Abstract Background Few papers deal with pathologic characteristics and outcome of the 3 different cholangiocarcinomas based on location (intrahepatic, peri-hilar, distal). There is little evidence ...regarding similarity and differences. Patients and Methods From two tertiary referral Italian Centers (in Bologna and Verona), 479 patients with cholangiocarcinoma were evaluated between 1980 and 2011. Several pathologic characteristics and their impact on survival were analyzed among resected patients for cholangiocarcinomas depending on the site of origin. Results Tumour location was intrahepatic in 172 cases (36%), peri-hilar in 243 (51) and distal in 64(13%). Curative resection was performed in 339 (70%) patients. Intrahepatic cholangiocarcinoma showed higher probability to achieve R0 resection (81%), but was more frequently associated with presence of microvascular invasion (71%). Distal cholangiocarcinoma presented less R0 resections (58%), higher lymphnode involvement (60%) and lower microvascular invasion (49%). Hilar cholangiocarcinoma had intermediate characteristics (R0: 65% of cases). Median follow up was 30.2 ± 38 months; the 5 years overall survival was 31% in the resected population. Overall survival curves were similar among the three groups. At univariate analysis surgical margins, lymphnode status, perineural invasion, T category, TNM stage, microvascular invasion, tumour grading had significant impact on survival. At multivariate analysis, only microvascular invasion was significantly related to long term results (HR = 1,7; 95% CI = 1,0–2,5)”. Conclusion Micro-vascular invasion has the strongest impact on survival in all three types of cholangiocarcinoma. In case of comparable pathologic characteristics and stage, the three tumors show similar outcome; depending on location, it shows a different tendency to invade bordering structures which affect the outcome.
Background
The benefit of surgical intervention for cancer should be estimated in relation to the life expectancy of the general population. The aim of this study was to provide a measure of relative ...survival after hepatectomy for hepatocellular carcinoma (HCC).
Methods
Consecutive patients with liver cirrhosis and HCC who underwent hepatectomy were divided into age quartiles for analysis. Short‐ and mid‐term survival rates were used to estimate survival until death for all patients, in relation to age and other co‐variables. Years of life lost (YLL) were estimated using a reference cohort, derived from the general population matched for sex, age and year of diagnosis.
Results
Some 919 patients were included in the study. The following age quartiles were identified: less than 60 years (229 patients), 60–66 years (230), 67–70 years (231) and over 70 years (229). Postoperative mortality rates were similar between age quartiles, as were survival rates up to 3 years (P = 0·404). A statistically significant reduction in 5–10‐year survival rates was observed with ageing (P = 0·001). Relative survival calculation showed that the youngest age quartile (less than 60 years) experienced the longest entire postoperative lifespan (15·6 years) but also the greatest number of YLL (11·0 years). Patients aged over 70 years had the shortest entire postoperative lifespan (6·4 years) but also the smallest number of YLL (3·7 years).
Conclusion
Although survival after liver resection for HCC is shortest in elderly patients, relative survival estimates suggest that hepatectomy can be of benefit in these patients, with a small loss of the entire individual lifespan.
Hepatectomy for HCC of benefit in elderly
Conventional criteria for liver transplantation for patients with hepatocellular carcinoma are single HCC ≤ 5 cm or less than or equal to three HCCs ≤ 3 cm. We prospectively evaluated the possibility ...of slightly extending these criteria in a down‐staging protocol, which included patients initially outside conventional criteria: single HCC 5–6 cm or two HCCs ≤ 5 cm or less than six HCCs ≤ 4 cm and sum diameter ≤ 12 cm, but within Milan criteria in the active tumors after the down‐staging procedures. The outcome of patients down‐staged was compared to that of Milan criteria after liver transplantation and since the first evaluation according to an intention‐to‐treat principle. From 2003 to 2006, 177 patients with HCC were considered for transplantation: the transplantation rate was comparable between the Milan and down‐staging groups: 88/129 cases (68%) versus 32/48 cases (67%), respectively. At a median follow‐up of 2.5 years after transplantation, the 1 and 3 years' disease‐free survival rates were comparable: 80% and 71% in the Milan group versus 78% and 71% in the down‐staging. The actuarial intention‐to‐treat survival was 27/48 patients (56.3%) in the down‐staging and 81/129 cases (62.8%) in the Milan group, p = n.s. The proposed down‐staging criteria provide a comparable outcome to the conventional criteria.
This study of a new down‐staging protocol for patients with HCC moderately beyond the Milan criteria on waiting list for liver transplantation shows that both the intention‐to‐treat analysis and the post‐operative outcome were comparable between down‐staging and conventional criteria group. See also editorial by Lo in this issue on page 2485.
We study the effect of pendent methyl groups on the alkaline stability of model anion exchange polymers based on poly(2,6-dimethyl-1,4-phenylene)oxide (PPO) with grafted trimethylammonium groups. The ...polymer backbone is modified varying the synthesis procedure: by the bromination route, the ionomeric ammonium groups are inserted on the structural methyl group of PPO (Br-PPO-TMA), while by the chloromethylation route the ammonium groups are attached in the ortho-position to the methyl group of PPO (Cl-PPO-TMA). The properties of the membranes are studied by NMR and FTIR spectroscopy, thermogravimetry, water uptake, mechanical tensile tests, small-angle X-ray scattering (SAXS) and impedance spectroscopy. SAXS analysis indicates a better nanophase separation for Cl-PPO-TMA, which is consistent with a slightly larger water uptake and ionic conductivity. The properties of the two polymers are also compared before and after the aging in 2 M NaOH at 80 °C for different times. The thermogravimetric analysis shows the loss of the ammonium groups and the backbone ether cleavage after alkali treatments. The samples prepared by the bromination route show a higher stability of ionic conductivity, presumably due to a reduced alkaline attack of the ammonium groups, although DFT calculations do not show major differences of thermodynamic and kinetic reaction parameters. After alkaline treatment, the mechanical properties are more degraded for the Br-PPO-TMA compound. The decreased mechanical properties can be attributed to a reduction of the average chain length of PPO by alkaline scission of the ether links. Both synthesis routes have advantages and disadvantages, but the higher reproducibility and the better mechanical properties of samples prepared by chloromethylation are considered preponderant benefits.
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•Small changes in the polymeric structure can affect the performances of anion exchange membranes.•The chloromethylation route leads to less fragile ionomers with a higher ductility.•The samples prepared by the bromination route show a higher stability of ionic conductivity.
We investigate the extent to which people's earlier circumstances and experiences shape subsequent life-courses. We do this using UK longitudinal data to provide a dynamic analysis of employment and ...caregiving histories for 4339 people over 15–20 years between 1991 and 2010. We analyse these histories as sequences using optimal matching and cluster analysis to identify five distinct employment-caregiving pathways. Regression analysis shows that prior to embarking on these pathways, people are already differentiated by life-stage, gender and attitudes towards family and gender roles. Difference-in-differences estimation shows that some initial differences in income, subjective health and wellbeing widen over time, while others narrow. In particular, those following the most caregiving-intensive pathways not only end up poorer but also experience a relative decline in subjective health and wellbeing. These results confirm that earlier circumstances exert a strong influence on later life-courses consistent with pre-determination, persistence and path dependence.
•Previous circumstances and experiences strongly influence subsequent life-courses.•Persistent caregivers are likely to be older and female.•Persistent caregivers also tend to hold traditional views on gender roles.•The income, health and wellbeing disadvantages of persistent caregivers accumulate.•After 15–20 years caregivers end up poorer and have lower wellbeing and health.
Purpose
In this study, we aim to analyze the learning curve of each step of robotic transabdominal pre-peritoneal inguinal hernia repair (rTAPP) in two surgeons with varying degrees of expertise with ...the robotic platform but no experience with laparoscopic hernia repair.
Methods
Data on 124 rTAPP cases performed by two surgeons were retrospectively reviewed. Cumulative sum (CUSUM) analysis was applied to visualize the learning curve of rTAPP on operation time of each step of the procedure the peritoneal flap creation (T1), the completion of the critical view of the myopectineal orifice (T2), the mesh application (T3) and the peritoneal flap closure (T4). Each intraoperative and postoperative outcome was compared according to surgeon’s experience with the robotic platform and learning phase. The robotic surgeon mentored the surgeon-in-training and was present during all surgeries in his learning period.
Results
The surgeon in training with the robotic platform showed a learning phase till the 20th procedure followed by a gradual improvement in performances. The expert surgeon showed a learning phase till the 35th procedure after which a constant decrease of operative time was recorded till the last procedure included. The operative times of each step of the procedures of both surgeons were significantly improved after the learning phase. In the late phase, the surgeon in training could achieve operative times in T2 and T3, which are similar to those of an experienced robotic surgeon with no experience with TAPP before the completion of the learning phase.
Conclusions
In conclusion, the learning phase of rTAPP surgery may vary between 20 and 35 cases, depending on the surgeon’s experience in robotic surgery.
Improved understanding of risk factors associated with carbapenem‐resistant‐Klebsiella pneumoniae (CR‐KP) infection after liver transplantation (LT) can aid development of effective preventive ...strategies. We performed a prospective cohort study of all adult patients undergoing LT at our hospital during 30‐month period to define risk factors associated with CR‐KP infection. All patients were screened for CR‐KP carriage by rectal swabs before and after LT. No therapy was administered to decolonize or treat asymptomatic CR‐KP carriers. All patients were monitored up to 180 days after LT. Of 237 transplant patients screened, 41 were identified as CR‐KP carriers (11 at LT, 30 after LT), and 20 developed CR‐KP infection (18 bloodstream‐infection, 2 pneumonia) a median of 41.5 days after LT. CR‐KP infection rates among patients non‐colonized, colonized at LT, and colonized after LT were 2%, 18.2% and 46.7% (p < 0.001). Independent risk factors for CR‐KP infection identified by multivariate analysis, included: renal‐replacement‐therapy; mechanical ventilation > 48 h; HCV recurrence, and colonization at any time with CR‐KP. Based on these four variables, we developed a risk score that effectively discriminated patients at low versus higher risk for CR‐KP infection (AUC 0.93, 95% CI 0.86–1.00, p < 0.001). Our results may help to design preventive strategies for LT recipients in CR‐KP endemic areas.
In a single‐center prospective cohort study to assess the risk factors for infection with carbapenem‐resistant Klebsiella pneumoniae after liver transplantation, the authors analyze the significance of carbapenem‐resistant K. pneumoniae rectal carriage before and after liver transplantation, and develop a risk score that effectively discriminates patients at low versus higher risk for infection.
Metastatic pancreatic cancer has a median overall survival of less than 12 months, even if treated with chemotherapy. Selected patients with oligometastatic disease could benefit from multimodal ...treatments connecting chemotherapy and surgical treatment or radiofrequency ablation (RFA) of metastases.
We present a patient with oligometastatic pancreatic cancer recurrence who was successfully treated with a multimodal therapeutic approach. A 57-year-old male initially presenting with resectable pancreatic cancer underwent pancreatoduodenectomy. The histopathological diagnosis revealed ductal pancreatic adenocarcinoma with positive surgical resection margins and negative lymph nodes. He completed six cycles of adjuvant therapy with gemcitabine (1000 mg/mq 1,8,15q 28), followed by external radiotherapy (54 Gy in 25 fractions) associated with gemcitabine 50 mg/mq twice weekly. Three years later, the patient developed multiple liver metastases, and he started FOLFIRINOX (oxaliplatin 85 mg/mq, irinotecan 180 mg/mq, leucovorin 400 mg/mq and fluorouracil 400 mg/mq given as a bolus followed by 2400 mg/mq as a 46 h continuous infusion,1q 14) as a first-line treatment. The CT scan showed a partial response after 6 cycles. After multidisciplinary discussion, the patient underwent a laparotomic metastasectomy of the three hepatic lesions. After additional postsurgical chemotherapy with 4 cycles of the FOLFIRINOX schedule, the patient remained free of recurrence for 12 months. A CT scan showed a new single liver metastasis, which was treated with radiofrequency ablation (RFA). A second radiofrequency ablation was performed when the patient developed another single liver lesion 12 months after the first RFA; currently, the patient is free from recurrence with an overall survival of 6 years from the diagnosis.
Our case has benefited from successful multimodal treatment, including surgical and local ablative techniques and systemic chemotherapy. A multimodal approach may be warranted in selected patients with oligometastatic pancreatic cancer and could improve overall survival. Further research is needed to investigate this approach.
Given that a large proportion of Master's students in UK universities are from mainland China, we sought to quantify the extent to which their approaches to learning (AtL) and epistemological beliefs ...(EBs) differ from those of non-Chinese students, and how these differences affected first-semester grades. To this end, we surveyed a large cohort of Master's students (n = 564, 65.3% Chinese) at a UK Business School at the beginning of an academic year to minimise influences that might change attitudes towards AtL and EBs. Primary data on AtL and EBs were collected using two standard survey instruments, along with data on social class, prior attainment, and nationality. This unique combination of measures, controls and large sample size allowed for an analysis that was more comprehensive than previous studies. Our findings showed that achievement among Chinese students was unrelated to AtL but was associated with EBs and social background. For example, when controlling for other factors, Chinese students who had confidence in their learning ability achieved higher grades, while non-Chinese students who perceived knowledge as certain underperformed. Moreover, Chinese students whose fathers held lower status jobs achieved significantly higher grades when controlling for other characteristics.
Liver resection (LR) for patients with small hepatocellular carcinoma (HCC) with preserved liver function, employing liver transplantation (LT) as a salvage procedure (SLT) in the event of HCC ...recurrence, is a debated strategy.
From 1996 to 2005, we treated 227 cirrhotic patients with HCC transplantable: 80 LRs and 147 LTs of 293 listed for transplantation. Among 80 patients eligible for transplantation who underwent LR, 39 (49%) developed HCC recurrence and 12/39 (31%) of these patients presented HCC recurrence outside Milan criteria. Only 10 of the 39 patients underwent LT, a transplantation rate of 26% of patients with HCC recurrence.
According to intention‐to‐treat analysis of transplantable HCC patients who underwent LR (n = 80), compared to all those listed for transplantation (n = 293), 5‐year overall survival was 66% in the LR group versus 58% in patients listed for LT, respectively (p = NS); 5‐year disease‐free survival was 41% in the LR group versus 54% in patients listed for LT (p = NS).
Comparable 5‐year overall (62% vs. 73%, p = NS) and disease‐free (48% vs. 71%, p = NS) survival rates were obtained for SLT and primary LT for HCC, respectively.
LR is a valid treatment for small HCC and in the event of recurrence, SLT is a safe and effective procedure.
By intention to treat analysis of survival of transplantable HCC patients who underwent liver resection (LR) compared to those listed for transplantation, this study shows that LR for patients with small HCC with preserved liver function, employing LT as a salvage procedure (SLT) in the event of HCC recurrence, is a safe and effective strategy. See also editorial by Botha in this issue on page 1085.
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