Abstract Background Liver hemangiomas are rarely large, symptomatic, or presenting atypical imaging patterns. Surgery is rarely needed; indications and choice of the best technique remain not ...precisely defined. Methods Features of hemangiomas and surgical indications were assessed in 74 patients (mean follow-up 63.2 months). In 40 operated patients, the results of liver resection versus enucleation were compared. Results Most hemangiomas (60/74, 81.1%) showed no size increment. In 40 operated patients (40/74, 54.1%) the mean tumor size (11.9 cm, range 2.6–46.0) was larger than in nonoperated patients (11.9 vs 6.0 cm, P = .0002). Surgical indications were specific symptoms, tumor enlargement, Kasabach-Merritt syndrome, and uncertain diagnosis. Mortality (nil), morbidity (10.0%), and transfusion rate (15.0%) were similar for 28 liver resections versus 12 enucleations; bleeding was more related to large hemangioma size than to the choice of either technique. Liver ischemia techniques, autotransfusion, and intraoperative blood salvage reduced the risk of transfusion. Conclusions Surgery is rarely indicated, has a low risk, and has similar results for liver resection versus enucleation. Risk of bleeding is related more to the large size of the hemangioma than to the type of surgery (resection or enucleation). In these patients, management, the need for surgery, and the choice of technique should be carefully individualized.
Intraductal biliary lesions can involve the main hepatic confluence. Assessment of the extension of pedunculated biliary lesions during per-oral cholangioscopy (POCS) can optimize and personalize the ...surgical strategy. Four consecutive cases of pedunculated biliary lesions were analysed. Cholangioscopy was performed with a disposable single-operator cholangioscope. POSC was successfully performed in four patients (three female, mean age 50 years), showing involvement of the main biliary confluence in three of four pedunculated biliary lesions; direct biopsy sampling was diagnostic in two of three cases (in one patient, biopsy were not performed due to the smooth appearance of the intrabiliary lesion). No adverse events occurred after POCS. Surgery required excision of the main hepatic confluence in two of three cases (one patient was not resectable). POCS can diagnose intrabiliary extension of protruding biliary lesions, providing important information to plan the surgical intervention.
The liver represents the first metastatic site in 5-12% of metastatic breast cancer (MBC) cases. In absence of reliable evidence, liver metastasectomy (LM) could represent a possible therapeutic ...option for selected MBC patients (patients) in clinical practice. A retrospective analysis including MBC patients who had undergone an LM after a multidisciplinary Tumor Board discussion at the Hepatobiliary Surgery Unit of Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS in Rome, between January 1994 and December 2019 was conducted. The primary endpoint was overall survival (OS) after a MBC-LM; the secondary endpoint was the disease-free interval (DFI) after surgery. Forty-nine MBC patients underwent LM, but clinical data were only available for 22 patients. After a median follow-up of 71 months, median OS and DFI were 67 months (95% CI 45-103) and 15 months (95% CI 11-46), respectively. At univariate analysis, the presence of a negative resection margin (R0) was the only factor that statistically significantly influenced OS (78 months
16 months; HR 0.083,
< 0.0001) and DFI (16 months
5 months; HR 0.17,
= 0.0058). A LM for MBC might represent a therapeutic option for selected patients. The radical nature of the surgical procedure performed in a high-flow center and after a multidisciplinary discussion appears essential for this therapeutic option.
Objective
The aim of this study was to determine the prognostic significance of the preoperatively assessed tumor doubling time (DT) in patients undergoing liver resection for mass-forming ...intrahepatic cholangiocarcinoma (IHC).
Methods
We evaluated 79 patients who underwent curative resection for IHC, and in whom the same imaging technique was preoperatively available in two consecutive occasions, to allow the calculation of the DT. The influence of DT and other clinical and pathological variables on tumor recurrence and patient survival was determined by the Kaplan–Meier method and uni- and multivariate analysis.
Results
Median overall survival was 40 months; 1-, 3-, and 5-year survival rates were 86.1, 55.1, and 35.1 %, respectively. Median disease-free survival was 17 months; 1-, 3-, and 5-year disease-free survival rates were 62.0, 29.1, and 23.3 %, respectively. At univariate analysis, DT <70 days (
p
< 0.001) and advanced tumor stage (
p
= 0.024) were associated with worse overall survival and maintained significance at multivariate analysis.
Conclusions
DT is a clinically useful parameter to estimate the prognosis of “mass-forming” IHC in patients undergoing liver resection.
Abstract After surgery, in sepsis and various critical illnesses, factors such as severity of the acute phase response, liver dysfunction, and hemodilution from blood loss have cumulative impacts in ...decreasing cholesterol; therefore, degree of hypocholesterolemia often reflects severity of illness. The direct correlation between cholesterol and several plasma proteins is mediated by the parallel impact of commonly shared determinants. Cholestasis is associated with a moderation of the degree of hypocholesterolemia. In human sepsis, the poor implications of hypocholesterolemia seem to be aggravated by the simultaneous development of hypertriglyceridemia. Cholesterol and triglyceride levels reflect altered lipoprotein patterns, and the issue is too complex and too poorly understood to be reduced to simple concepts; nevertheless, these simple measurements often represent helpful adjunctive clinical tools.
This study was performed prospectively to assess the effect of systemic chemotherapy (FOLFIRI protocol) in patients with initially unresectable colorectal liver metastases (CRLM) and, after ...performing liver resection in patients with downsized metastases, to compare the postoperative and long-term results with those of patients with primarily resectable CRLM. Records from a prospective database including all consecutive admissions for CRLM between June 2000 and June 2004 were reviewed. The analysis addressed all patients who underwent hepatectomy for primarily resectable CRLM (Group A), or underwent chemotherapy for primarily unresectable CRLM and among these, particularly the patients who were finally resected after downsizing of CRLM (Group B). There were 60 primarily resected patients (Group A). Forty-two other patients underwent chemotherapy; after an average of nine courses, 18 of them (42.8%) with significantly downsized lesions were explored and 15 (35.7%, Group B) were resected, whereas three had peritoneal metastases. Group B differed from Group A for a significantly higher rate of synchronous CRLM upon diagnosis of colorectal cancer, a larger size of CRLM upon evaluation in our center, and a lower rate of major hepatectomies (20.0% vs. 51.6 %) at surgery. No patient in Group B had positive margins of resection. Operative mortality was nil and morbidity was 20.0% in both groups. In Group B vs. Group A median survival after hepatectomy was 46 vs. 47 months (n.s), 3-year survival rate was 73% vs. 71% (n.s.), disease-free survival rate was 31% vs. 58% (p = 0.04) and, at a median follow-up of 34 months, tumor recurrence rate was 53.3% vs. 28.3% (n.s.). Four out of the eight Group B patients with recurrence underwent a re-resection, and were alive at 9 to 67 months after the first resection. These results show that in about one-third of the patients with primarily unresectable CRLM, downsizing of the lesions by chemotherapy (FOLFIRI protocol) permitted a subsequent curative resection. In these patients, operative risk and survival did not differ from the figures observed in primarily resectable patients and, in spite of a lower disease-free survival with more frequent recurrence, re-resection still represented a valid option to continue treatment.
If we consider only the major injuries, in our experience surgery was the definitive treatment in 64% of patients (41 of 64), which is the same rate reported by Grönroos in Karvonen et al3 (64%; 14 ...of 22). ...it seems that the general policy of our 2 centers is the same, and that reported laparotomies all were necessary. On this topic we would like to emphasize that jaundiced patients with complete biliary strictures are the...
Background Obtaining a definitive tissue diagnosis in patients with hilar biliary strictures (HBS) is often difficult. Objective To describe our experience using a newly developed forward-viewing ...linear echoendoscope (FVL-EUS) with FNA as a primary diagnostic tool in patients with HBS. Design Case series. Setting A tertiary care, academic medical center. Patients Four patients with HBS who underwent the procedure. Main Outcome Measurements Performance of FNA with the FVL-EUS. Results Visualization and puncture of the primary lesion with a definitive tissue diagnosis was obtained in all of the 4 cases performed. Metastatic hilar cholangiocarcinoma and recurrent neuroendocrine tumor were diagnosed in 2 patients and followed by placement of a self-expandable metal stent, when possible. In the other 2 patients, a diagnosis of resectable hilar cholangiocarcinoma and poorly differentiated adenocarcinoma of unclear origin without evidence of vascular involvement was made, and plastic stents were placed before surgery; the first patient was found to have peritoneal metastases, and resection was aborted, and in the second patient, a gallbladder tumor was diagnosed in the surgical specimen. Limitation The small number of patients. Conclusions These preliminary data suggest that FVL-EUS used as a primary tool for the evaluation of patients with HBS may be of value and should be further explored in properly designed studies with a meaningful number of patients.
Background Bleeding is the most relevant operative risk during mesohepatectomy because of the wideness of the resection surfaces and the exposure of main intrahepatic vascular structures. Preliminary ...extraparenchymal exposure of the main hepatic veins, with the possibility of clamping them in association with the Pringle maneuver, and the maintenance of a low central venous pressure during mesohepatectomy, can contribute to substantially reducing operative bleeding. Study Design We report the results obtained in 18 mesohepatectomies, performed for liver metastases (13 patients) and for hepatocellular carcinoma (5 patients). Liver resection was performed without preliminary exposure of the main hepatic veins in nine patients (group A) and with preliminary looping of the main hepatic veins in nine patients (group B), without complications related to the maneuver. Results Intermittent pedicle clamping was used in all patients; in six patients in group B (66.7%), clamping of the main hepatic veins was also performed (mean duration, 37 minutes; range 16 to 68 minutes). Intraoperative blood transfusions were needed in 5 patients (5 of 18, 27.8%): 4 belonged to group A (44.4%) and 1 to group B (11.1%). Mortality was nil and morbidity was 33.3%, involving four patients in group A and two in group B (none related to the exposure, looping, and clamping of the main hepatic veins). Conclusions Preliminary control of the main hepatic veins is a safe maneuver. During mesohepatectomy, clamping of these veins, associated with pedicle clamping, is effective in reducing operative bleeding. In our patients, this resulted in a low blood transfusion rate, similar to that of classic major hepatectomies, despite the higher complexity of mesohepatectomy.
Primary leiomyosarcoma of the liver is a rare tumor whose development patterns are unsatisfactorily known.
A 26-year-old male patient with a previous history of radiochemotherapy treatment for ...Hodgkin's lymphoma was referred to our unit with a histological and radiological diagnosis of primary hepatic leiomyosarcoma. Six months before referral, in a workup for hypertension, a CT scan of the abdomen had shown a 2.5-cm lesion in liver segment VII, which was interpreted as an angioma. Shortly before referral the lesion had grown to 7.8 cm, associated with two smaller lesions in segments VIII and III, and a diagnosis of hepatic leiomyosarcoma was made at biopsy. After referral he underwent a right hepatectomy with wedge resection of segment III. This was followed by rapid progression of the disease, in spite of transient stabilization under gemcitabine treatment. Octreotide was also administered after the detection of elevated chromogranin A in serum. The patient died 25 months after liver resection.
The challenges and peculiarities of this case are related to the rarity of the tumor, its accidental discovery without immediate suspicion of its nature, its very aggressive behavior that was only partly controlled by chemotherapy, and the unusual expression of a neuroendocrine phenotypic feature with high serum chromogranin A levels.
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