103 research outputs found
Transhepatic anterior approach to the inferior vena cava in large retroperitoneal tumors resected en bloc with the right liver lobe
No full textBackground. The operative approach to large retrohepatic tumors can be challenging because of the difficulty in exposing the inferior vena cava (IVC) and controlling bleeding. The anterior approach to the IVC associated with the hanging maneuver for liver transection, originally described in large hepatic tumors, may also facilitate removal of large masses set behind the liver.
Methods. A prospective cohort of 10 patients with large retrohepatic tumors involving the IVC was selected according to restrictive criteria (ie, single low-grade tumor, sufficient liver remnant, normal hepatic function, absence of cholestasis, and symptoms secondary to lower vena cava obstruction). In all cases, the anterior approach and the hanging maneuver were applied intentionally to expose the IVC without any liver mobilization. Depending on tumor invasiveness, either IVC-preserving (n = 7) or IVC-removing (n = 3) strategies were applied. Our aim was to assess the safety of the technique and the possible benefits for patient outcome.
Results. The cohort represented less than 1% of a series of 1,168 major hepatectomies performed in our unit between 2005 and 2011. The median age of the patients was 58; adrenal tumors and retroperitoneal sarcomas accounted for 70% of the series. Total vascular liver exclusion was necessary in 3 patients. Median operative time was 420 min. R0 resection was obtained in all cases, with no mortality and 40% overall morbidity. Overall survival was 83% at 5 years.
Conclusion. The transhepatic, anterior approach to the IVC is a safe procedure that improves vascular control, facilitates vein repair or reconstruction, and allows potentially curative resection of large retrohepatic tumors. This approach should be the preferred choice to be adopted in properly selected patients
Competing risk analysis on outcome after hepatic resection of hepatocellular carcinoma in cirrhotic patients
No full textTo investigate death for liver failure and for tumor recurrence as competing events after hepatectomy of hepatocellular carcinoma. METHODS Data from 864 cirrhotic Child-Pugh class A consecutive patients, submitted to curative hepatectomy (1997-2013) at two tertiary referral hospitals, were used for competing-risk analysis through the Fine and Gray method, aimed at assessing in which circumstances the oncological benefit from tumour removal is greater than the risk of dying from hepatic decompensation. To accomplish this task, the average risk of these two competing events, over 5 years of follow-up, was calculated through the integral of each cumulative incidence function, and represented the main comparison parameter. RESULTS Within a median follow-up of 5.6 years, death was attributable to tumor recurrence in 63.5%, and to liver failure in 21.2% of cases. In the first 16 mo, the risk of dying due to liver failure exceeded that of dying due to tumor relapse. Tumor stage only affects death from recurrence; whereas hepatitis C infection, Model for End-stage Liver Disease score, extent of hepatectomy and portal hypertension influence death from liver failure (P < 0.05 in all cases). The combination of these clinical and tumoral features identifies those patients in whom the risk of dying from liver failure did not exceed the tumour-related mortality, representing optimal surgical candidates. It also identifies those clinical circumstances where the oncological benefit would be borderline or even where the surgery would be harmful. CONCLUSION Having knowledge of these competing events can be used to weigh the risks and benefits of hepatic resection in each clinical circumstance, separating optimal from non-optimal surgical candidates
Permanent Pancreatic Duct Occlusion With Neoprene-based Glue Injection After Pancreatoduodenectomy at High Risk of Pancreatic Fistula : A Prospective Clinical Study
No full textOBJECTIVE: The aim of this study was to assess safety and efficacy of pancreatic duct occlusion (PDO) with neoprene-based glue in selected patients undergoing pancreatoduodenectomy (PD) at high risk of postoperative pancreatic fistula (POPF). BACKGROUND DATA: PD is the reference standard approach for tumors of the pancreaticoduodenal region. POPF is the most relevant complication after PD. PDO has been proposed as an alternative to anastomosis to manage the pancreatic stump. METHODS: A single-center, prospective, nonrandomized trial enrolled 100 consecutive PD for cancer. Patients at high risk for POPF according to Fistula Risk Score (FRS) >15% (≥6 points) were treated with PDO using neoprene glue (study cohort); patients with FRS ≤15% (≤5 points) received pancreaticojejunal anastomosis (PJA: control cohort). Primary endpoint was complication rate grade ≥3 according to Dindo-Clavien Classification (DCC). Other postoperative outcomes were monitored (ClinicalTrials.gov NCT03738787). RESULTS: Fifty-one patients underwent PDO and 49 PJA. DCC ≥3, postoperative mortality, and POPF grade B-C were 25.5% versus 24.5% (P = 0.91), 5.9% versus 2% (P = 0.62), and 11.8% versus 16.3% (P = 0.51) in the study versus control cohort, respectively. At 1 and 3 years, new-onset diabetes was diagnosed in 13.7% and 36.7% of the study cohort versu 4.2% and 12.2% in controls (P = 0.007). CONCLUSIONS: PDO with neoprene-based glue is a safe technique that equalizes early outcome of selected patients at high risk of POPF to those at low risk undergoing PJA. Neoprene-based PDO, however, triples the risk of diabetes at 1 and 3 years
Transarterial chemoembolization as adjuvant treatment after surgery: The cure of huge hepatocellular carcinoma?
No full textContrast-Enhanced Harmonic Endoscopic Ultrasound-Guided Fine-Needle Aspiration versus Standard Fine-Needle Aspiration in Pancreatic Masses: A Propensity Score Analysis
No full textDiagnostic yield of endoscopic ultrasound-guided liver biopsy in comparison to percutaneous liver biopsy: a systematic review and meta-analysis
No full textBackground: It is still unclear whether endoscopic ultrasound liver biopsy (EUS-LB) determines superior results in comparison to percutaneous liver biopsy (PC-LB). Aim of this meta-analysis was to compare the diagnostic outcomes of these two techniques. Research Design and Methods: Literature search was conducted through June 2021 and identified 7 studies. The primary outcome was total length of specimen. Results were expressed as odds ratio (OR) or mean difference along with 95% confidence interval (CI). Results: Pooled total length of specimen was 29.9 mm (95% CI 24.1–35.7) in the EUS-LB group and 29.7 mm (95% CI 27.1–32.2) in the PC-LB group, with no difference between the two approaches (mean difference −0.35 mm, 95% CI −5.31 to 4.61; p = 0.89), although sensitivity analysis restricted to higher quality studies found a superior performance of PC-LB over EUS-LB. Pooled number of complete portal tracts was 12.9 (7.7–18) in the EUS-LB and 14.4 (10.7–18) in the PC-LB group, with no difference in direct comparison (mean difference −1.58, −5.98 to 2.81; p = 0.48). No difference between the two groups was observed in terms of severe adverse event rate (OR 1.11, 0.11–11.03; p = 0.93). Conclusion: EUS-LB and PC-LB are comparable in terms of diagnostic performance and safety profile
Liver resection and transplantation for metastases from gastroenteropancreatic neuroendocrine tumors
No full textAround 60% of gastroenteropancreatic neuroendocrine tumors (GEP-NETs) present liver metastases (NELM), which highly impact on prognosis. Treatment options for NELM mainly depend on the liver disease burden. In this review we propose a treatment algorithm for NELM with disease extension within the interest of liver resection (LR) and liver transplantation (LT). Preliminary resection of the primary and all the extrahepatic disease eases the access to liver-directed treatments and possibly confers a prognostic advantage. Solitary and oligometastatic disease deemed resectable with a conventional surgical commitment should be treated by LR. Despite the prognostic advantage of LR as compared to non-surgical options (80% 5-year overall survival [OS]) and the potential for cure, LR is burdened by high rates of recurrence (40% 5-year recurrence-free survival [RFS]). Neoadjuvant strategies by systemic and locoregional therapies may improve patient selection, especially in cases of borderline resectable NELM. In such patients, the oncological advantage of LR should be weighed against the high surgical risks and has to be preceded by a risk-benefit assessment. In young patients (<55 years) with G1/G2 unresectable NELM limited to <50% of the liver and no extrahepatic disease (Milan-NET criteria), LT may be considered. Patient selection is instrumental for good long-term outcomes (89% 10-year OS). The survival benefit increases over time with respect to non-transplant options. For patients exceeding the Milan-NET criteria, locoregional treatments can downstage the disease and occasionally allow LT. In G3 NETs and in cases not responding to liver-directed treatments, a systemic approach is usually warranted; debulking surgery can be considered in syndromic patients
Postoperative morbidity and mortality after pancreatoduodenectomy with pancreatic duct occlusion compared to pancreatic anastomosis: a systematic review and meta-analysis
No full textBackground: Pancreatoduodenectomy is burdened by elevated postoperative morbidity. Pancreatic duct ligation or occlusion have been experimented as an alternative to reduce the insurgence of postoperative pancreatic fistula. The aim of this systematic review and meta-analysis was to compare postoperative mortality and morbidity (pancreatic fistula, postoperative hemorrhage, delayed gastric emptying, pancreatic exocrine insufficiency and diabetes mellitus) between patients undergoing pancreatic anastomosis or pancreatic duct ligation/occlusion after pancreatoduodenectomy. Methods: A systematic review and meta-analysis of 13 studies was conducted following the PRISMA guidelines and the Cochrane protocol (PROSPERO ID: CRD42021249232). Results: No difference in postoperative mortality was highlighted. Pancreatic anastomosis was found to be protective considering all-grades pancreatic fistula (RR: 2.38, p = 0.0005), but pancreatic duct occlusion presented a 3-folded reduced risk to develop "grade C" pancreatic fistula (RR: 0.36, p = 0.1186), although not significant. Diabetes mellitus was more often diagnosed after duct occlusion (RR: 1.61, p < 0.0001); no difference was found in terms of pancreatic exocrine insufficiency (RR: 1.19, p = 0.151). Conclusion: Postoperative mortality is not influenced by the pancreatic reconstruction technique. Pancreatic anastomosis is associated with a reduction in all-grades pancreatic fistula. More high-quality studies are needed to clarify if duct sealing could reduce the prevalence of "grade C" fistula
Should a History of Extraperitoneal Disease Be a Contraindication to Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Colorectal Cancer Peritoneal Metastases?
No full textBACKGROUND: Survival improvements have been reported in selected patients affected by colorectal peritoneal metastases who were undergoing cytoreductive surgery with intraperitoneal hyperthermic chemotherapy. Treatment of peritoneal metastases associated with extraperitoneal disease is still controversial.
OBJECTIVE: We assessed the prognostic impact of a history of extraperitoneal disease that was curatively treated either at the same time as or before the onset of peritoneal metastases.
DESIGN: We reviewed 2 prospective databases. Peritoneal involvement was scored by Peritoneal Cancer Index.
SETTINGS: Our study was conducted in 2 high-volume peritoneal malignancy management institutions.
PATIENTS: A total of 148 patients with peritoneal metastases were included. In 27 patients, extraperitoneal disease involving the liver (n = 23), lung (n = 1), both lung and liver (n = 2), or inguinal lymph nodes and liver (n = 1) was curatively treated either simultaneously with peritoneal metastases (n = 22) or before their onset (n = 5).
INTERVENTIONS: All of the macroscopic tumors were removed by means of peritonectomy procedures and visceral resections. Microscopic residual disease was treated by mitomycin C/cisplatin-based hyperthermic intraperitoneal chemotherapy.
MAIN OUTCOME MEASURES: Overall survival was the primary outcome measure.
RESULTS: After a median follow-up of 34.6 months (95% CI, 22.6-65.7 mo), 5-year survival of patients treated for both peritoneal and extraperitoneal disease versus peritoneal metastases alone was 16.5% versus 52.0% (p = 0.019). After multivariate analysis, reduced survival correlated with extraperitoneal disease (p = 0.001), Peritoneal Cancer Index >19 (p = 0.004), and peritoneal residual disease >2.5mm (p = 0.018). Three prognostic groups were defined, and median survival was not reached for group 1 (Peritoneal Cancer Index 19 and no extraperitoneal disease), reached in 27.0 months for group 2 (Peritoneal Cancer Index 9 and extraperitoneal disease), and reached in 11.6 months for group 3 (Peritoneal Cancer Index >19 and no extraperitoneal disease or Peritoneal Cancer Index >9 and extraperitoneal disease).
LIMITATIONS: The main study limitation is its observational nature.
CONCLUSIONS: A history of extraperitoneal disease is associated with poorer prognosis. However, survival benefit may be obtained in selected patients with limited peritoneal involvement. See Video Abstract at http://links.lww.com/DCR/A655
Angiotensin Receptor 1 Blockers Prolong Time to Recurrence after Radiofrequency Ablation in Hepatocellular Carcinoma patients: A Retrospective Study
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