The prognosis of untreated patients with hepatocellular carcinoma (HCC) is heterogeneous, and survival data were mainly obtained from control arms of randomized studies. Clinical practice data on ...this topic are urgently needed, so as to help plan studies and counsel patients. We assessed the prognosis of 600 untreated patients with HCC managed by the Italian Liver Cancer Group. Prognosis was evaluated by subdividing patients according to the Barcelona Clinic Liver Cancer (BCLC) classification. We also assessed the main demographic, clinical, and oncological determinants of survival in the subgroup of patients with advanced HCC (BCLC C). Advanced (BCLC C: n = 138; 23.0%) and end‐stage HCC (BCLC D; n = 210; 35.0%) represented the majority of patients. Overall median survival was 9 months, and the principal cause of death was tumor progression (n = 279; 46.5%). Patients' median survival progressively and significantly decreased as BCLC stage worsened (BCLC 0: 38 months; BCLC A: 25 months; BCLC B: 10 months; BCLC C: 7 months; BCLC D: 6 months; P < 0.0001). Female gender (hazard ratio HR = 0.55; 95% confidence interval CI = 0.33‐0.90; P = 0.018), ascites (HR = 1.81; 95% CI = 1.21‐2.71; P = 0.004), and multinodular (>3) HCC (HR = 1.79; 95% CI = 1.21‐2.63; P = 0.003) were independent predictors of survival in patients with advanced HCC (BCLC C). Conclusion: BCLC adequately predicts the prognosis of untreated HCC patients. In untreated patients with advanced HCC, female gender, clinical decompensation of cirrhosis, and multinodular tumor are independent prognostic predictors and should be taken into account for patient stratification in future therapeutic studies. (Hepatology 2015;61:184–190)
Introduction
On February 20, 2020, a severe case of pneumonia due to SARS-CoV-2 was diagnosed in northern Italy (Lombardy). Some studies have identified obesity as a risk factor for severe disease in ...patients with COVID-19. The purpose of this study was to investigate the incidence of SARS-CoV-2 infection and its severity in patients who have undergone bariatric surgery.
Material and Methods
During the lockdown period (until May 2020), we contacted operated patients by phone and social networks (e.g., Facebook) to maintain constant contact with them; in addition, we gave the patients a dedicated phone number at which to call us for emergencies. We produced telemedicine and educational videos for obese and bariatric patients, and we submitted a questionnaire to patients who had undergone bariatric surgery in the past.
Results
A total of 2145 patients (313 male; 1832 female) replied to the questionnaire. Mean presurgical BMI: 44.5 ± 6.8 kg/m
2
. Mean age: 44.0 ± 10.0 year. Mean BMI after surgery: 29.3 ± 5.5 kg/m
2
(
p
< 0.05). From February to May 2020, 8.4% of patients reported that they suffered from at least one symptom among those identified as related to SARS-CoV-2 infection. Thirteen patients (0.6%) tested positive for COVID-19. Six patients (0.3%) were admitted to the COVID Department, and 2 patients (0.1%) were admitted to the ICU.
Conclusions
Although the reported rates of symptoms and fever were high, only 0.6% of patients tested positive for COVID-19. Among more than 2000 patients who underwent bariatric surgery analyzed in this study, only 0.1% needed ICU admission.
Purpose
To analyze the safety of laparoscopic ventral hernia delayed repair in bariatric patients with a composite mesh.
Materials and Methods
This retrospective single-center observational trial ...analyzed all bariatric/obese patients with concomitant ventral hernia who underwent laparoscopic abdominal hernia repair before bariatric surgery (group A) and laparoscopic delayed repair after weight loss obtained by the bariatric procedure (group B).
Results
Group A (30 patients) had a mean BMI of 37.8 ± 5.7 kg/m
2
(range: 34.0–74.2 kg/m
2
); group B (170 patients) had a mean BMI of 24.6 ± 4.5 kg/m
2
(range 19.0–29.8 kg/m
2
) (
p
< 0.05). Mean operative time: group A, 51.7 ± 26.6 min (range 30–120); group B 38.9 ± 21.5 min (range 25–110) (
p
< 0.05). Average length of stay: group A, 2.0 ± 2.7 days (range 1–5) versus group B, 2.8 ± 1.9 days (range 1–4) (
p
> 0.5). Recurrent hernia group A 1/30 (3.3%) versus recurrent hernia group B 4/170 (2.3%) (
p
> 0.5). Bulging: group A, 3/30 (10.0%) versus group B, 0/170 (0%) (
p
= 0.23).
Conclusion
The present study demonstrates the safety of performing LDR in patient candidates for bariatric surgery in cases of a large abdominal hernia (W2–W3) with a low risk of incarceration or an asymptomatic abdominal hernia. In the case of a small abdominal hernia (W1) or strongly symptomatic abdominal hernia, repair before bariatric surgery, along with subsequent bariatric surgery and any revision of the abdominal wall surgery with weight loss, is preferable.
Purpose
To compare sleeve gastrectomy (SG) to SG associated with Rossetti fundoplication (SG + RF) in terms of
de novo
gastro-esophageal reflux disease (GERD) after surgery, weight loss, and ...postoperative complications.
Materials and methods
Patients affected by morbid obesity, without symptoms of GERD, who were never in therapy with proton pump inhibitors (PPIs), were randomized into two groups. One group underwent SG and the other SG + RF. The study was stopped on February 2020 due to the COVID pandemic.
Results
A total of 278 patients of the programmed number of 404 patients were enrolled (68.8%).
De novo
esophagitis was considered in those patients who had both pre- and postoperative gastroscopy (97/278, 34.9%). Two hundred fifty-one patients (90.3%) had completed clinical follow-up at 12 months. SG + RF resulted in an adequate weight loss, similar to classic SG at 12-month follow-up (%TWL = 35. 4 ± 7.2%) with a significantly better outcome in terms of GERD development. One year after surgery, PPIs were necessary in 4.3% SG + RF patients compared to 17.1% SG patients (
p
= 0.001). Esophagitis was present in 2.0% of SG + RF patients versus 23.4% SG patients (
p
= 0.002). The main complication after SG + RF was wrap perforation (4.3%), which improved with the surgeon’s learning curve.
Conclusion
SG + RF seemed to be an effective alternative to classic SG in preventing de novo GERD. More studies are needed to establish that an adequate learning curve decreases the higher percentage of short-term complications in the SG + RF group.
Graphical abstract
Purpose
To propose an algorithm of treatment for leakage after laparoscopic sleeve gastrectomy (LSG).
Materials and Methods
Sixty-nine patients who developed gastric leakage out of 4294 patients who ...underwent LSG from 2010 to 2018 were considered in this study. Patients’ outcomes in terms of incidence of resolution and time to leakage resolution were compared by leakage characteristics and type of treatment. Three patients were lost to follow up.
Results
Leakage occurred in a median of 6 days from surgery, and for majority of patients (80.3%), it was in the upper part of the sleeve. The median dimension of leakage was 6.5 mm. Low level leakage resulted in a lower time of resolution (
p
< 0.001). Patients with clinical leakage were treated with surgery or endoscopic placement of a self-expandable metal stent (SEMS). The median time of leakage resolution was 42 days. The hospitalization time for SEMS was shorter with a 68.3% of complete resolution compared with the 29.4% of surgery. In patients with subclinical and small leakage, a conservative treatment was successful in 87.5%. Overall 39.4% of patients needed a second line treatment after that the first failed.
Conclusion
Leakage could be treated conservatively if subclinical and < 5 mm. Surgery is mandatory if a perigastric collection is present or an organ lesion is suspected. SEMS seems to be the best option to treat high level leakage.
The objective of the study is to evaluate 10 years of down-staging strategy for liver transplantation (LT) with a median follow-up of 5 years. Data on long-term results are poor and less information ...is available for hepatocellular carcinoma (HCC) non-responder patients or those ineligible for down-staging. The outcome of 308 HCC candidates and the long-term results of 231 LTs for HCC performed between 2003 and 2013 were analyzed. HCCs were divided according to tumor stage and response to therapy: 145 patients were T2 (metering Milan Criteria, MC), 43 were T3 successfully down-staged to T2 (Down-Achieved), 20 were T3 not fully down-staged to T2 (Down-not Achieved), and 23 patients were T3 not receiving down-staging treatments (No-Down). The average treatment effect (ATE) of LT for T3 tumors was estimated using the outcome of 535 T3 patients undergoing non-LT therapies, using inverse probability weighting regression adjustment. The 24-month drop-out rate during waiting time was significantly higher in the down-staging groups: 27.6% vs. 9.2%, p < 0.005. After LT, the tumor recurrence rate was significantly different: MC 7.6%, Down-Achieved 20.9%, Down-not Achieved 31.6%, and No-Down 30.4% (p < 0.001). The survival rates at 5 years were: 63% in Down-Achieved, 62% in Down-not Achieved, 63% in No-Down, and 77% in MC (p = n.s.). The only variable related to a better outcome was the effective down-staging to T2 at the histological evaluation of the explanted liver: recurrence rate = 7.8% vs. 26% (p < 0.001) and 5-year patient survival = 76% vs. 67% (p < 0.05). The ATE estimation showed that the mean survival of T3-LT candidates was significantly better than that of T3 patients ineligible for LT 83.3 vs 39.2 months (+44.6 months); p < 0.001. Long term outcome of T3 down-staged candidates was poorer than that of MC candidates, particularly for cases not achieving down-staging. However, their survival outcome was significantly better than that achieved with non-transplant therapies.
Background
The role of clinically significant portal hypertension on the prognosis of cirrhotic patients undergoing hepatic resection for hepatocellular carcinoma (HCC) is debated.
Aims
In this ...study, our aim was to assess the role of clinically significant portal hypertension after hepatic resection for HCC in patients with cirrhosis.
Methods
We assessed the prognostic role of the presence of clinically significant portal hypertension (oesophageal/gastric varices/portal hypertensive gastropathy or a platelet count <100 × 109/L associated with splenomegaly) in 152 patients with compensated cirrhosis who underwent hepatic resection for HCC at the Italian Liver Cancer centres. Survival rates were assessed in the whole series, in the subgroup of Child‐Pugh score 5 patients with uninodular HCC ≤5 cm, and in Child‐Pugh score 5 patients with uninodular HCC ≤2 cm and normal bilirubin.
Results
Median survival was similar in patients with and without clinically significant portal hypertension (79 vs 77 months, P = 0.686). Child‐Pugh score 5 was the only variable significantly associated with survival by Cox multiple regression (P = 0.007). In Child‐Pugh score 5 patients with single HCC ≤5 cm or in those with single HCC ≤2 cm and normal bilirubin, there was no survival difference between patients with and without clinically significant portal hypertension (median survival: 94 vs 78 months, P = 0.121 and >100 vs 86 months, P = 0.742).
Conclusions
Presence of clinically significant portal hypertension has no influence on survival of patients with well‐compensated cirrhosis undergoing hepatic resection for HCC.
The Barcelona Clinic Liver Cancer (BCLC) advanced stage (BCLC C) of hepatocellular carcinoma (HCC) includes a heterogeneous population, where sorafenib alone is the recommended treatment. In this ...study, our aim was to assess treatment and overall survival (OS) of BCLC C patients subclassified according to clinical features (performance status PS, macrovascular invasion MVI, extrahepatic spread EHS or MVI + EHS) determining their allocation to this stage. From the Italian Liver Cancer database, we analyzed 835 consecutive BCLC C patients diagnosed between 2008 and 2014. Patients were subclassified as: PS1 alone (n = 385; 46.1%), PS2 alone (n = 146; 17.5%), MVI (n = 224; 26.8%), EHS (n = 51; 6.1%), and MVI + EHS (n = 29; 3.5%). MVI, EHS, and MVI + EHS patients had larger and multifocal/massive HCCs and higher alpha‐fetoprotein (AFP) levels than PS1 and PS2 patients. Median OS significantly declined from PS1 (38.6 months) to PS2 (22.3 months), EHS (11.2 months), MVI (8.2 months), and MVI + EHS (3.1 months; P < 0.001). Among MVI patients, OS was longer in those with peripheral than with central (portal trunk) MVI (11.2 vs. 7.1 months; P = 0.005). The most frequent treatments were: curative approaches in PS1 (39.7%), supportive therapy in PS2 (41.8%), sorafenib in MVI (39.3%) and EHS (37.3%), and best supportive care in MVI + EHS patients (51.7%). Independent prognostic factors were: Model for End‐stage Liver Disease score, Child‐Pugh class, ascites, platelet count, albumin, tumor size, MVI, EHS, AFP levels, and treatment type. Conclusion: BCLC C stage does not identify patients homogeneous enough to be allocated to a single stage. PS1 alone is not sufficient to include a patient into this stage. The remaining patients should be subclassified according to PS and tumor features, and new patient‐tailored therapeutic indications are needed. (Hepatology 2018;67:1784‐1796).
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