Background & Aims
Although hepatocellular adenoma (HCA) is more frequently observed in obese patients, however, the effect of weight loss as a therapeutic option was never studied.
Methods
In this ...rapid communication we described our non‐surgical management of large HCA (>5 cm) encountered in patients with morbid obesity. Non‐surgical management consisted mainly of oral contraception withdrawal and weight loss, which was the only option in two patients. All demographics, radiological and histological data were studied. Patients were followed regularly every 6 months.
Results
Between 2004 and 2013, 116 patients presented with HCA and 15 with morbid obesity (13%) were studied. Five men underwent surgery and females were either operated (period before 2010; n = 5) or proposed to non‐surgical management (period after 2010; n = 5).Weight loss was advocated to all females, including four with residual HCA after resection and to non‐operated patients, including two with haemorrhagic HCA. Four (40%) females showed significant weight loss. In resected patients, weight loss allowed stability (n = 1) or slight regression (n = 1) of residual HCA. In the two patients treated only by weight loss, significant decrease was observed in the weight with significant decrease (>50%) in the size and number of HCA to a non‐surgical size (<5 cm). Severe morbidity was 40% in operated patients and 0% in non‐operated patients. After a follow‐up period of 38 months (18–60), no complication or degeneration was encountered in the non‐operated group.
Conclusion
Like oral contraception, weight loss should be considered as the first therapeutic option in the management of HCA in obese patients.
Full text
Available for:
BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
Liver resection (LR) for hepatocellular carcinoma (HCC) as the first‐line treatment in transplantable patients followed by “salvage transplantation” (ST) in case of recurrence is an attractive ...concept. The aim was to identify patients who gain benefit from this approach in an intention‐to‐treat study. From 1998 to 2008, among 329 potential candidates for liver transplantation (LT) with HCC within the Milan criteria (MC), 138 with good liver function were resected (LR group) from a perspective of ST in case of recurrence, and 191 were listed for LT first (LT group). The two groups were compared on an intention‐to‐treat basis with special reference to management of recurrences and transplantability after LR. Univariate and multivariate analyses were performed to identify resected patients who developed recurrence beyond MC. Five‐year overall and disease‐free survival was similar in both groups: LT versus LR group, 60% versus 77% and 56% versus 40%, respectively. Among the 138 patients in the LR group, 20 underwent LT before recurrence, 39 (28%) had ST, and 51 (37%) with recurrence were not transplanted including 21 within MC who were excluded for advanced age, acquired comorbidities, or refusal and 30 (22%) with recurrence beyond MC. Predictive factors for nontransplantability due to recurrence beyond MC included microscopic vascular invasion (hazard ratio HR 2.38 range, 1.10‐7.29), satellite nodules (HR 2.46 range, 1.01‐6.68), tumor size > 3 cm (HR 1.34 range, 1.03‐3.12), poorly differentiated tumor (HR 3.18 range, 1.31‐7.70), and liver cirrhosis (HR 1.90 range, 1.04‐3.12). Conclusion: The high risk of failure of ST after initial LR for HCC within MC suggests the use of tissue analysis as a selection criterion. The salvage LT strategy should be restricted to patients with favorable oncological factors. (HEPATOLOGY 2012;;55:132–140)
Full text
Available for:
BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Abstract Background Although laparoscopic pancreatic resection (LPR) has become a routine, large single center series are still lacking. Our aim was to analyze the results of a large European single ...center series of LPR. Study Design Between January 2008 and September 2015, 300 LPR were performed and studied prospectively including 165 (55%) distal pancreatectomies, 68 (23%) pancreatoduodenectomies (PD), 30 (10%) enucleations, 35 (11%) central pancreatectomies and 2 (1%) total pancreatectomies. Results Mean age was 54 ± 15.4 years old (17-87) and most patients were women (58%). LPR was performed for malignancy (46%), low potential malignant (44%) or benign (10%) diseases. The mean operative duration was 211 ± 102 min (30-540) and 351± 59 (240-540) min for PD, and decreased with the learning curve. Mean blood loss was 229 ±269 ml (0-1500) and 13 patients (4%) were transfused. Conversion was required in 12 patients (4%), and only 5 in the last 250 patients (2% vs 14%, P<0.001). Mortality occurred in 4 (1.3%) patients and only after PD (5.8%). Common complications were pancreatic fistula (n=124, 41%), bleeding (n=35, 12%) and reoperation (n=28, 9%). The postoperative outcome was less favorable in procedures with a reconstruction phase (n=105) than in those without (n=195) with increased mortality (3.8% vs 0%, p=0.04), overall morbidity (76% vs % 52%, p<0.001) and mean hospital stay (26 ±15vs 16±10 days, p<0.001). Conclusions LPR without a reconstruction phase has an excellent outcome. LPR with a reconstruction phase, especially PD, has a less favorable outcome and further randomized studies are required to conclude on the safety and benefits of this approach.
OBJECTIVE:To evaluate the parietal peritoneum (PP) as an autologous substitute for venous reconstruction during hepatopancreatobiliary (HPB) surgery.
BACKGROUND:Venous resection during liver or ...pancreatic resection may require a rapidly available substitute especially when the need for venous resection is unforeseen.
METHODS:The PP was used as an autologous substitute during complex liver and pancreatic resections. Postoperative anticoagulation was standard and venous patency was assessed by routine computed tomographic scans.
RESULTS:Thirty patients underwent vascular resection during pancreatic (n = 18) or liver (n = 12) resection, mainly for malignant tumors (n = 29). Venous resection was an emergency procedure in 4 patients due to prolonged vascular occlusion. The PP, with a mean length of 22 mm (15–70), was quickly harvested and used as a lateral (n = 28) or a tubular (n = 2) substitute for reconstruction of the mesentericoportal vein (n = 24), vena cava (n = 3), or hepatic vein (n = 3). Severe morbidity included Clavien grade-III complications in 4 (13%) patients but there was no PP-related or hemorrhagic complications. Histological vascular invasion was present in 18 (62%) patients, and all had an R0 resection (100%). After a mean follow-up of 14 (7–33) months, all venous reconstructions were patent except for 1 tubular graft (97%).
CONCLUSIONS:A PP can be safely used as a lateral patch for venous reconstruction during HPB surgery; this could help reduce reluctance to perform vascular resection when oncologically required. Clinical trials identificationNCT02121886.
Lymphadenectomy ensures accurate staging for patients with intrahepatic cholangiocarcinoma, especially for those without preoperatively suspected positive lymph nodes (clinically node-negative); ...however, its prognostic value has been poorly documented. The aim of this study was to evaluate the prognostic value of lymphadenectomy on long-term outcomes in patients undergoing surgery for clinically node-negative intrahepatic cholangiocarcinoma.
Data from all patients who underwent liver resection with or without lymphadenectomy for preoperatively diagnosed intrahepatic cholangiocarcinoma between 2000 and 2016 at 3 tertiary hepatobiliary centers were analyzed retrospectively. Propensity score matching in a 1:1 ratio was conducted based on clinically relevant covariates between patients with clinically node-negative intrahepatic cholangiocarcinoma who underwent liver resection with (LND group) and without (NLND group) lymphadenectomy. Overall survival and disease-free survival were compared in the matched cohort.
Among 350 patients who underwent surgery during the study period, 192 (55%) with clinically node-negative intrahepatic cholangiocarcinoma met the inclusion criteria. After propensity score matching, 2 well-balanced groups of 56 patients each were analyzed. There was no significant difference regarding postoperative variables among these 112 matched patients. Patients who underwent a liver resection with lymphadenectomy achieved better 3- and 5-year overall survival (78% and 65% vs 52% and 46%, P = .017) and disease-free survival (46% and 34% vs 31% and 31%; P = .042) compared with patients who underwent liver resection without lymphadenectomy.
Lymphadenectomy can be associated with better long-term outcomes in patients with node-negative intrahepatic cholangiocarcinoma. Our data may support routine lymphadenectomy for node-negative intrahepatic cholangiocarcinoma with the objective of achieving better long-term outcomes.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background Laparoscopic pancreaticoduodenectomy (LPD) is a difficult procedure that has become increasingly popular. Nevertheless, comparative data on outcomes remain limited. Our aim was to compare ...the outcomes of LPD and open pancreaticoduodenectomy (OPD). Study Design Between April 2011 and April 2014, 46 LPD were performed and compared with 46 OPD, which theoretically can be done by the laparoscopic approach. Patients were also matched for demographic data, associated comorbidities, and underlying disease. Patient demographics and perioperative and postoperative outcomes were studied from our single center prospective database. Results Lower BMI (23 vs 27 kg/m2 , p < 0.001) and a soft pancreas (57% vs 47%, p = 0.38) were observed in patients with LPD, but there were no differences in associated comorbidities or underlying disease. Surgery lasted longer in the LPD group (342 vs 264 minutes, p < 0.001). One death occurred in the LPD group (2.1% vs 0%, p = 0.28) and severe morbidity was higher (28% vs 20%, p = 0.32) in LPD due to grade C pancreatic fistula (PF) (24% vs 6%, p = 0.007), bleeding (24% vs 7%, p = 0.02), and revision surgery (24% vs 11%, p = 0.09). Pathologic examination for malignant diseases did not identify any differences between the LPD and OPD as far as size (2.51 vs 2.82 cm, p = 0.27), number of harvested (20 vs 23, p = 0.62) or invaded (2.4 vs 2, p = 0.22) lymph nodes, or R0 resection (80% vs 80%; p = 1). Hospital stays were similar (25 vs 23 days, p = 0.59). There was no difference in outcomes between approaches in patients at a lower risk of PF. Conclusions This study found that LPD is associated with higher morbidity, mainly due to more severe PF. Laparoscopic pancreaticoduodenectomy should be considered only in the subgroup of patients with a low risk of PF.
Background
In our first experience, laparoscopic pancreatoduodenectomy (LPD) was associated with higher morbidity than open PD. Since, the surgical technique has been improved and LPD was avoided in ...some patients at very high risk of postoperative pancreatic fistula (POPF). We provide our most recent results.
Method
Between 2011 and 2018, 130 LPD were performed and divided into 3 consecutive periods based on CUSUM analysis and compared: first period (
n
= 43), second period (
n
= 43), and third period (
n
= 44).
Results
In the third period of this study, LPD was more frequently performed in women (46%, 39%, 59%,
p
= 0.21) on dilated Wirsung duct > 3 mm (40%, 44%, 57%;
p
= 0.54). Intraductal papillary mucinous neoplasm (IPMN) became the primary indication (12%, 39%, 34%;
p
= 0.037) compared to pancreatic adenocarcinoma (35%, 16%, 16%;
p
= 0.004). Malignant ampulloma re-increased during the third period (30%, 9%, 20%;
p
= 0.052) with the amelioration of surgical technique. The operative time increased during the second period and decreased during the third period (330, 345, 270;
p
< 0.001) with less blood loss (300, 200, 125;
p
< 0.001). All complications decreased, including POPF grades B/C (44%, 28%, 20%;
p
= 0.017), bleeding (28%, 21%, 14%;
p
= 0.26), Clavien-Dindo III–IV (40%, 33%, 16%;
p
= 0.013), re-interventions (19%, 14%, 9%;
p
= 0.43), and the hospital stay (26, 19, 18;
p
= 0.045). Less patients with similar-sized adenocarcinoma were operated during the second period (70%, 33%, 59%;
p
= 0.002) with more harvested lymph nodes in the third period (21,19, 25;
p
= 0.031) and higher R0 resection (70%, 79%, 84%;
p
= 0.5). On multivariate analysis the protective factors against POPF of grades B/C were pancreatic adenocarcinoma and invasive IPMN, BMI < 22.5 kg/m
2
, and patients operated in the third period.
Conclusion
This study showed that the outcome of LPD significantly improves with the learning curve and patient selection. For safe implementation and during the early learning period, LPD should be indicated in patients at lower risk of POPF.
Full text
Available for:
EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
The use of robotic assistance in minimally invasive pancreatic resection is quickly growing.
Methods
We present a systematic review of the literature regarding all types of robotic ...pancreatic resection (RPR). Our aim is to show for which procedures there is enough experience to permit safe training and provide an estimation of how many centers could serve as teaching institutions.
Results
Sixty‐four studies reporting on 4587 RPRs were analyzed. A total of 2598 pancreatoduodenectomies (PD) were reported by 28 centers from Europe (6/28; 21.4%), the Americas (11/28; 39.3%), and Asia (11/28; 39.3%). Six studies reported >100 robot PD (1694/2598; 65.2%). A total of 1618 distal pancreatectomies (DP) were reported by 29 centers from Europe (10/29; 34.5%), the Americas (10/29; 34.5%), and Asia (9/29; 31%). Five studies reported >100 robotic DP (748/1618; 46.2%). A total of 154 central pancreatectomies were reported by six centers from Europe (1/6; 16.7%), the Americas (2/6; 33.3%), and Asia (3/6; 50%). Only 49 total pancreatectomies were reported. Finally, 168 enucleations were reported in seven studies (with a mean of 15.4 cases per study). A single center reported on 60 enucleations (35.7%). Results of each type of robotic procedure are also presented.
Conclusions
Experience with RPR is still quite limited. Despite high case volume not being sufficient to warrant optimal training opportunities, it is certainly a key component of every successful training program and is a major criterion for fellowship accreditation. From this review, it appears that only PD and DP can currently be taught at few institutions worldwide.
Full text
Available for:
FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
As adenoma in other locations, hepatic adenoma (HA) may transform into hepatocellular carcinoma (HCC) and hepatocyte dysplasia is most probably the intermediate step between both conditions. ...Malignant HA may appear as microscopic or macroscopic areas of HCC within the HA. These areas are typically well differentiated and without vascular extension or satellite nodules. AFP measurements are not reliable as they are usually normal. The risk of malignant transformation of HA cannot be reliably quantified yet. Several series are concordant to show that approximately 5% of patients whose HA have been resected had pathological evidence of HCC within their HA. This figure however does not take into account fully transformed HA where evidence of the preexisting benign lesion might have disappeared. The risk of malignant transformation is correlated with the diameter of the HA and it is very unusual when it is <5 cm and the same holds true for patients with multiple HA. These results suggest that small HA could be safely observed as they are also at low risk of bleeding. These conclusions might not apply to male patients who are at lower risk of HA, except in specific conditions, but appear to be at a much higher risk of malignant changes.
In liver transplantation (LT), graft aberrant hepatic arteries (aHAs) frequently require complex arterial reconstructions, potentially increasing the risk of post‐operative complications. However, ...intrahepatic hilar arterial shunts are physiologically present and may allow selective aHA ligation. Thus, we performed a retrospective study from a single‐center cohort of 618 deceased donor LTs where a selective reconstruction policy of aHAs was prospectively applied. In the presence of any aHA, the vessel with the largest caliber was first reconstructed. In case of adequate bilobar arterial perfusion assessed on intraparenchymal Doppler ultrasound, the remnant vessel was ligated; otherwise, it was reconstructed. Consequently, outcomes of three patient groups were compared: the “no aHAs” group (n = 499), the “reconstructed aHA” group (n = 25), and the “ligated aHA” group (n = 94). Primary endpoint was rate of biliary complications. Only 38.4% of right aHAs and 3.1% of left aHAs were reconstructed. Rates of biliary complications in the no aHA, reconstructed aHA, and ligated aHA groups were 23.4%, 28%, and 20.2% (p = 0.667), respectively. The prevalence rates of primary non‐function (p = 0.534), early allograft dysfunction (p = 0.832), and arterial complications (p = 0.271), as well as patient survival (p = 0.266) were comparable among the three groups. Retransplantation rates were 3.8%, 4%, and 5.3% (p = 0.685), respectively. In conclusion, a selective reconstruction policy of aHAs based on Doppler assessment of bilobar intraparenchymal arterial flow did not increase post‐operative morbidity and avoided unnecessary and complex arterial reconstructions.
Full text
Available for:
BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
PDF
