Microwave assisted liver resection: clinical feasibility study and preliminary results.

AIM: The main goal of liver resection for malignant tumors is nowadays represented by properly parenchymal transection and careful control of hemostasis. Applying the concept of precoagulation of liver transection line we developed a new technique that provides the pre coagulation of the resection line using microwaves technologies. The purpose of this study is to evaluate the feasibility of this new liver transection technique demonstrating the high performance of this procedure, the accuracy in terms of squeeze effect on veins and portal branch and in terms of reducing the intra operative blood loss. METHODS: From December 2010 to January 2012 a total of ten patients (6 men and 4 women) affected by liver metastatic disease from colon rectal cancer and primitive liver cancer were treated (five patients with metastatic colorectal cancer disease and five patient with hepatocellular carcinoma respectively): patients requiring major liver resection were excluded from the present study focusing attention on minor liver resection. RESULTS: The technique used for the parenchyma transection is similar to those previously described by our group for hepatic radiofrequency assisted liver resection. There was no need for vascular occlusive clamping while during each surgical procedure the underpass of the hepatic hilum was done for safety control of any kind of hepatic bleeding. There was no need for ties and clips excluding the main vascular an bile pedicles that were sutured between ties. CONCLUSION: In conclusion this study with a small group of patients suggest surgical advantages in terms of statement for best practice in oncologic resection of liver malignancy. It allows a complete resection obtaining a negative pathologic margin, no blood loss and need for blood transfusions factors predicting post operative morbidity and survival, and consistently reducing time of procedure and avoidance of parenchymal ischemia. Further studies should confirm this preliminary data extending surgical indication to major hepatic resection.

[Atypical presentation of angiomiolypoma in a patient with peritoneal metastases from ovarian cancer: a case report]. / Presentazione atipica di un angiomiolipoma renale in paziente affetta da metastasi peritoneali da adenocarcinoma papillifero ovarico: considerazioni su un caso clinico.

A renal mass with not typical instrumental characteristic in patient in follow-up for ovarian neoplasia sets to the surgeon serious doubts about proper surgical strategy. Achieve of the conservative renal surgery assisted by the intraoperative use of the radiofrequency energy has allowed to preserve the renal function and the diagnosis of unknown angiomyolipoma.

Radiofrequency ablation of liver tumours with transpleurodiaphragmatic access.

Radiofrequency thermoablation (RFA) is used to treat unresectable liver tumours. RFA is performed using an abdominal access (laparotomic, laparoscopic and percutaneous). A transpleurodiaphragmatic approach has recently been proposed, particularly for the treatment of tumours which are placed near to inferior vein cava and hepatic veins and which are difficult to reach for an abdominal access. A patient with a liver metastasis of the segment VIII underwent RFA with an associated wedge resection of the segment VII, both were performed with a transthoracic access. Peri- and postoperative complications did not occurred. The patient was discharged on fifth postoperative day, and she is disease free after a follow up of 6 months. A transpleurodiaphragmatic access can be considered a safe and efficacy procedure to perform an RFA of a liver tumour in selected cases.

Radiofrequency thermal ablation of hepatocellular carcinoma: our five year experience.

PURPOSE: We describe our experience in the multimodal treatment of HCC patients both using the PRFTA and IRFTA treatment associated or not with hepatic resection, valuating the feasibility, the complication, length of hospital stay and survival rate of selected HCC patients. MATERIALS AND METHODS: Between March 1998 and January 2004, 53 HCC patients undergoing PRFTA and IRFTA treatment. We describe 41 patients with monofocal disease and 12 patients with multifocal disease: in this last group 7 patients had unilobar involvement while 5 patients had multilobar tumour. RESULTS: We reported patients underwent RFTA because not candidates to surgical procedures and patients underwent liver resection and open radiofrequency treatment associated. We successfully used percutaneous and intraoperative approach being the last one significantly advantageous in lesions greater than 5 cm, multiple bilobar tumours and tumours close to the hilum and major vessels: the laparotomic approach permitted the temporary occlusion of the vascular inflow allowing Pringle manoeuvre. DISCUSSION: Hepatocarcinoma still represent one of the major causes of cancer related death worldwide. Systemic therapeutic agents and locoregional agents are rarely correlated to complete response and usually associated to high toxicities: the potentially curative or palliative benefit of RFTA in non surgical candidates improve overall patients survival significally better then the chemotherapy regimens. CONCLUSION: RFTA appears to have several advantages, which also include a reducing in morbidity, a shortening of the hospital stay and good response to patients requirement in term of enduring pain.

Laparoscopic billroth II gastrectomy for completely stricturing duodenal ulcer: technical details.

BACKGROUND: The authors report a series of three patients who underwent laparoscopic gastrectomy for gastric outlet obstruction due to stricturing duodenal ulcer. MATERIALS AND METHODS: In all cases an intracorporeal resection of the antrum and an antecolic end to side gastrojejunostomy (Billroth II) were performed. Technical details are discussed in the paper. RESULTS: Mean operative time was 260 minutes, mean blood loss was 43 millilitres. There were no postoperative complications and all patients were discharged on the fifth postoperative day. A follow up of three years shows that no patient had recurrence and post-gastrectomy syndromes. CONCLUSIONS: Laparoscopic Billroth II gastrectomy is a safe and feasible procedure with benefits such as quick hospital stay, decreased postoperative pain, good cosmesis and reduced morbidity.

An atypical presentation of Crohn disease in the elderly. A case report and Literature review.

The Authors present a case of an insidious onset of Crohn Disease (CD) in an elderly patient. Diagnosis complicated by extraintestinal manifestation properly of old age could be delayed and often made after surgery on the histological specimen as in our case. CD is uncommon as primary manifestation in old age, often unsuspected, incorrectly diagnosed and in many case the clinical features may lead to late diagnosis. Differential diagnosis of CD in elder people with fever, diarrhoea and abdominal pain is difficult and other symptoms affecting intestinal tract can closely mimic CD symptoms, although the pattern of clinical presentation in older patient resemble those in younger.

Heat-shock protein 70 favours human liver recovery from ischaemia-reperfusion.

BACKGROUND: Pringle's manoeuvre controls excessive bleeding, but results in ischaemia-reperfusion injury during liver surgery. Activation of the heat-shock protein system of cell defense has been demonstrated after ischaemia-reperfusion injury in animal tissues. The aim of the present study was to determine whether the ischaemia-reperfusion accompanying hepatic surgery induces heat-shock protein 70 (HSP70) in human liver and whether the induction of HSP70 is related to the recovery of liver function. METHODS: Heat-shock protein 70 and gamma-actin mRNAs were assayed in the liver biopsies of 10 subjects undergoing partial hepatectomy for localized lesions. Measurements were performed before the Pringle's manoeuvre and at the end of the surgery. Transaminases and fibrinogen were measured before and at 12, 24 and 36 h following hepatectomy. RESULTS: After an average 40 +/- 8-min period of warm ischaemia, a significant increase of HSP70 mRNA (187 +/- 67%, 2P < 0.05) was observed. The acute increase of HSP70 mRNA correlates with the decrease of transaminases (AST: rs -0.964, ALT: rs -0.891, P < 0.002) and the increase of fibrinogen (rs -0.7, P < 0.02) observed between 12 and 24 h following surgery. CONCLUSIONS: Heat-shock protein 70 is induced by ischaemia-reperfusion injury in human liver. Its induction seems to have beneficial effects, including a prompt reduction of transaminases and a rapid recovery of fibrinogen synthesis.

[Intraoperative use of radiofrequency thermoablation of liver tumors: considerations on indications and related therapeutic aspects]. / L'impiego intraoperatorio della termoablazione a radiofrequenza di neoplasie epatiche: considerazioni su indicazioni ed aspetti terapeutici associati.

PURPOSE: To evaluate the usefulness of intraoperative radiofrequency thermoablation of liver tumours in association or not with hepatic resection. MATERIALS AND METHODS: 21 patients were treated between January 1998 and December 2001, there were 4 hepatocellular carcinoma and 17 metastasis. In 13 cases radiofrequency was associated to hepatectomy, in 3 cases to resection of extraepatic disease and in 5 cases were performed alone. 23 lesions were treated by radiofrequency (range 1-3); the mean dimension was 26 millimetres (range 8-70). A clamping of the liver pedicle was always done. RESULTS: There were no operative deaths, 3 (14.3%) patients developed complications related to radiofrequency (2 biliary leakages, 1 hepatic abscess). 14 (66.7%) patients were alive after a mean follow up of 14.5 months, 2 of all (9.5%) had a recurrence in the site previously treated with thermoablation. Association between hepatectomy and radiofrequency increased the number of curative liver resections from 10.1% to 16.3% (in case of colorectal metastasis). DISCUSSION: Intraoperative radiofrequency is useful to increase the number of curative hepatectomies, to treat liver masses which demonstrate unresectable or found by ultrasonography at the operating time and even to reach tumours difficult to manage by percutaneous approach. In any case the aim is to obtain the absence of macroscopic neoplastic disease (RO status). It is a safe and effective therapeutic strategy, anyway all procedures and indications are still not completely cleared. CONCLUSIONS: Intraoperative thermoablation of liver tumour is safe and effective and increases therapeutic the number of curative hepatectomies. Further progresses may improve the efficacy and extend the indications of this strategy.

Increased expression of peripheral benzodiazepine receptors and diazepam binding inhibitor in human tumors sited in the liver.

The peripheral benzodiazepine receptor system triggers intracellular metabolic events and has been associated with cell proliferation. Its endogenous ligand, the diazepam binding inhibitor, contributes to steroidogenesis by promoting cholesterol delivery to the inner mitochondrial membrane. The present study was undertaken to verify whether this system is altered in tumors sited in the liver. Peripheral benzodiazepine receptors and diazepam binding inhibitor were studied using immunocytochemistry and in situ hybridization in 9 human tumors sited in the liver, in liver hyperplasia, cirrhotic nodular regeneration, intestinal adenocarcinoma and in surrounding non-tumoral tissue. Immunocytochemical staining and in situ hybridization demonstrated that peripheral benzodiazepine receptors and diazepam binding inhibitor were more prominently expressed in neoplastic cells than in non-tumoral tissue. They were present in the same cells, suggesting that diazepam binding inhibitor may act in an intracrine manner in these cells. Higher peripheral benzodiazepine receptors and diazepam binding inhibitor expression in tumor cells suggest an implication of this system in the metabolism of neoplastic cells. Furthermore the evaluation of peripheral benzodiazepine receptor and diazepam binding inhibitor expression might be useful in evaluating malignancy and in diagnostic approaches of tumors in liver tissue.

Up-regulation of peripheral benzodiazepine receptor system in hepatocellular carcinoma.

Increased number of peripheral benzodiazepine receptors (PBRs) have been found in some tumors outside the liver. The present study was to verify whether the PBR system is altered in hepatocellular carcinoma (HCC). The levels of endogenous benzodiazepine-like compounds (BZDs), measured by radioreceptor binding technique after HPLC purification and the endogenous ligand for PBRs, termed diazepam binding inhibitor (DBI), measured by radioimmunoassay utilizing a specific antibody for human DBI, were studied in the blood of 15 normal subjects, 12 liver cirrhosis and 10 patients with HCC. The levels of BZDs in serum were increased hundred fold in liver cirrhosis patients and slightly elevated in HCC patients. DBI was found to be increased in HCC patients. The binding recognition sites for PBRs (Bmax) were increased 4 to 7 fold in HCC tissue in comparison with that found in non-tumoral liver tissue (NTLT). On the contrary the concentrations of DBI were found to be significantly decreased in HCC tissue in comparison with the respective NTLT. These results seem to suggest an implication of PBRs and of their putative endogenous ligands in the metabolism of these neoplastic cells and possibly in their proliferation. The up-regulation of PBRs found in HCC tissue seems to indicate an increased functional activity of these receptors and opens up the possibility of new pharmacological and diagnostic approaches while the changes in the circulating endogenous ligands for the above receptors might be envisaged as early markers of tumorigenesis in liver cirrhosis.

[The recurrence of hepatitic C in orthotopic liver transplantation]. / La recidiva di epatite C nel trapianto ortotopico di fegato (OLT).

BACKGROUND: This study is a review of hepatitis C recurrence in patients undergoing an orthotopic liver transplantation (OLT); to verify how many patients HCV-positive before OLT confirm a persistent viremia after OLT and how many with viremia show hepatitis histological evidence. METHODS: Thirty consecutive patients, 24 males, median age 52.5 underwent OLT for posthepatitic C cirrhosis since January 1993 in the "Transplantation Center" of Genoa. Serology included anti-HCV search, HCV-RNA and HBV-DNA determinations, biopses were performed in the transplanted liver within the month after operation, subsequently at every hepatic enzymes increase. RESULTS: Twenty-one patients are currently alive, median follow-up of 14.5 months. Before OLT anti-HCV antibodies search was positive in all the patients while the HCV-RNA by PCR resulted positive in 17 and negative in 4. Before OLT the HBV-DNA in patients with associated hepatitis B was negative. After OLT 5 patients, of the 17 HCV-RNA positive before OLT, have turned negative then all became again positive from 6 to 12 months later; 2 of the 4 patients HCV-RNA negative before OLT have turned positive, and remained still negative two with hepatitis C associated with hepatitis B. Although viral replication was present in 95% of the patients, clinical and histological evidence of recurrence was ascertained only in 29%. CONCLUSIONS: It should be noted that the hepatitis histological picture doesn't correspond to a severe worsening of clinical conditions, an evolution justifying transplantation. The long-term results of this therapeutic choice are still uncertain due to the high incidence of recurrences.

Differential device performances for hepatic arterial chemotherapy: a technical report on totally implantable pumps and ports for both continuous and bolus infusion.

Performances of totally implantable infusion systems were analyzed in patients with colorectal liver metastases undergoing intra-arterial treatment. It consisted of 14-day continuous infusion of 5-fluor-2'deoxyuridine with pumps (pump14, 44 patients) or ports fed by external pumps (port14, 34 patients), or bolus infusion of cisplatin (port21, 57 patients) or epirubicin (port7, 22 patients) every 3rd week and weekly, respectively. Toxicity and disease progression were the most common causes of treatment interruption. System failure occurred in 2 pump14, 9 port14, 6 port21 and 2 port7 cases. Pocket problems were most frequent in the pump14 group (30%), whereas catheter- and infusion-related problems were mostly observed in the port14 group (109%). The devices were still functional after 12 months in 92% of pump14, 24% of port14, 65% of port21 and in 78% of port7 patients. Although implantable ports allow adequate infusion periods, in most cases they appear especially suitable for bolus infusions.

Plasma somatostatin response to an oral test meal in liver transplant patients.

Ten liver transplant patients were studied in basal conditions and after ingestion of a standard mixed test meal. Control groups included 10 normal subjects, 10 patients with nonalcoholic liver cirrhosis, and seven kidney transplant patients. Plasma somatostatin, blood glucose, and plasma insulin, C-peptide, and glucagon were determined before and 15, 30, 45, 60, 90, 120, and 180 minutes after the start of the meal. In liver transplant patients, basal somatostatin and insulin levels were significantly lower than in cirrhotics and were comparable to those recorded in controls and in kidney transplant patients. The time course of the somatostatin secretory response after the meal was similar in any group, but the increase, evaluated as the incremental area above baseline, was significantly higher in liver transplant patients than in controls and cirrhotics and comparable to that recorded in kidney transplant patients. Insulin incremental areas were also lower than in cirrhotics and comparable to those recorded in controls and kidney transplant patients. The data suggest that in liver transplant patients an increased somatostatin response to a meal may be related to a relative beta-cell secretory defect, which in turn seems consequent to immunosuppressive treatment.

[Severe infections after orthotopic hepatic transplant]. / Infezioni gravi dopo trapianto epatico ortotopico.

METHODS: The authors analysed severe infections in 43 consecutive patients undergoing orthotopic liver transplant. Prophylaxis and full anti-infection monitoring was performed in all cases. Immunosuppressive therapy was administered in the form of primary cyclosporine in 27 cases and primary OKT3 in 16 cases. RESULTS: Twenty-seven patients are still alive (median 8 months, range 2-40) and 16 died (median 22 days, range 10-92) of whom 4 without and 12 with infection, including two deaths owing to non-correlated causes with infection after recovery. Twenty-three patients underwent 33 episodes of severe infection (plus four with inconclusive positive cultures) without any case of protozoal or viral infection. All episodes occurred within two months of surgery and affected the lung (10), abdomen (7), lung + abdomen (1), urinary tract (1), lung + urinary tract (1), as well as two diffused cases and 7 cases of isolated bacteremia deriving from the donor (1), venous catheters (3), mild otorhinolaryngeal infection (1) and two unknown sources (2). Eighteen infective agents were identified in 45 cases. The bacteria involved in single-agent episodes were: 11 Gram+, 9 Gram- and five fungi. Polymicrobic and bacterial/fungal episodes were repeatedly observed in two and two cases. Postoperative renal insufficiency significantly influenced both the incidence of and mortality due to infection. Overall mortality was also influenced by early graft function, postoperative complications and reoperations, and the incidence of infections by the portal clamping stage, reject and prolonged coma. CONCLUSIONS: The absence of severe viral infections and the gradual reduction of mortality caused by infection appear to be parallel to the aggressive antiviral prophylaxis, the gradual improvement of intra- and postoperative management and primary immunosuppression with OKT3.

[Performance and complications of totally implantable port device in bolus hepatic intra-arterial chemotherapy]. / Funzionalità e complicanze dei "port" totalmente impiantabili per la chemioterapia intraarteriosa epatica in bolo.

The performances of totally implantable ports were analyzed in patients with colorectal metastases undergoing intraarterial treatment. Seventy-nine patients received bolus infusion of Cisplatin (DDP, 57 cases) or Epirubicin (EPI, 22 cases) every 21 and 7 days, respectively. Disease progression or toxicity were the most common causes of interruption of treatment, whereas failure of ports occurred in six and two patients out of DDP and EPI groups, respectively. The incidence of single problems for each port was 65% in DDP group and 64% in EPI group, whereas rate of complications for each patient was 30% and 32%, respectively. The 12-months device duration rate in the two groups was 65% (median 17 months) in DDP group and 78% (median 18 months) in EPI group. The implantable ports employed for bolus arterial infusion, allowed adequate treatment periods in most cases, without any difference as far as intervals between cycles is concerned.

Palliative chemoembolization of hepatocellular carcinoma with mitoxantrone, Lipiodol, and Gelfoam. A phase II study.

Transcatheter chemoembolization, in conjunction with various drugs, has been widely used for palliative treatment of hepatocellular carcinoma. A phase II study was carried out on mitoxantrone chemoembolization. High risk cirrhotic patients were excluded from this study. Fourteen mg/m2 mitoxantrone and up to 20 ml Lipiodol were injected, followed by Gelfoam embolization as indicated. Thirty-seven patients (33 with cirrhosis) were treated. Sixty-nine cycles were delivered, with mean (+/-SD) Lipiodol and emulsified mitoxantrone doses of 11.3+/-3.8 ml and 11.8+/-5.2 mg, respectively. Thirteen, 16, and 8 patients received one, two, and three cycles, respectively, with time intervals of 123+/-60 days. Thirty patients received Gelfoam embolization at the first cycle, 9 at the second and 4 at the third. No treatment-related deaths occurred. Complications were mild and transient, including nausea/vomiting in most cases, fever over 38 degrees C 67%, pain 74%, ascites 8%, jaundice 3%, bleeding 3%, pancreatitis 3%, myelosuppression 44%, diarrhea 5%. Treatment response rate was 49% (including 16% minor responses) with 16% early progressions. With a median follow-up of 12 months, the 12-month response duration and survival rates were 56% and 79% respectively. Transcatheter chemoembolization with mitoxantrone appears to be a promising method for the palliation of advanced hepatocellular carcinoma, and deserves to be evaluated in well controlled randomized studies.

HLA class-I-soluble antigen serum levels in liver transplantation. A predictor marker of acute rejection.

The serum levels of sHLA-I have been determined in 16 patients following liver transplantation. sHLA-I levels did not show remarkable variations in six patients without evidence of transplant-related complications. sHLA-I levels strongly increased in 10 patients undergoing acute rejection episodes. In these patients, an average 20% daily increase of sHLA-I levels was detected on the 6 days preceding and on the 2 days following the rejection episode. A fast decrease of sHLA-I levels was observed in seven patients following treatment of acute rejection with anti-CD3 mAb. The serum level of sHLA-I antigens positively correlated with ALT serum level and inversely correlated with PT. The determination of sHLA-I in serum may therefore be proposed as a useful marker in the monitoring of patients following liver transplantation. The increase of sHLA-I antigens may predict the onset of acute rejection whereas their decrease may be related to a good response of acute rejection to immunosuppressive treatment.