Vincenzo Pugliese

Hepatic Adenoma and Focal Nodular Hyperplasia: Differential Diagnosis and Treatment

The diagnosis of benign hepatic tumors as hepatic adenoma (HA) and focal nodular hyperplasia (FNH) remains a challenge for clinicians and surgeons. The importance of differentiating between these lesions is based on the fact that HA must be surgically resected and FNH can be only observed. A series of 23 female patients with benign liver tumors (13 FNH, 10 HA) were evaluated, and a radiologic diagnostic algorithm was employed with the aim of establishing preoperative criteria for the differential diagnosis. All patients were submitted to surgical biopsy or hepatic resection to confirm the diagnosis. Based only on clinical and laboratory data, distinction was not possible. According to the investigative algorithm, the diagnosis was correct in 82.6% of the cases; but even with the development of imaging methods, which were used in combination, the differentiation was not possible in four patients. For FNH cases scintigraphy presented a sensitivity of 38.4% and specificity of 100%, whereas for HA the sensitivity reached 60% and specificity 85.7%. Magnetic resonance imaging, employed when scintigraphic findings were not typical, presented sensitivities of 71.4% and 80% and specificities of 100% and 100% for FNH and HA, respectively. Preoperative diagnosis of FNH was possible in 10 of 13 (76.9%) patients and was confirmed by histology in all of them. In one case, FNH was misdiagnosed as HA. The diagnosis of HA was possible in 9 of 10 (90%) adenoma cases. Surgical biopsy remains the best method for the differential diagnosis between HA and FNH and must be performed in all doubtful cases. Surgical resection is the treatment of choice for all patients with adenoma and can be performed safely. With the evolution of imaging methods it seems that the preoperative diagnosis of FNH may be considered reliable, thereby avoiding unnecessary surgical resection.

Management of Hepatic Hemangiomas: A 14-Year Experience

Hemangioma is the most common primary tumor of the liver and its diagnosis has become increasingly prevalent. Most of these lesions are asymptomatic and are managed conservatively. Large hemangiomas are often symptomatic and reports of surgical intervention are becoming increasingly frequent. We present our experience, over the last 14 years, with diagnosis and management of 249 liver hemangiomas, with special attention to a conservative strategy. Clinical presentation, diagnosis, treatment, and longterm outcome are analyzed. Of 249 patients, 77 (30.9%) were symptomatic, usually with right abdominal upper quadrant pain. Diagnosis was based on a radiologic algorithm according to the size and characteristics of the tumor; diagnosis by this method was not possible in only one case (0.4 %). Giant hemangiomas (>4 cm) were found in 68 patients (27.3%) and in 16 were larger than 10 cm. Eight patients (3.2%) underwent surgical treatment; indications were incapacitating pain in 6, diagnostic doubt in 1, and stomach compression in 1. No postoperative complications or mortality were observed in this series. Patients who did not undergo surgery (n = 241) did not present any complication related to the hemangioma during long-term follow-up (mean = 78 months). Hemangioma is a benign course disease with easy diagnosis and management. We propose a conservative approach for these lesions. Resection, which can be safely performed, should be reserved for the rare situations such as untreatable pain, diagnostic uncertainty, or compression of adjacent organs.

Four hundred thirty consecutive pediatric living donor liver transplants: Variables associated with posttransplant patient and graft survival

The availability of living donors allows transplant teams to indicate living donor liver transplantation (LDLT) early in the course of liver disease before the occurrence of life‐threatening complications. Late referral to transplant centers is still a problem and can compromise the success of the procedure. The aim of this study was to examine the perioperative factors associated with patient and graft survival for 430 consecutive pediatric LDLT procedures at Sirio‐Libanes Hospital/A. C. Camargo Hospital (São Paulo, Brazil) between October 1995 and April 2011. The studied pretransplant variables included the following: recipient age and body weight, Pediatric End‐Stage Liver Disease score, z score for height/age, bilirubin, albumin, international normalized ratio, hemoglobin, sodium, presence of ascites, and previous surgery. The analyzed technical aspects included the graft‐to‐recipient weight ratio and the use of vascular grafts for portal vein reconstruction. In addition, the occurrence of hepatic artery thrombosis (HAT), portal vein thrombosis (PVT), and biliary complications was also analyzed. The liver grafts included 348 left lateral segments, 5 monosegments, 51 left lobes, and 9 right lobes. In a univariate analysis, an age < 12 months, a low body weight (≤10 kg), malnutrition, hyperbilirubinemia, and HAT were associated with decreased patient and graft survival after LDLT. In a multivariate analysis, a body weight ≤ 10 kg and HAT were significantly associated with decreased patient and graft survival. The use of vascular grafts significantly increased the occurrence of PVT. In conclusion, a low body weight (≤10 kg) and the occurrence of HAT independently determined worse patient and graft survival in this large cohort of pediatric LDLT patients. Liver Transpl, 2012.

Living donor liver transplantation for children in Brazil weighing less than 10 kilograms

Infants with end‐stage liver disease represent a treatment challenge. Living donor liver transplantation (LDLT) is the only option for timely liver transplantation in many areas of the world, adding to the technical difficulties of the procedure. Factors that affect morbidity and mortality can now be determined, which opens a new era for improvement. We have accumulated an 11‐year experience with LDLT for children weighing <10 kg. From October 1995 to October 2006, a total of 222 LDLT in patients <18 years of age were performed; 129 primary LDLT and 7 retransplants (4 LDLT and 3 deceased donor grafts) were performed in 129 infants weighing <10 kg. Forty‐seven patients received grafts with graft‐to‐recipient weight ratio (GRWR) of >4%. Two patients received monosegmental grafts, and 2 patients underwent delayed abdominal wall closure. Portal vein thrombosis occurred in 5.4% of the patients, hepatic artery thrombosis in 3.1%, and both in 1.5%. Among several variables studied, only the bilirubin level at the time of transplantation was associated with increased risk of death (P = 0.009). Grafts with GRWR >4% had no negative effect on patient survival. There were 7 retransplants, and 4 patients received a second parental LDLT. Patient survival rates at 1, 3, and 10 years after transplantation were 88.8%, 84.7%, and 82% for all children, and 87.5%, 84.9%, and 84.9% for infants weighing <10 kg. LDLT has results comparable to other modalities of liver transplantation in infants. Monosegment grafts were rarely required in this series, although they may be necessary in patients with lower body weight. Liver Transpl 13:1153–1158, 2007.

Liver transplantation: fifty years of experience.

Since 1963, when the first human liver transplantation (LT) was performed by Thomas Starzl, the world has witnessed 50 years of development in surgical techniques, immunosuppression, organ allocation, donor selection, and the indications and contraindications for LT. This has led to the mainstream, well-established procedure that has saved innumerable lives worldwide. Today, there are hundreds of liver transplant centres in over 80 countries. This review aims to describe the main aspects of LT regarding the progressive changes that have occurred over the years. We herein review historical aspects since the first experimental studies and the first attempts at human transplantation. We also provide an overview of immunosuppressive agents and their potential side effects, the evolution of the indications and contraindications of LT, the evolution of survival according to different time periods, and the evolution of methods of organ allocation.

Schistosoma mansoni infection in the liver graft: The impact on donor and recipient outcomes after transplantation.

The increasing number of transplants performed each year has led to the identification of unusual diseases in liver grafts from asymptomatic donors that were unrecognized before liver transplantation. Here we report our experience with patients who received liver grafts infected with schistosomiasis. From September 1991 to August 2010, 482 pediatric liver transplants were performed at A. C. Camargo Hospital/Sírio‐Libanês Hospital (São Paulo, Brazil). For the identification of Schistosoma mansoni infections, pathology slides for the recipients were reviewed; these included postreperfusion and follow‐up liver biopsy samples. We were able to identify 6 cases of schistosomiasis transmitted through infected grafts (5 of these grafts were from living donors). All living donors were confirmed to have normal liver chemistries, negative fecal tests for parasitic diseases, and normal abdominal ultrasound findings. Liver biopsy was not performed before transplantation. In all cases, features of schistosomiasis were absent in the liver explants. The living donors were treated with praziquantel and were taught to avoid risk factors for reinfection. No specific treatment for schistosomiasis was given to the recipients. There were no perioperative deaths, but 2 recipients died after living donor liver transplantation (LDLT) because of Kaposis sarcoma and non‐Hodgkins lymphoma. In conclusion, using liver grafts infected with S. mansoni eggs did not compromise the results of LDLT in this pediatric cohort. Because of the parasites life cycle and the therapeutic target of praziquantel, only donors should be treated for the infection. Three years of follow‐up showed an uneventful recovery for the living donors. Liver Transpl 17:1299–1303, 2011.

Left Lateral Segmentectomy for Pediatric Live-Donor Liver Transplantation : Special Attention to Segment IV Complications

Background. During left lateral segmentectomy for live-donor liver transplant, the vascular inflow to segment IV can be compromised. An area of ischemia can be seen intraoperatively and further segment IV resection may be needed to prevent necrosis and abscess formation. Methods. From July 1995 to February 2007, 324 consecutive living donor liver transplantations were performed at Hospital A. C. Camargo and Hospital Sirio-Libanes, Sao Paulo, Brazil. Two hundred eleven left lateral segments were transplanted in this period. Data on 204 left lateral segments donors were available for this analysis. Results. There were 108 female and 96 male donors. Median age was 29 years (range, 16–48 years). Median follow-up time was 2.2 years (range, 2 months–11.8 years). Median intensive care unit stay was 1 day (range, 1–3 days), and median hospital stay was 5 days (range, 4–47 days). Postoperative complications were encountered in 39 donors (19.1%). Partial segment IV resection on the course of the primary surgery due to parenchyma discoloration was required in 107 cases (52.5%). Ten patients (4.9%) developed segment IV necrosis or abscesses, although four of them had had segment IVB resection intraoperatively. Segment IV necrosis or abscess significantly increased hospital stay and the number of readmissions, from 5.5±3.5 days to 8.4±3.7 days (P=0.012) and from 6 of 194 (3%) to 5 of 10 (50%) (P=0.001), respectively. Conclusions. Middle hepatic segment abscess or necrosis was the most frequent complication after left lateral segmentectomy (4.9%). Objective intraoperative strategies need to be developed to evaluate middle hepatic segment ischemia to identify and treat patients at higher risk.

Systemic hemodynamic changes in mansonic schistosomiasis with portal hypertension treated by azygoportal disconnection and splenectomy

ObjectiveThe aim of this study was to assess systemic hemodynamic changes in patients with Mansons schistosomiasis and portal hypertension during azygoportal disconnection and splenectomy.MethodsSixteen patients with portal hypertension secondary to hepatosplenic schistosomiasis with indication for surgery were studied prospectively. All underwent invasive hemodynamic monitoring with pulmonary artery catheter. The first systemic hemodynamic assessment was performed preoperatively. In the intraoperative period new hemodynamic data were collected as follows: a) after laparotomy; b) 15–30 min after splenic artery ligature; c) 15–30 min after splenectomy; and d) after ligation of the collateral circulation.ResultsThe results indicated preoperatively that the patients presented with an increased cardiac index (4.40 ± 0.94 L/min/m2) together with a reduction in the systemic vascular resistance index (1692.25 ± 434.91 dyne.s/cm5.m2). The stroke index (53.74 ± 10.40 ml/beat/m2) and both left (5.71 ± 1.50 kg.m/m2) and right heart work indexes (1.12 ± 0.74 kg.m/m2) were also elevated. The mean pulmonary artery pressure was increased (17.81 ± 9.00 mm Hg) and the pulmonary vascular resistance index decreased (164.31 ± 138.69 dyne.s/cm5.m2). From the moment that the splenic artery was ligated until the end of the procedure, the cardiac index (3.45 ± 0.90 L/min/m2) was reduced and the systemic vascular resistance index (2059.50 ± 590.05 dyne.s/cm5.m5) increased. The systolic index (44.25 ± 11.01 ml/beat/m2) and the left ventricle work index (4.33 ± 1.29 kg.m/m2) also reduced. The mean pulmonary artery pressure (19.18 ± 9.21 mm Hg) and the right ventricle work index (0.94 ± 0.62 mm Hg) remained elevated after the surgical procedure.ConclusionsThe data allowed us to conclude that hepatosplenic schistosomiasis induces a hyperdynamic circulatory state that was corrected after splenectomy and azygoportal disconnection, remaining a mild pulmonary hypertension. Therefore, these changes are correlated with the portosystemic collateral circulation, especially as a consequence of splanchnic hyperflow.

Tumor growth pattern as predictor of colorectal liver metastasis recurrence

BACKGROUND Surgical resection is the gold standard therapy for the treatment of colorectal liver metastases (CRM). The aim of this study was to investigate the impact of tumor growth patterns on disease recurrence. METHODS We enrolled 91 patients who underwent CRM resection. Pathological specimens were prospectively evaluated, with particular attention given to tumor growth patterns (infiltrative vs pushing). RESULTS Tumor recurrence was observed in 65 patients (71.4%). According to multivariate analysis, 3 or more lesions (P = .05) and the infiltrative tumor margin type (P = .05) were unique independent risk factors for recurrence. Patients with infiltrative margins had a 5-year disease-free survival rate significantly inferior to patients with pushing margins (20.2% vs 40.5%, P = .05). CONCLUSIONS CRM patients with pushing margins presented superior disease-free survival rates compared with patients with infiltrative margins. Thus, the adoption of the margin pattern can represent a tool for improved selection of patients for adjuvant treatment.

Trombose de veia porta após desconexão ázigo-portal e esplenectomia em pacientes esquistossomóticos: Qual a real importância?

CONTEXT: Portal vein thrombosis is the most frequent complication after esophagogastric devascularization and splenectomy for hepatosplenic schistosomosis. OBJECTIVE: To evaluate portal vein thrombosis in 155 patients with schistosomal portal hypertension submitted to esophagogastric devascularization and splenectomy. METHODS: We retrospectively analyzed not only the incidence and predictive factors of this complication, but also clinical, laboratorial, endoscopic and Doppler sonography outcome of these patients. RESULTS: Postoperative portal thrombosis was observed in 52.3% of the patients (partial in 45.8% and total in 6.5%). Postoperative diarrhea was more frequent in patients with portal vein thrombosis. Fever was a frequent postoperative symptom (70%) but occurred in a higher percentage when total portal vein thrombosis was present (100%). Superior mesenteric vein thrombosis occurred in four patients (2.6%) and was associated with total thrombosis of the portal vein. There was no statistical difference between patients with and without portal vein thrombosis according to clinical and endoscopic parameters during late follow-up. It was not possible to identify any predictive factor for the occurrence of this complication. CONCLUSIONS: Portal vein thrombosis is an early and frequent event after esophagogastric devascularization and splenectomy, usually partial with benign outcome and low morbidity. Total portal vein thrombosis is more frequently associated with a high morbidity complication, the superior mesenteric vein thrombosis. Long-term survival was not influenced by either partial or total portal thrombosis.