short wire system was associated with a trend toward a shorter time compared to the other two techniques. There were no statistically significant differences in complication rates between the three groups. Three pertinent articles were included in the review. The mean procedure success and complication rates were 92% and 7%, respectively. CONCLUSIONS The literature review and our results show that all these techniques have equally efficacy and safety for guide-wire cannulation.

Ultrasound-Guided Intraoperative Ablation Therapies

The increased application of laparoscopy in the field of abdominal oncology has led to an increased use of laparoscopic ultrasound (LUS) as a valuable tool for staging of neoplastic diseases [1]. In regard to liver surgery, LUS provides, in experienced hands, a wealth of information for resectability assessment by detecting nonpalpable lesions and visualizing sharp relationships between tumors and vascular structures [2, 3]. Moreover, LUS can serve as guidance for any interventional procedure such as biopsy or thermal ablation of a lesions in radiofrequency (RFA) or microwave (MWA) ablation [4]. LUS-guided thermal ablation of liver tumors can be mastered relatively quickly by a surgeon already familiar with laparoscopic and ultrasound techniques. The learning curve mainly relates to the interpretation of the ultrasonographic images and to the technical tricks of interventional maneuvers [4].