[Show abstract][Hide abstract]ABSTRACT: Introductions:
Different staging systems have been devised for patients undergoing resection for hepatocellular carcinoma (HCC) with disparate results. The aim of this study was to create a new nomogram to predict individual survival after hepatectomy for HCC.
Based on the "Hepatocellular Carcinoma: Eastern & Western Experiences Network," data from 2046 patients who underwent HCC resections at ten centers were reviewed. Patient survival was analyzed with Cox-regression analysis to construct a unique nomogram and contour plots to predict survival.
The nomograms built on the multivariate analyses, which showed that the independent predictors were tumor size, tumor number, vascular invasion, cirrhosis, preoperative bilirubin value, and esophageal varices, showed good calibration and discriminatory abilities with C-index value of 0.62 (95 % CI, 0.59-0.69) and 0.61 (95 % CI, 0.56-0.64) for overall and disease-free survival, respectively. The 5-year survival contour plots showed that the presence of vascular invasion was associated with decreased survival, regardless of the tumor number or size. Cirrhosis and varices were equally associated with decreased survival, according to the tumor number or size.
These nomograms accurately predict individual prognosis after HCC resection and support an expansion of the selection criteria for resection. They offer useful guidance to clinicians for individual survival prediction.
Preview · Article · Mar 2016 · Journal of Gastrointestinal Surgery
[Show abstract][Hide abstract]ABSTRACT: Primary intrahepatic lithiasis is defined by the presence of gallstones at the level of cystic dilatations of the intrahepatic biliary tree. Liver resection is considered the treatment of choice, with the purpose of removing stones and atrophic parenchyma, also reducing the risk of cholangiocarcinoma. However, in consequence of the considerable incidence of infectious complications, postoperative morbidity remains high. The current study was designed to evaluate the impact of preoperative bacterial colonization of the bile ducts on postoperative outcome.
The clinical records of 73 patients treated with liver resection were reviewed and clinical data, operative procedures, results of bile cultures, and postoperative outcomes were examined.
Left hepatectomy (38 patients) and left lateral sectionectomy (19 patients) were the most frequently performed procedures. Overall morbidity was 38.3 %. A total of 133 microorganisms were isolated from bile. Multivariate analysis identified previous endoscopic or percutaneous cholangiography (p = 0.043) and preoperative cholangitis (p = 0.003) as the only two independent risk factors for postoperative infectious complications.
Postoperative morbidity was strictly related to the preoperative biliary infection. An effective control of infections should be always pursued before liver resection for intrahepatic stones and an aggressive treatment of early signs of sepsis should be strongly emphasized.
No preview · Article · Sep 2015 · World Journal of Surgery
[Show abstract][Hide abstract]ABSTRACT: Bile duct dilatations (BDD) are rare congenital anomalies of the biliary tree characterized by cystic dilatation of the common bile duct (CBD) and/or intrahepatic bile ducts. Despite the etiology is not fully understood, the presence of an anomalous biliopancreatic junction (ABPJ) is the most widely accepted etiopathogenic hypothesis. BDD are associated with cholangitis, biliary lithiasis, and risk of cholangiocarcinoma. Cholangiography in magnetic resonance is to date the most accurate preoperative imaging technique to classify the disease according to the Todani classification. Complete cyst excision with cholecystectomy followed by Roux-en-Y hepaticojejunostomy represents the gold standard treatment for the CBD component of the disease (type I and IV BDD). A cysto-enteric anastomosis is currently thought to be a dangerous and incomplete treatment. The treatment of intrahepatic bile duct dilatations remains controversial (type IVA and V BDD). A liver resection should be considered for patients in whom the impaired intrahepatic bile ducts can be completely resected after a careful evaluation of presence and severity of underlying chronic liver and kidney disease. Liver transplantation is recommended in patients with diffuse bilobar forms of the disease complicated by repeated sepsis or to patients with cirrhosis or portal hypertension. For type II BDD a limited cyst excision is recommended; CBD resection is not routinely indicated. For type III BDD the transduodenal excision is currently replaced by conservative endoscopic sphincterotomy. The risk of development of cholangiocarcinoma that can occur even after complete cyst excision justifies a careful long-term follow-up.
[Show abstract][Hide abstract]ABSTRACT: Primary hepatolithiasis (PHL) is endemic in East Asia and is much less common in Western countries, where, however, it is becoming increasingly recognized. Although the etiology remains not fully understood, in Western countries PHL is strictly related to congenital bile duct strictures and dilatations. Biliary pain represents the most frequent initial symptom but cholangitis is common in patients with a long history of previous surgical or nonsurgical treatments. PHL is more frequently located in the left hemiliver, but right bile ducts and bilateral location are not unfrequent. Complications of PHL include recurrent cholangitis, liver abscesses, pyogenic sepsis, parenchymal atrophy, persistent liver dysfunction resulting in secondary biliary cirrhosis, and cholangiocarcinoma. In PHL limited to one hemiliver (sector or segment), liver resection represents the only treatment which can allow to remove intrahepatic stones together with affected bile ducts and significantly reduces the risk of cholangiocarcinoma. 2-10 % of patients with hepatolithiasis develop an intrahepatic cholangiocarcinoma, which is usually difficult to diagnose preoperatively in these patients. Morbidity after liver resection is frequently characterized by septic complications, mainly in patients with preoperative recurrent cholangitis and previous endoscopic or percutaneous treatments. Percutaneous and endoscopic procedures for treatment of PHL are widely reported in the literature with good results, but high stone recurrence rates, frequent recurrent cholangitis, and the risk of cholangiocarcinoma should be carefully evaluated.
[Show abstract][Hide abstract]ABSTRACT: Diagnosis of benign liver tumors is experiencing exponential growth, mainly owing to the diffusion of more accurate imaging techniques. This monograph examines the epidemiology, histopathology and genetics of these tumors and provides a systematic overview of their evolution and differential diagnosis. Care is taken to document surgical indications accurately, with a view to assisting in the avoidance of useless interventions. Open, laparoscopic and robotic surgical techniques are described and illustrated, emphasizing the optimization of intra- and postoperative management in order to avoid potential complications and degeneration. In these chapters, attention is drawn to the ways in which the surgical management of benign liver tumors differs from that of malignant tumors. The book concludes by examining the role of interventional radiology in patients with benign liver tumors.
[Show abstract][Hide abstract]ABSTRACT: Introduction:
The Y-box binding protein-1 (YB-1) is a multifunctional oncoprotein involved in the proliferation and aggressiveness of cancer cells. The aim of this study was to determine whether strong YB-1 expression in neoplastic cells of colorectal liver metastases (CRLM) may have an impact on liver disease-free survival following liver resection.
Materials and methods:
Immunohistochemistry was performed to evaluate YB-1 in 66 patients who underwent liver resection for CRLM. YB-1 expression was classified as weak (low-staining intensity) and strong (high-staining intensity).
YB-1 expression was observed in the cytoplasm of all CRLM. YB-1 expression was weak in 17 patients (25.8%) and strong in 49 patients (74.2%). Liver recurrence rate was significantly higher in the strong than in the weak expression group: 55.1 vs. 23.5% (p = 0.023). Multivariable logistic regression analysis showed that YB-1 strong expression was the only independent risk factor for liver recurrence. The 5-year specific liver disease-free survival rate was 76.0% in the weak expression group and 41.5% in the strong expression group (p = 0.034). These results were not influenced by clinical prognostic factors of tumor recurrence.
This is the first study showing that the degree of YB-1 expression in tissue specimens of CRLM predicts liver recurrence following liver resection.
No preview · Article · Sep 2014 · Journal of Gastrointestinal Surgery
[Show abstract][Hide abstract]ABSTRACT: Background:
We aimed to evaluate the feasibility and long-term results of 2-stage hepatectomy (TSH) in patients with bilobar colorectal liver metastases (CRLM).
We performed a retrospective multicenter study including 4 Italian hepatobiliary surgery units. One hundred thirty patients were selected for TSH between 2002 and 2011. The primary endpoint was feasibility of TSH and analysis of factors associated with failure to complete the procedure. The secondary endpoint was the long-term survival analysis.
Patients presented with synchronous CRLM in 80.8% of cases, with a mean number of 8.3 CRLM and with concomitant extrahepatic disease in 20.0% of cases. The rate of failure to complete TSH was 21.5% and tumor progression was the most frequent reason for failure (18.5% of cases). Primary tumor characteristics, type, number, and distribution of CRLM were not associated with significantly different risks of disease progression. Multivariable logistic regression analysis showed that tumor progression during prehepatectomy chemotherapy was the only independent risk factor for failure to complete TSH. The 5- and 10-year overall survival rates for patients who completed TSH were 32.1% and 24.1%, respectively, with a median survival of 43 months. Duration of prehepatectomy chemotherapy ≥6 cycles was found to be the only independent predictor of overall and disease-free survival.
This study showed that selection of patients by response to prehepatectomy chemotherapy may be extremely important before planning TSH because tumor progression while receiving prehepatectomy chemotherapy was associated with significantly higher risk of failure to complete the second stage. For patients who completed the TSH strategy, long-term outcomes can be achieved with results similar to those observed after single-stage hepatectomy.
No preview · Article · Aug 2014 · Journal of the American College of Surgeons
[Show abstract][Hide abstract]ABSTRACT: IntroductionAs mortality and morbidity after a curative resection remains high, it is essential to identify pre-operative factors associated with an early death after a major resection.Methods
Between 1998 and 2008, we selected a population of 331 patients having undergone a major hepatectomy including segment I with a lymphadenectomy and a common bile duct resection for a proven hilar cholangiocarcinoma in 21 tertiary centres. The study's objective was to identify pre-operative predictors of early death (<12 months) after a resection.ResultsThe study cohort consisted of 221 men and 110 women, with a median age of 61 years (range: 24–85). The post-operative mortality and morbidity rates were 8.2% and 61%, respectively. The 1-, 3- and 5-year overall survival rates were 85%, 64% and 53%, respectively. The median tumour size was 23 mm on pathology, ranging from 8 to 40. A tumour size >30 mm [odds ratio (OR) 2.471 (95% confidence interval (CI) 1.136–7.339), P = 0.001] and major post-operative complication [OR 3.369 (95% CI 1.038–10.938), P = 0.004] were independently associated with death <12 months in a multivariate analysis.Conclusion
The present analysis of a series of 331 patients with hilar cholangiocarcinoma showed that tumour size >30 mm was independently associated with death <12 months.
[Show abstract][Hide abstract]ABSTRACT: Objective: The purpose of the study was to analyze clinical presentation, surgical management, and long-term outcome of patients suffering from biliary diverticulum, namely Todani type II congenital bile duct cyst (BDC). Background: The disease incidence ranges between 0.8% and 5% of all reported BDC cases with a lack of information about clinical presentation, management, and outcome. Methods: A multicenter European retrospective study was conducted by the French Surgical Association. The patients' medical records were included in a Web site database. Diagnostic imaging studies, operative and pathology reports underwent central revision. Results: Among 350 patients with congenital BDC, 19 type II were identified (5.4%), 17 in adults (89.5%) and 2 in children. The biliary diverticulum was located at the upper, middle, and lower part of the extrahepatic biliary tree in 11, 4, and 4 patients (58%, 21%, and 21%, respectively). Complicated presentation occurred in 6 patients (31.6%), including one case of synchronous carcinoma. Surgical techniques included diverticulum excision in all patients. Associated resection of the extrahepatic biliary tree was required in 11 cases (58%) and could be predicted by the presence of complicated clinical presentation. There was no mortality. Long-term outcome was excellent in 89.5% of patients (median follow-uptime: 52 months). Conclusions: According to the present largest Western series of Todani type II BDC, the type of clinical presentation rather than BDC location, was able to guide the extent of biliary resection. Excellent long-term outcome can be achieved in expert centers.
No preview · Article · Jun 2014 · Annals of Surgery
[Show abstract][Hide abstract]ABSTRACT: The aims of the present research are to investigate the possible predictors of pancreatic cancer, in particular smoking status, alcohol consumption, hypercholesterolemia, and diabetes mellitus, in patients with histologically confirmed pancreatic carcinoma and to examine the synergism between risk factors. A case-control study (80 patients and 392 controls) was conducted at the Teaching Hospital "Agostino Gemelli" in Rome. A conditional logistic regression was used for the statistical analysis and results were presented as odds ratio (OR) and 95% confidence intervals (95% CI). We also investigated the possible interactions between risk factors and calculated the synergism index (SI). The multivariate analysis revealed that hypercholesterolemia and alcohol consumption resulted in important risk factors for pancreatic cancer even after the adjustment for all variables (OR: 5.05, 95% CI: 2.94-8.66; OR: 2.25, 95% CI: 1.30-3.89, resp.). Interestingly, important synergistic interactions between risk factors were found, especially between ever smoking status and alcohol consumptions (SI = 17.61) as well as alcohol consumption and diabetes (SI = 17.77). In conclusion, the study confirms that hypercholesterolemia and alcohol consumption represent significant and independent risk factors for pancreatic cancer. Moreover, there is evidence of synergistic interaction between diabetes and lifestyle factors (drinking alcohol and eating fatty foods).
Full-text · Article · Apr 2014 · BioMed Research International
[Show abstract][Hide abstract]ABSTRACT: After hepatectomy, bile leaks remain a major cause of morbidity, cost, and disability. This study was designed to determine if a novel intraoperative air leak test (ALT) would reduce the incidence of post-hepatectomy biliary complications.
Rates of postoperative biliary complications were compared among 103 patients who underwent ALT and 120 matched patients operated on before ALT was used. All study patients underwent major hepatectomy without bile duct resection at 3 high-volume hepatobiliary centers between 2008 and 2012. The ALT was performed by placement of a transcystic cholangiogram catheter to inject air into the biliary tree, the upper abdomen was filled with saline, and the distal common bile duct was manually occluded. Uncontrolled bile ducts were identified by localization of air bubbles at the transection surface and were directly repaired.
The 2 groups were similar in diagnosis, chemotherapy use, tumor number and size, resection extent, surgery duration, and blood loss (all, p > 0.05). Single or multiple uncontrolled bile ducts were intraoperatively detected and repaired in 62.1% of ALT vs 8.3% of non-ALT patients (p < 0.001). This resulted in a lower rate of postoperative bile leaks in ALT (1.9%) vs non-ALT patients (10.8%; p = 0.008). Independent risk factors for postoperative bile leaks included extended hepatectomy (p = 0.031), caudate resection (p = 0.02), and not performing ALT (p = 0.002) (odds ratio = 3.8; 95% CI, 1.3-11.8; odds ratio = 4.0; 95% CI, 1.1-14.3; and odds ratio = 11.8; 95% CI, 2.4-58.8, respectively).
The ALT is an easily reproducible test that is highly effective for intraoperative detection and repair of open bile ducts, reducing the rate of postoperative bile leaks.
No preview · Article · Dec 2013 · Journal of the American College of Surgeons