Predrag Bulajic

Prevalence and clinicopathologic features of multiple squamous cell carcinoma of the esophagus

Background. The occurrence of independent synchronous esophageal carcinoma in patients with grossly invasive esophageal cancer (GEC) is well known. Although multiple primary carcinoma of the esophagus is not uncommon, the exact prevalence is controversial, and its clinicopathologic features remain relatively unknown.

Effects of n-3 Fatty Acids Supplementation on Plasma Phospholipids Fatty Acid Composition in Patients with Obstructive Jaundice- a Pilot Study

Nutritional and immunological status of patients with obstructive jaundice is usually severely altered, with high mortality rates. The n-3 polyunsaturate fatty acids (PUFA), particularly eicosapentaenoic acid (EPA, 20:5 n-3), posess potent immunomodulatory activities. Thus, our aim was to compare the plasma phospholipid fatty acid (FA) composition of these patients with healthy subjects, as well as before and after 7 days preoperative supplementation with high doses of EPA (0.9 g per day) and docosahexaenoic acid (DHA, 22:6 n-3, 0.6 g per day). We found impaired FA status in obstructive jaundice patients, especially EPA, DHA and PUFA, but significantly increased content of total n-3 FA, 22:5 n-3 FA and particularly EPA, which increased more than 3 fold, after 7 days supplementation. In addition, the n6/n3 ratio significantly decreased from 14.24 to 10.24, demonstrating severely improved plasma phospholipid profile in these patients after the intervention.

A radiofrequency-assisted minimal blood loss liver parenchyma dissection technique.

Background/Aims: Intraoperative blood loss is still a major concern for surgeons operating on the liver since it is associated with a significantly higher rate of postoperative complications and shorter long-term survival. An original radiofrequency (RF)-assisted minimal blood loss technique for transecting liver parenchyma is presented. Methods: In a prospective study, starting November 2001 and ending December 2005, a total of 90 RF-assisted liver resections were done. Pre-cut coagulative desiccation was produced by the Cool-tip™ (Valleylab, Tyco) water-cooled, single, RF tumor ablation electrode connected to a 480-kHz 200 W generator (Valleylab Cool-tip™ RF System). Vascular occlusion techniques and low central venous pressure anesthesia were not used. Results: Only 14 (15.5%) patients received blood transfusion (mean transfused blood volume 397 ml; mode 310 ml) and 10 of 14 patients received <310 ml of blood. There was no statistical difference between the patients who underwent major and minor liver resection in frequency of blood transfusion. Blood loss was associated with dense adhesions and difficult liver mobilization and not with liver transection. Conclusion: The ‘sequential coagulate-cut’ RF-assisted liver resection technique is a safe liver transection technique associated with minimal blood loss and it has facilitated tissue-sparing liver resection.

Hepatocellular carcinoma: From clinical practice to evidence-based treatment protocols

Hepatocellular carcinoma (HCC) is one of the major malignant diseases in many healthcare systems. The growing number of new cases diagnosed each year is nearly equal to the number of deaths from this cancer. Worldwide, HCC is a leading cause of cancer-related deaths, as it is the fifth most common cancer and the third most important cause of cancer related death in men. Among various risk factors the two are prevailing: viral hepatitis, namely chronic hepatitis C virus is a well-established risk factor contributing to the rising incidence of HCC. The epidemic of obesity and the metabolic syndrome, not only in the United States but also in Asia, tend to become the leading cause of the long-term rise in the HCC incidence. Today, the diagnosis of HCC is established within the national surveillance programs in developed countries while the diagnosis of symptomatic, advanced stage disease still remains the characteristic of underdeveloped countries. Although many different staging systems have been developed and evaluated the Barcelona-Clinic Liver Cancer staging system has emerged as the most useful to guide HCC treatment. Treatment allocation should be decided by a multidisciplinary board involving hepatologists, pathologists, radiologists, liver surgeons and oncologists guided by personalized -based medicine. This approach is important not only to balance between different oncologic treatments strategies but also due to the complexity of the disease (chronic liver disease and the cancer) and due to the large number of potentially efficient therapies. Careful patient selection and a tailored treatment modality for every patient, either potentially curative (surgical treatment and tumor ablation) or palliative (transarterial therapy, radioembolization and medical treatment, i.e., sorafenib) is mandatory to achieve the best treatment outcome.

Radiofrequency-Assisted Liver Resection Does Not Induce Severe Liver Damage

We read with interest the article by Mitsuo et al. [1] and were surprised by the conclusion that RF-assisted hepatectomy may induce severe postoperative liver damage and that the RF-assisted technique is not a safe procedure for liver transection in partial hepatectomy. We believe that to avoid misinterpretation and not to discredit an emerging and efficient procedure, certain issues need to be discussed. The authors used the original RF ‘‘CoolTip’’ precoagulation technique as it was described by Weber and Habib [2]. This technique implies that the noninsulated tip of the electrode is inserted through the entire liver mass until it reaches the undersurface, and when coagulation is completed, it is retracted upward to the liver surface in consecutive coagulation cycles. Precoagulation performed in this manner is maximal and complete for each cycle (cycle end is determined by change in current and impedance by generator) and requires more time and more RF energy than is really necessary. The liver surface is cut after the entire transection line has been precoagulated. Also, needlessly large coagulated and desiccated margins are achieved and, after transection, subsequently left on the remnant liver. The RF-assisted technique described by Mitsuo et al. used Pringle’s maneuver. It is unclear why Pringle’s maneuver was used, when this is a minimal blood-loss liver transection technique where only precoagulated, devitalized, liver tissue is cut. On the other hand, it is well established that hepatic blood flow occlusion is associated with a significant increase in the coagulation area which will lead to more extensive tissue necrosis and subsequently cause high levels of ALT [3–5]. The possibility of not using Pringle’s maneuver is one of the significant advantages of RF hepatectomy since ischemia– reperfusion hepatocellular injury is avoided. Furthermore, vascular occlusion abolishes the protective ‘‘heat sink’’ effect on vessels we do not intend to occlude. It is unclear why there was a 15% bile leak rate in the RF group compared with a 0% leak in the conventional group. RF energy induces desiccation and coagulation resulting in ‘‘welding’’ of the liver tissue, and it is equally effective for blood vessels and bile ducts. If there was no bleeding from the cut vessels, why should there be more bile leaks? In our series we have had no significant postoperative bleeding and no bile leaks. The authors did not specify the anatomic location of the resected segments. This is an important issue because the extent of liver mobilization and manipulation is an important cause of hepatocyte injury during liver surgery [6]. The degree of postcoagulation elevation of AST and ALT is noticeably higher in patients who have had preoperative chemotherapy and the incidence of these patients has not been described [7]. RF resection techniques in which Pringle’s maneuver is not used are not associated with high ALT levels. We base our observations on more than 250 RF ‘‘CoolTip’’-assisted hepatectomies using our own modification of the original Habib technique called the ‘‘sequential coagulate cut technique’’ [8, 9]. The electrode is advanced through liver tissue in the same way as the CUSA tip under optical guidance, the width of the coagulation rim is minimal, and Pringle’s maneuver is never used. In only five patients we had ALT levels close to 1000, while the majority had levels within the 100–200 range and all returned to normal within 7 days. There was no increase in the bilirubin level and postoperative bile fistulas were not observed. M. Milicevic (&) P. Bulajic The First Surgical Clinic, University of Belgrade School of Medicine, Koste Todorovica No. 6, Belgrade 11000, Serbia e-mail: machak@sbb.co.yu

Preoperative neutrophil-to-lymphocyte ratio as a prognostic predictor after curative-intent surgery for hepatocellular carcinoma: experience from a developing country

Purpose The aim of the study was to evaluate a prognostic value of preoperative neutrophil-to-lymphocyte ratio (NLR) on long-term survival of cirrhotic and noncirrhotic hepatocellular cancer (HCC) patients managed by a curative-intent liver surgery in a developing country. Patients and methods During the study period between November 1, 2001, and December 31, 2012, 109 patients underwent potentially curative hepatectomy for HCC. Data were retrospectively reviewed from the prospectively collected database. The median follow-up was 25 months. NLR was estimated by dividing an absolute neutrophil count by an absolute lymphocyte count from the differential blood count. Receiver operating characteristic curve was constructed to assess the ability of NLR to predict long-term outcomes and to determine an optimal cutoff value for all patients group, the subgroup with cirrhosis, and the subgroup without cirrhosis. The optimal cutoff values were 1.28, 1.28, and 2.09, respectively. Results The overall 3- and 5-year survival rates were 49% and 45%, respectively, for low NLR group and 38% and 26%, respectively, for high NLR group. The difference was statistically significant (p=0.015). Overall survival was similar between low and high NLR groups in patients with cirrhosis; no difference was found between the groups (p=0.124). In patients without cirrhosis, low NLR group had longer overall survival compared with high NLR group (p=0.015). Univariate analysis identified four factors as significant predictors of long-term survival: cirrhosis, Child-Pugh score, platelet count, and NLR. On multivariate analysis, only platelet count and NLR were independent prognostic factors of long-term survival. Conclusion Prognostic value of NLR was confirmed in noncirrhotic HCC patients who underwent curative-intent liver surgery. In HCC patients with cirrhosis, the prognostic role of NLR was not confirmed.

Microscopic assessment of the tissue-sparing potential of radiofrequency-assisted liver resection techniques in a porcine model

The aim of the present study was to microscopically assess the tissue‐sparing potential of contemporary radiofrequency‐assisted liver resection (RF‐LR) techniques.

Laparotomija kao metoda izbora u postavljanju dijagnoze peripankreaticne tuberkulozne limfadenopatije

Peripancreatic lymph node tuberculosis is a rare disease with a difficult diagnosis. The case of a 61-year-old patient who was admitted because of intermittent dull pain in upper abdomen lasting 3-4 months followed by nausea, loss of appetite and body weight. The applied diagnostic procedures indicate a change in the head of the pancreas. The method of choice for establishing a definitive histopathological diagnosis is the biopsy of the lesion. Biopsy changes can be done using U.S., CT, Endo U.S. and laparoscopy. Surgery is a last resort only to establish a definitive histopathological diagnosis.

Hepatocelularni karcinom udruzen sa ehinokoknom cistom jetre kao dijagnosticki problem

The presence of benign and/or malignant liver lesions is not easy to determine, especially differentiated. Preoperative diagnosis has to include more procedures for correlation of data in order to establish the correct diagnosis and proper treatment. The case of a 72-year-old female patient who was admitted because of the appearance of persistent dull pain under right rib cage. Ultrasound and CT findings verify the presence of two changes in the right liver, various radiographic characteristics. One change was good, other cystic. The presence of easily elevated tumor markers (AFP) in favor of hepatocellular carcinoma. The nature of other types of cystic changes was not clear. Intraoperatively and histologically confirmed to be a simultaneous presence of hepatocellular carcinoma and hydatid cysts in the right lobe of the liver. Surgical treatment is the only solution for the simultaneous treatment of both changes in the liver.

Radiofrequency-assisted liver resections for metastatic colorectal cancer: Technique and feasibility

Radiofrequency (RF)-assisted resection techniques are associated with minimal blood loss providing safe hemostasis of the transected liver 1-3 parenchyma. Different RF-assisted liver resection techniques have been developed. The presented RF technique is the sequentional coagulate-cut liver resection technique (“The Belgrade technique”) and the difference from other techniques is the way the electrode is used. A coagulate-cut liver resection cycle can be described as a process of creating a 30-mm long and 6-8 mm wide cylinder of coagulated and desiccated liver tissue by applying RF energy through the non-insulated tip of the electrode inserted into the liver parenchyma and then dividing the coagulated tissue by surgical scalpel or scissors. From January 2001 to January 2014, 830 RF-assisted liver resections were performed for various indications at the HPB unit of the Clinic for Digestive Surgery, Clinical center of Serbia, Belgrade. Among 830 liver resections, 470 resections were performed in 383 patients with colorectal cancer liver metastasis. Sixty-six patients experienced repeated liver resection ranging from a second to a fifth resection. The majority of patients had bi-lobar spread of the disease before the first liver resection was performed. No difference was found in the postoperative morbidity between the patients after the first, the second and the third liver resection (F=0.168; p=0.846). 90-days mortality was 5.7% after the repeated liver resections and 2.5% in patients with one liver resection (X2=2.278; 4,13 p=0.165). Single HPB unit experience has demonstrated that RF-assisted liver resection technique is feasible, safe and effective procedure in the management of patients with CRC liver metastasis.