Riccardo Boetto

Adrenalectomy may improve cardiovascular and metabolic impairment and ameliorate quality of life in patients with adrenal incidentalomas and subclinical Cushing's syndrome

BACKGROUND Adrenalectomy represents the definitive treatment in clinically evident Cushings syndrome; however, the most appropriate treatment for patients with subclinical Cushings syndrome (SCS) with an adrenal incidentaloma remains controversial. This study was aimed to assess whether adrenalectomy may improve cardiovascular and metabolic impairment and quality of life compared with conservative management. METHODS Twenty patients with adrenal incidentaloma underwent laparoscopic adrenalectomy for SCS, whereas 15 were managed conservatively. Hormonal laboratory parameters of corticosteroid secretion, arterial blood pressure (BP), glycometabolic profile, and quality of life (by the SF-36 questionnaire) were compared at baseline and the end of follow-up. RESULTS The 2 groups were equivalent concerning all the examined parameters at baseline. In the operative group, laboratory corticosteroid parameters normalized in all patients but not in the conservative-management group (P < .001). In operated patients, a decrease in BP occurred in 53% of patients, glycometabolic control improved in 50%, and body mass index decreased; in contrast, no improvement or some worsening occurred in the conservative-management group (P < .01). SF-36 evaluation improved in the operative group (P < .05). CONCLUSION Adrenalectomy can be more beneficial than conservative management in SCS and may achieve remission of laboratory hormonal abnormalities and improve BP, glycemic control, body mass index, and quality of life.

Subnormothermic Machine Perfusion for Non–Heart-Beating Donor Liver Grafts Preservation in a Swine Model: A New Strategy to Increase the Donor Pool?

We previously reported that subnormothermic machine perfusion (sMP; 20°C) is able to improve the preservation of livers obtained from non-heart-beating donors (NHBDs) in rats. We have compared sMP and standard cold storage (CS) to preserve pig livers after 60 minutes of cardiac arrest. In the sMP group livers were perfused for 6 hours with Celsior at 20°C. In the CS group they were stored in Celsior at 4°C for 6 hours as usual. To simulate liver transplantation, both sMP- and CS-preserved livers were reperfused using a mechanical continuous perfusion system with autologus blood for 2 hours at 37°C. At 120 min after reperfusion aspartate aminotransferase levels in sMP versus CS were 499 ± 198 versus 7648 ± 2806 U/L (P < .01); lactate dehydrogenase 1685 ± 418 versus 12998 ± 3039 U/L (P < .01); and lactic acid 4.78 ± 3.02 versus 10.46 ± 1.79 mmol/L (P < .01) respectively. The sMP group showed better histopathologic results with significantly less hepatic damage. This study confirmed that sMP was able to resuscitate liver grafts from large NHBD animals.

Unilateral adrenal hyperplasia: A novel cause of surgically correctable primary hyperaldosteronism

BACKGROUND Primary hyperaldosteronism may be caused by an aldosterone-producing adenoma (APA), which is correctable by unilateral adrenalectomy or by idiopathic adrenal hyperplasia, a bilateral disease without any indication for surgery. This study sought to assess the prevalence and the results of surgery in unilateral adrenal hyperplasia (UAH). METHODS The study included 35 patients who underwent unilateral adrenalectomy because of primary hyperaldosteronism after unequivocal successful lateralization by adrenal venous sampling. Demographics, biochemical evaluation, and blood pressure were assessed pre- and postoperatively. Pathology was categorized as APA (isolated adenoma), nodular (multiple micromacronodules), and diffuse UAH (gland thickening without nodules). RESULTS Pathology revealed 9 APAs and 23 nodular and 3 diffuse UAHs. Patients with APAs and UAHs were statistically similar regarding demographics and preoperative blood pressure levels. Bilateral adrenal involvement was evident at imaging in 10 patients (11% in APA versus 35% in UAH, P = NS). After surgery, biochemical cure of the disease was achieved in all patients; blood pressure levels normalized in 66.6% of patients and ameliorated in 22.2% in APA versus 34.6% and 50% in patients with UAH (P = NS). At a long-term follow-up, only 1 patient with nodular UAH experienced a biochemical recurrence of disease. CONCLUSION UAH is not rare, sharing the same features of APA. When disease lateralization is confirmed by adrenal venous sampling, unilateral adrenalectomy achieves excellent long-term results.

Diverting loop ileostomy after restorative proctocolectomy: predictors of poor outcome and poor quality of life

Aim  Diverting loop ileostomy is used to minimize the impact of anastomotic complication after restorative proctocolectomy (RPC). However, the ileostomy itself may have complications and therefore affect quality of life (QOL). The aim of this study was to analyse the predictors of complications of the ileostomy formation and closure and of the QOL of these patients.

Intestinal Surgery for Crohn’s Disease: Predictors of Recovery, Quality of Life, and Costs

IntroductionThe aim of this prospective study was to analyze the impact of different surgical techniques on patients undergoing intestinal surgery for Crohn’s disease (CD) in terms of recovery, quality of life, and direct and indirect costs.Patients and methodsForty-seven consecutive patients admitted for intestinal surgery for CD were enrolled in this prospective study. Surgical procedures were evaluated as possible predictors of outcome in terms of disability status (Barthel’s Index), quality of life (Cleveland Global Quality of Life score), body image, disease activity (Harvey–Bradshaw Activity Index), and costs (calculated in 2008 Euros). Univariate and multivariate analyses were performed.ResultsSignificant predictors of a long postoperative hospital stay were the creation of a stoma, postoperative complications, disability status on the third post-operative day, and surgical access (R2 = 0.59, p < 0.01). Barthel’s index at discharge was independently predicted by laparoscopic-assisted approach, ileal CD, and colonic CD (R2 = 0.53, p < 0.01). The disability status at admission showed to be an independent predictor of quality of life score at follow-up. The overall cost for intestinal surgery for CD was 12,037 (10,117–15,795) euro per patient and stoma creation revealed to be its only predictor (p = 0.006).ConclusionsLaparoscopy was associated with a shorter postoperative length of stay; stoma creation was associated with a long and expensive postoperative hospital stay, and stricturoplasty was associated with a slower recovery of bowel function.

Liver Autotransplantation for the Treatment of Unresectable Hepatic Metastasis: An Uncommon Indication—A Case Report

Ex situ ex vivo liver surgery represents a method to expand the surgical indications to treat otherwise unresectable liver tumors. We report the case of a 38-year old woman with hepatic metastasis from a pancreatoblastoma that was judged to be unresectable due to the involvement of the three hepatic veins. To treat the primary tumor, she underwent a pancreaticoduodenectomy, adjuvant chemotherapy, and thermal ablation of a liver metastasis. After appropriate preoperative study and with the permission of the ethics committee, she underwent ex situ ex vivo liver resection. The hepatectomy was performed by removing the whole liver en bloc with the retrohepatic vena cava. The inferior vena cava was reconstructed by interposition of a prosthetic graft. The ex situ ex vivo hepatic resection, a left hepatic lobectomy included the lesion in segments 1-5-7-8. The two hepatic veins were reconstructed using patches of saphenous vein. The organ was preserved continuously for 6 hours using hypothermic perfusion with 4°C Celsior solution. The liver was then reimplanted performing an anastomosis between the reconstructed hepatic veins and the caval prostheses. The patient was discharged at postoperative day 22 and is currently disease-free at 8 months after surgery and 44 months after the initial diagnosis. Ex situ, ex vivo liver surgery offers an additional option for patients with both primary and secondary liver tumors considered to be unresectable using traditional surgical approaches.

Survival benefit of transplantation for recurrence of hepatocellular carcinoma after liver resection.

BACKGROUND Liver transplantation (LT) for hepatocellular carcinoma (HCC) can be used for tumor recurrence after liver resection (LR) both for initially transplant-eligible patients as conventional salvage therapy (ST) and for non-transplant-eligible patients (beyond Milan criteria) with a goal of downstaging (DW). The aim of this study was to compare the intention-to-treat (ITT) survival rates of patients who are listed for LT, according to these two strategies. METHODS We analyzed a prospective database of 399 consecutive patients who underwent hepatic resection for HCC from 2002 to 2011 to identify patients included in the waiting list for tumor recurrence. Intention-to-treat (ITT) survivals were compared with those of patients resected for HCC within and beyond Milan criteria in the same period and not included in the LT waiting list. RESULTS The study group consisted of 42 patients, 28 in the ST group (within Milan) and 14 in the DW group (beyond Milan). The 5-year ITT survival rate was similar between the 2 groups, being 64% for ST and 60% for DW (P=.84). Twenty-five patients (15 ST and 10 DW) underwent LT, 13 (10 ST and 3 DW) were still awaiting LT, 4 (3 ST and 1 DW) dropped out of the waiting list because of tumor progression, and 7 (5 ST [33%] and 2 DW [20%]) had tumor recurrence. The 5-year ITT survival of ST patients was similar to that of 252 in-Milan HCC patients resected only (P=.3), whereas 5-year ITT survival of DW patients was significantly higher (P<.01) than that of 105 beyond-Milan HCC patients resected only. CONCLUSIONS LR seems to be a safe and effective therapy both as alternative to transplantation and as downstaging strategy for intermediate-advanced HCC. The survival benefit of salvage LT, however, seems to be higher in the 2nd than in the 1st group.

Laparoscopic microwave thermal ablation for late recurrence of local hepatocellular carcinoma after liver transplant: case report

Liver transplant is the preferred treatment for hepatocellular carcinoma in patients with cirrhosis, as both neoplastic and cirrhotic liver tissue can be removed. Treatment of recurring neoplasms is a difficult issue, especially in long-term survivors of liver transplant. No consensus has been reached on the treatment of recurrent hepatocellular carcinoma. Although patients with extrahepatic metastases are generally not candidates for local therapy, successful multimodal salvage therapy including resection or ablation can be achieved in liver transplant recipients with local recurrence of hepatocellular carcinoma. Microwave ablation is safe and effective for treating unresectable hepatocellular carcinoma, achieving excellent results in local disease down-staging or as a “bridge” to liver transplant, with no significant differences in local recurrence and complications compared with the more commonly used radiofrequency ablation. A patient with local recurrence of hepatocellular carcinoma 36 months after liver transplant for multifocal hepatocellular carcinoma and cirrhosis due to hepatitis C was successfully treated with laparoscopic microwave ablation without any postoperative complications. The patient is disease free 24 months after microwave ablation.

B1a lymphocytes in the rectal mucosa of ulcerative colitis patients

AIM To assess B1a cell expression in the rectal mucosa of ulcerative colitis (UC) patients in comparison with healthy controls. METHODS Rectal mucosa biopsies were collected from 15 UC patients and 17 healthy controls. CD5(+) B cells were analysed by three colour flow cytometry from rectal mucosal samples after mechanical disaggregation by Medimachine(®). Immunohistochemical analysis of B and T lymphocytes was also performed. Correlations between, on the one hand, rectal B1a cell concentrations and, on the other, erythrocyte sedimentation rate and C-reactive protein levels and clinical, endoscopic and histological disease activity indices were evaluated. RESULTS Rectal B-lymphocyte (CD19(+)/CD45(+)) rate and concentration were higher in UC patients compared with those in healthy controls (47.85% ± 3.12% vs 26.10% ± 3.40%, P = 0.001 and 501 ± 91 cells/mm(2) vs 117 ± 18 cells/mm(2), P < 0.001); Rectal B1a cell density (CD5(+)CD19(+)) was higher in UC patients than in healthy controls (85 ± 15 cells/mm(2) vs 31 ± 6.7 cells/mm(2), P = 0.009). Rectal B1a cell (CD5/CD19(+)) rate correlated inversely with endoscopic classification (Rs = -0.637, P < 0.05). CONCLUSION B1a lymphocytes seem to be involved in the pathogenesis of UC, however, the role they play in its early phases and in disease activity, have yet to be defined.

A novel approach to severe acute pancreatitis in sequential liver-kidney transplantation: the first report on the application of VAC therapy

This work is the first report of vacuum‐assisted closure (VAC) therapy applied as a life‐saving surgical treatment for severe acute pancreatitis occurring in a sequential liver‐ and kidney‐transplanted patient who had percutaneous biliary drainage for obstructive “late‐onset” jaundice. Surgical exploration with necrosectomy and sequential laparotomies was performed because of increasing intra‐abdominal pressure with hemodynamic instability and intra‐abdominal multidrug‐resistant sepsis, with increasingly difficult abdominal closure. Repeated laparotomies with VAC therapy (applying a continuous negative abdominal pressure) enabled a progressive, successful abdominal decompression, with the clearance of infection and definitive abdominal wound closure. The application of a negative pressure is a novel approach to severe abdominal sepsis and laparostomy management with a view to preventing compartment syndrome and fatal sepsis, and it can lead to complete abdominal wound closure.