Pathologic response to non-surgical locoregional therapies as potential selection criteria for liver transplantation for hepatocellular carcinoma.

BACKGROUND: Preoperative locoregional treatments (PLT) are performed to avoid progression before liver transplantation for hepatocellular carcinoma (HCC). The objective of this study was to analyze the prognostic factors affecting the outcome in patients who received PLT. MATERIAL AND METHODS: A retrospective analysis of patients who underwent liver transplantation (LT) was performed. All patients who underwent PLT with confirmed pathological diagnosis of HCC were included. The rate of tumor necrosis (TN) was assessed by microscopic histological examination. RESULTS: From January 1997 to December 2010, PLT was performed in 154 patients ROC analysis individuated a TN cut-off value at 40%. Ninety-one patients (59.1%) of the patients presented TN>40%. At multivariate analysis, TN<40% (HR=1.76; p=0.04) and vascular invasion (VI) (HR=2.16; p<0.01) were associated with lower Overall Survival (OS). At multivariate analysis, TN<40% (HR=1.59; p=0.001) and VI (HR=2.51; p=0.001) were significant associated with lower Disease Free Survival (DFS). One, 3 and 5 years OS was 87.9%, 82.0% and 69.1% for patients with TN>40% and 82.5%, 64.2% and 53.2% for those with TN<40% (p=0.02). Tumour size <5 cm (p=0.02); age <55 years (p=0.02); absence of VI (p=0.02) and multiple procedures (p=0.04) were predictive factors for TN>40%. CONCLUSIONS: Response to preoperative locoregional treatment can be used as potential selection criteria for LT.

Biliary strictures after liver transplantation: is percutaneous treatment indicated?

BACKGROUND: Biliary complications are common after orthotopic liver transplantation. Our study's aim is to evaluate the efficacy of percutaneous treatment of biliary strictures after orthotopic liver transplantation (OLT). MATERIAL/METHODS: Sixty-five patients with biliary anastomotic strictures received percutaneous transhepatic balloon cholangioplasty (PTBC). Three dilatations were performed with a 2- to 4-week period between the procedures. Primary and secondary patency were evaluated, with a follow-up between 6 months and 6 years. RESULTS: PTBC successfully treated strictures in 52.3% (34/65) of cases. The normalization of clinical and biological features was noted at 2.3 months on average. Neither intercurrent episodes of sepsis nor a worsening of liver function were noted during the treatment; a significant complication was recorded in 8 patients. No patient needed surgery for the treatment of complications after PTBC. Factors related to a successful PTBC included older age at transplantation and single-site stricture. There were 7 recurrent strictures after PTBC, all successfully treated by nonsurgical procedures. The number of dilatations performed affected both the likelihood of success and the long-term risk of stricture recurrence. Of the 31 PTBC failures, 19 underwent subsequent surgical revision, 8 were treated endoscopically, and 4 were re-transplanted. Multifocal stenoses, central hepatic duct involvement, and intrahepatic localization resulted associated with treatment failure. CONCLUSIONS: PTBC should be considered as a first choice option for treatment of biliary strictures after liver transplantation as well as endoscopic treatment. For solitary extrahepatic strictures that fail PTBC and ERCP, surgical revision provides good results.

Intraductal papillary mucinous neoplasm of the pancreas (IPMN): clinico-pathological correlations and surgical indications.

BACKGROUND: Intraductal papillary mucinous neoplasms (IPMNs) are increasingly recognized entities, whose management remains sometimes controversial, due to the high rate of benign lesions and on the other side to the good survival after resection of malignant ones. METHODS: Retrospective analysis of a prospectively collected Western series of IPMN. RESULTS: Forty cases of IPMN were analysed (1992-2007). Most patients were symptomatic (72.5%); cholangio-MRI had the best diagnostic accuracy both for the tumour nature (83.3%) and for the presence of malignancy (57.1%). ERCP was done in 8 cases (20%), and the results were poor. Thirteen patients were treated by pancreatic resection and 27 were maintained in follow-up. Total pancreatectomy was performed in 46% of the cases; in situ and invasive carcinoma were recognized in 15.4% and 38.4% of the cases, respectively. The mean follow-up was 42 months (range 12-72). One only patients with nodal metastases died 16 months after the operation for disease progression, while 91.6% of the operated patients are disease free. Out of the 27 not resected patients, 2 out of 4 presenting a lesion at high risk for malignancy died, while the remaining are in good conditions and disease free, with a mean follow-up of 31 months. CONCLUSION: Therapeutic indication for IPMNs is mainly based upon radiological evaluation of the risk of malignancy. While the main duct tumours should be resected, preserving whenever possible a portion of the gland, the secondary ducts tumours may be maintained under observation, in absence of radiological elements of suspicion such as size larger than 3 cm, or a wall greater than 3 mm or nodules or papillae in the context of the cyst.

Pancreatic transection from blunt trauma associated with vascular and biliary lesions: a case report.

Major injuries of the pancreas may result in considerable morbidity and mortality when associated with vascular and visceral injuries. In such cases, a right diagnosis and a prompt surgical intervention are necessary to give a chance to the patient. We herein describe a case of blunt abdominal trauma in a 29-year-old man whose pancreatic rupture was associated with hepatic artery, splenic vein and extrahepatic bile duct damage. Immediate surgery was performed after computer tomograghy (CT), the haemorrhagic lesions dictat the emergency transfer to the operating room. Spleno-pancreatic resection was done with reconstruction of the hepatic artery, ligation of the splenic vein and a Roux-en-Y bilio-jejunal diversion. The early post-operative course was complicated by stenosis of the arterial reconstruction, which was treated by endovascular angioplasty followed by percutaneous drainage of symptomatic pseudocyst, rest and antibiotics. Finally, the patient was discharged and was alive without clinical problems at the time when we wrote this case report. The present case underlines the clinical relevance of vascular and visceral injuries associated with pancreatic trauma and the problems arising in the diagnostic evaluation and the surgical strategy of complex multiple visceral and vascular lesions in blunt abdominal trauma.