1,721,349 research outputs found
Reply to "hepatic venous pressure gradient for preoperative assessment of patients with resectable hepatocellular carcinoma: A comment for moving forward"
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Comment on: 'Long-term impact of liver function on curative therapy for hepatocellular carcinoma: Application of the ALBI grade'
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Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for cholangiocarcinoma
No full textTo increase resectability in patients affected by cholangiocarcinoma undergoing major hepatic resection, two methods of portal vein occlusion can be applied: radiological portal vein embolization (PVE) or surgical portal vein ligation (PVL). The rationale behind these approaches is to induce atrophy of the tumor-bearing lobe with subsequent hypertrophy in the contralateral lobe by diverting the portal venous flow into the liver section that is expected to remain. One limiting factor for performing major liver resection is the remaining liver volume (FLR): in the case of normal hepatic function, an FLR of approximately 25% is considered to be sufficient to maintain liver function after resection. A novel concept has recently been described, consisting of 2-staged extended hepatectomy with initial surgical exploration, PVL, and in situ liver splitting (ALPPS) to induce rapid hypertrophy, over a short period of time, of the future liver remnant (FLR) in patients with marginally resectable cholangiocarcinoma. The first step of this novel surgical approach consists of an in situ split liver procedure, with PVL and transection followed by definitive resection 9 days later. In general, it takes 2-6 weeks to achieve sufficient growth of the FLR for curative liver resection after PVE alone. A more rapid increase in FLR volume occurred after ALPPS; this decreased the time to surgery to a mean of 9 days, compared with 21-30 days after PVE. In addition, ALPPS induced an increase in the FLR also after failed PVE, rendering these patients resectable. Moreover, ALPPS involved complete separation of the FLR from the liver lobes to be resected. The accelerated hypertrophy effect observed with ALPPS, as compared to PVL and PVE alone, even with inclusion of segment IV, should be attributed to the "in situ" split procedure. This procedure leads to a complete devascularization of segment IV and also prevents formation of vascular collaterals between the left lateral and the right extended liver lobe. The combination of PVL and the in situ split procedure obviously induces a much stronger stimulus leading to rapid hypertrophy of the FLR
Portal vein embolization and cholangiocarcinoma
No full textPreoperative portal vein embolization (PVE) is increasingly used to optimize the volume and function of the future liver remnant (FLR) and to reduce the risk for complications after major hepatectomy for cholangiocarcinoma. In patients with hilarcholangiocarcinoma who are candidates for extended hepatectomy, careful preoperative preparation using biliary drainage, FLRvolumetry, and PVE optimizes the volume and function of the FLR prior to surgery. Appropriate use of PVE has led to improved postoperative outcomes after major hepatectomy for cholangiocarcinoma and oncological outcomes similar to those in patients who undergo resection without PVE. FLRvolumetry is necessary for proper selection of patients for PVE. Analysis of the degree of hypertrophy of the FLR after PVE complements analysis of the pre-PVEFLR volume. FLR degree of hypertrophy and FLR volume are the best predictors of early outcome after major hepatectomy for cholangiocarcinom
Comments to âLong-Term Survival Benefit and Potential for Cure After R1 Resection for Colorectal Liver Metastasesâ
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Retransplantation (causes, outcome)
No full textOrthotopic liver transplantation (OLT) has been established as the definitive therapy
for all types of end-stage liver failure. In spite of the steady improvement in survival
of OLT recipients over the past two decades, a proportion of those patients experience
graft failure and require retransplantation (re-OLT). Over the last 10 years, the
reported waitlist admission for re-OLT varied between 5.5 and 14 % [1–3].
Re-OLT indications can be divided into “early” and “late” causes.
Causes of early graft failure are:
• Primary non-function (PNF)
• Vascular complications (hepatic artery thrombosis, portal thrombosis, hepatic
vein thrombosis)
• Acute rejection
Causes of late graft failure include:
• Recurrence of liver disease (viral infection, autoimmune diseases)
• Chronic rejectio
Prognostic factors for hepatocellular carcinoma recurrence
No full textThe recurrence of hepatocellular carcinoma, the sixth most common neoplasm and the third leading cause of cancer-related mortality worldwide, represents an important clinical problem, since it may occur after both surgical and medical treatment. The recurrence rate involves 2 phases: an early phase and a late phase. The early phase usually occurs within 2 years after resection; it is mainly related to local invasion and intrahepatic metastases and, therefore, to the intrinsic biology of the tumor. On the other hand, the late phase occurs more than 2 years after surgery and is mainly related to de novo tumor formation as a consequence of the carcinogenic cirrhotic environment. Since recent studies have reported that early and late recurrences may have different risk factors, it is clinically important to recognize these factors in the individual patient as soon as possible. The aim of this review was, therefore, to identify predicting factors for the recurrence of hepatocellular carcinoma, by means of invasive and non-invasive methods, according to the different therapeutic strategies available. In particular the role of emerging techniques (e.g., transient elastography) and biological features of hepatocellular carcinoma in predicting recurrence have been discussed. In particular, invasive methods were differentiated from non-invasive ones for research purposes, taking into consideration the emerging role of the genetic signature of hepatocellular carcinoma in order to better allocate treatment strategies and surveillance follow-up in patients with this type of tumor
Orthotopic liver transplantation
No full textThe original technique of orthotopic liver transplantation (LT) envisages the removal of the native liver together with the infrahepatic inferior vena cava (IVC), while a subsequent evolution of this procedure includes the preservation of the IVC. In this latter case, the outflow reconstruction is achieved with an anastomosis of the donor IVC to the stump of the three major hepatic veins or to the IVC of the recipient. The two techniques had undergone a few modifications since their initial proposal. Although it is generally recognized that the preservation of the IVC carries some advantages in terms of shorter operation time, avoidance of venovenous bypass, and better hemodynamic stability and renal function, at present there is no definite agreement on which technique actually leads to better results. The sequence of vascular anastomosis is the same with the two techniques, that is, caval, portal, and arterial anastomoses, in an end-to-end fashion and with the general concept of avoiding an excessive length. Biliary reconstruction is the last step of the operation, and it is performed between the donor and recipient bile ducts or with a bilioenteric anastomosis
The Health Gain Obtainable from Pancreatic Resection for Adenocarcinoma in the Elderly.
No full textBACKGROUND:
In treating pancreatic ductal adenocarcinoma (PDAC), age does not represent a contraindication to surgery, even if aging is known to increase postoperative mortality and morbidity. Furthermore, long-term outcome remains poor and there is much debate on whether to operate or not in elderly patients. The aim of this study was to provide a general framework to evaluate the health gain obtainable from surgery for PDAC in relationship with age and tumor stage.
METHODS:
A Monte Carlo simulation model was built taking into consideration pertinent literature from population-based studies regarding surgical and non-surgical outcomes for stages I-II PDAC. The health gain obtainable from surgery, in comparison to the choice of not resecting patients, was measured through number needed-to-treat (NNT) calculation.
RESULTS:
Considering the typical stage I-II PDAC characteristics, the model showed that the mean lifespan after surgery was 28.1 ± 3.9 months and 9.3 ± 1.5 months after non-surgical therapies. The NNT with surgery in order to prevent one death at 5 years was 6 (95% CI 4-10), indicating an overall high gain obtainable from surgery. Sensitivity analyses on patient age and tumor stage suggested that starting from 76 years onward, the NNT progressively increases, resulting in a low cure rate of surgery in the elderly and becoming potentially harmful for patients aged above 80 years. These figures were more pronounced for tumor stages IIA and IIB.
CONCLUSIONS:
The present general framework suggests that the lifespan benefit obtainable from pancreatectomy in elderly patients is uncertain especially with the advancing of the tumor stage
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