Laparoscopic cholecystectomy in cirrhotic patients: the value of MELD score and Child-Pugh classification in predicting outcome.

BACKGROUND: Laparoscopic cholecystectomy is a challenging procedure in patients with cirrhosis. This study aims to evaluate the safety and outcome of laparoscopic cholecystectomy in patients with cirrhosis and examines the value of model for end-stage liver disease (MELD) score and Child-Pugh classification in predicting morbidity. MATERIALS AND METHODS: From January 1995 to July 2008, 220 laparoscopic cholecystectomies were performed in cirrhotic, Child-Pugh class A and B patients. Indications included symptomatic gallbladder disease and cholecystitis. MELD score ranged between 8 and 27. Child-Pugh class and MELD score were preoperatively calculated and associated with postoperative results. Data regarding patients and surgical outcome were retrospectively analyzed. RESULTS: No deaths occurred. Postoperative morbidity occurred in 19% of the patients and included hemorrhage, wound complications, and intra-abdominal collections controlled conservatively. Intraoperative difficulty due to liver bed bleeding was experienced in 19 patients. Conversion to open cholecystectomy was necessary in 12 cases. Median operative time was 95 min. Median hospital stay was 4 days. Patients with preoperative MELD score above 13 showed a tendency for higher complication rate postoperatively. Child-Pugh classification did not seem to predict morbidity effectively. CONCLUSION: Laparoscopic cholecystectomy can be performed safely in selected patients with cirrhosis Child-Pugh A and B and symptomatic cholelithiasis with acceptable morbidity. Some of its advantages are shorter operative time and reduced hospital stay. MELD score seems to predict morbidity more accurately than Child-Pugh classification system.

Hepatic resection for hepatocellular carcinoma exceeding Milan criteria.

BACKGROUND: Many hepatocellular carcinomas (HCCs) are discovered at an advanced stage. The efficacy of transplantation for such tumors is doubtable. The aim of this retrospective study was to determine liver resection efficacy in patients with large HCC regarding long term and disease- free survival. METHODS: Between 2002 and 2008, sixty six patients with large HCC (>5cm) underwent hepatectomy. Fifty nine patients had background cirrhosis due to hepatitis B, C or other reason and preserved liver function (Child A). Liver function was assessed by both Child's-Pugh grading and MELD score. Conventional approach of liver resection was performed in most cases. RESULTS: The 5-year overall survival was 32% with a median follow up of 33 months. The three year disease-free survival was 33% in our cohort. On multivariate analysis, only tumor size and grade remained independent predictors of adverse long term outcome. Multivariate analysis identified size of the primary tumour and degree of differentiation as risk factors for recurrence. Median blood loss was 540ml and median transfusion requirements were two units of pack red blood cells. Morbidity included pleural effusion (n=18), biliary fistula (n=4), peri-hepatic abscess (n=4), hyperbilirubinemia (n=3), pneumonia (n=5) and wound infection (n=6). No peri-operative mortality was reported in our study. CONCLUSION: Partial hepatectomy is safe in selective patients with large HCC. Surgical resection if feasible is suggested in patients with large HCC because it prolongs both overall and disease-free survival with low morbidity.

WITHDRAWN: Liver resection vs radio-frequency ablation in the treatment of small hepatocellular carcinoma.

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Clamp-crush technique vs. radiofrequency-assisted liver resection for primary and metastatic liver neoplasms.

BACKGROUND: Several techniques for liver resection have been developed. We compared radiofrequency-assisted (RF) and clamp-crush (CC) liver resection (LR) in terms of blood loss, operating time and short-term outcomes in primary and metastatic tumour resection. METHODS: From 2002 to 2007, 196 consecutive patients with primary or metastatic hepatic tumours underwent RF-LR (n= 109; group 1) or CC-LR (n= 87; group 2) in our unit. Primary endpoints were intraoperative blood loss (and blood transfusion requirements) and total operative time. Secondary endpoints included postoperative complications, mortality and intensive care unit (ICU) and hospital stay. Data were collected retrospectively on all patients with primary or secondary liver lesions. RESULTS: Blood loss was similar (P= 0.09) between the two groups of patients with the exception of high MELD score (>9) cirrhotic patients, in whom blood loss was lower when RF-LR was used (P < 0.001). Total operative time and transection time were shorter in the CC-LR group (P= 0.04 and P= 0.01, respectively), except for high MELD score (>9) cirrhotic patients, in whom total operation and transection times were shorter when RF-LR was used (P= 0.04). Rates of bile leak and abdominal abscess formation were higher after RF-LR (P= 0.04 for both). CONCLUSIONS: Clamp-crush LR is reliable and results in the same amount of blood loss and a shorter operating time compared with RF-LR. Radiofrequency-assisted LR is a unique, simple and safe method of resection, which may be indicated in cirrhotic patients with high MELD scores.

Model for end-stage liver disease (MELD) score, as a prognostic factor for post-operative morbidity and mortality in cirrhotic patients, undergoing hepatectomy for hepatocellular carcinoma.

BACKGROUND/AIMS: To evaluate the ability of the model for end-stage liver disease (MELD) in predicting the post-hepatectomy outcome for hepatocellular carcinoma (HCC). METHODS: Between 2001 and 2004, 69 cirrhotic patients with HCC underwent hepatectomy and the results were retrospectively analysed. MELD score was associated with post-operative mortality and morbidity, hospital stay and 3-year survival. RESULTS: Seventeen major and 52 minor resections were performed. Thirty-day mortality rate was 7.2%. MELD < or = 9 was associated with no peri-operative mortality vs. 19% when MELD > 9 (P < 0.02). Overall morbidity rate was 36.23%; 48% when MELD > 9 vs. 25% when MELD < or = 9 (P < 0.02). Median hospital stay was 12 days [8.8 days, when MELD < or = 9 and 15.6 days when MELD > 9 (P = 0.037)]. Three-year survival reached 49% (66% when MELD < or = 9; 32% when MELD > 9 (P < 0.01). In multivariate analysis, MELD > 9 (P < 0.01), clinical tumour symptoms (P < 0.05) and American Society of Anesthesiologists (ASA) score (P < 0.05) were independent predictors of peri-operative mortality; MELD > 9 (P < 0.01), tumour size >5 cm (P < 0.01), high tumour grade (P = 0.01) and absence of tumour capsule (P < 0.01) were independent predictors of decreased long-term survival. CONCLUSION: MELD score seems to predict outcome of cirrhotic patients with HCC, after hepatectomy.

Perioperative risk assessment for hepatocellular carcinoma by using the MELD score.

BACKGROUND/AIMS: The aim of this study was to evaluate the ability of Model for End-Stage Liver Disease (MELD) in predicting post hepatectomy outcome for hepatocellular carcinoma (HCC). METHODS: Between 2001 and 2005, 94 cirrhotic patients with HCC underwent hepatectomy and were analyzed retrospectively. MELD score associated with postoperative mortality and morbidity, hospital stay, and 3-year survival. RESULTS: Twenty-eight major and 66 minor resections were performed. Thirty-day mortality rate was 6.4%. MELD 9 (p = 0.01). Overall morbidity rate was 32%; 21% when MELD 9 (p = 0.01). Median hospital stay was 11 days (7 days, when MELD 9; p = 0.03). Three-year survival reached 48% (63% when MELD 9; p < 0.01). In multivariate analysis, MELD > 9 (p = 0.01), clinical tumor symptoms (p = 0.04), and American Society of Anesthesiologists score (p = 0.04) were independent predictors of perioperative mortality; MELD > 9 (p = 0.01), tumor size >5 cm (p = 0.01), presence of tumor symptoms (p = 0.02), high tumor grade (p = 0.01), and absence of tumor capsule (p = 0.01) were independent predictors of decreased long-term survival. CONCLUSION: MELD score seems to predict outcome of cirrhotic patients with HCC after hepatectomy.

Hepatic resection for large hepatocellular carcinoma in the era of UCSF criteria.

BACKGROUND: Treating patients with hepatocellular carcinoma (HCC) remains a challenge, especially when the disease presents at an advanced stage. The aim of this retrospective study was to determine the efficacy of liver resection in patients who fulfil or exceed University of California San Francisco (UCSF) criteria by assessing longterm outcome. METHODS: Between 2002 and 2008, 59 patients with large HCC (>5 cm) underwent hepatectomy. Thirty-two of these patients fulfilled UCSF criteria for transplantation (group A) and 27 did not (group B). Disease-free survival and overall survival rates were compared between the two groups after resection and were critically evaluated with regard to patient eligibility for transplant. RESULTS: In all patients major or extended hepatectomies were performed. There was no perioperative mortality. Morbidity consisted of biliary fistula, abscess, pleural effusion and pneumonia and was significantly higher in patient group B. Disease-free survival rates at 1, 3 and 5 years were 66%, 37% and 34% in group A and 56%, 29% and 26% in group B, respectively (P < 0.01). Survival rates at 1, 3 and 5 years were 73%, 39% and 35% in group A and 64%, 35% and 29% in group B, respectively (P= 0.04). The recurrence rate was higher in group B (P= 0.002). CONCLUSIONS: Surgical resection, if feasible, is suggested in patients with large HCC and can be performed with acceptable overall and disease-free survival and morbidity rates. In patients eligible for transplantation, resection may also have a place in the management strategy when waiting list time is prolonged for reasons of organ shortage or when the candidate has low priority as a result of a low MELD (model for end-stage liver disease) score.

Transthoracic approach (TTA) for subdiaphragmatic liver metastasectomy.

BACKGROUND: Hepatic and pulmonary recurrences are major determinants of survival for patients who have undergone curative resection of colorectal carcinoma. In a selected group of patients, resection of metachronous, liver and lung metastases prolongs survival despite the aggressive nature of these lesions. The experience from an exclusive transthoracic, transdiaphragmatic approach (TTA) is limited. We present our experience with metastasectomy in patients with metachronous liver and right lung metastases, in whom an exclusive transthoracic approach was performed. METHODS: Between 2002 and 2007, seven patients with metachronous colorectal liver and right-lung metastases, underwent an exclusive transthoracic approach. There were five men and two women, with a median age of 69 years (range 55 to 78 years). Liver resections performed included segmentectomy of segments VII, VIII, or both. Previous operations, including colon resection, adhesiolysis, ventral hernia repair, or transabdominal segment V resection, were performed in all patients. RESULTS: No peri-operative mortality was documented. Morbidity included pleural effusion (n=3) and post-operative pneumonia (n=1), which responded to conservative management. Median hospital stay was 8 days (range 5-12 days). With a median follow-up of 31 months, one patient died of generalized disease. CONCLUSION: The factors that led to the increase of performances in colonoscopy in our department were the use of proper sedation and analgesia, the permanent internal audit of the maneuver, as well as the motivation of the endoscopist to obtain good results.

Intrahepatic biliary cystadenoma: a need for radical resection.

BACKGROUND: Intrahepatic biliary cystadenoma (IBC) is a rare liver tumour, which has strong tendency to recur and malignant potential as it can progress to cystadenocarcinoma (IBCa). METHODS: From June 2003 to December 2006, four patients diagnosed with hepatic cystadenoma were operated on our Liver Surgical Unit. All patients were females with median age of 51 years (range 45-63 years). Liver resections included three left and one right hepatectomies. In two patients, IBC was diagnosed by abdominal imaging and serum tumour markers but the rest of the patients were initially misdiagnosed as simple cysts, treated by laparoscopic fenestration and referred to our unit after cyst recurrence. RESULTS: In all cases, the pathology report was consistent with liver cystadenomas. The postoperative course was uneventful and the median hospital stay was 8 days (range 5-12 days). In a median 18-month follow-up (range 2-40 months), all patients are alive and free of recurrence. CONCLUSION: Liver cystadenomas can be easily misdiagnosed with other hepatic cystic lesions. An aggressive surgical approach is recommended, due to their malignant potential and high recurrence rate after fenestration.

Radiofrequency-assisted liver resection.

BACKGROUND: Surgical resection remains the treatment of choice for primary, secondary liver cancer and a number of benign liver lesions. Complications are mainly related to blood loss. Radiofrequency-assisted liver resection (RF-LR) has been proposed in order to achieve minimal blood loss during parenchymal transection. PATIENTS AND METHODS: Between May 2005 and April 2007, 46 consecutive patients with various hepatic lesions underwent RF-LR using Radionics, Cool-Tip System. There were 28 men and 18 women with median age 65 years (range 54-76 years). Twelve major and 34 minor hepatectomies were performed for various diseases: hepatocellular carcinoma (n=19), metastatic carcinoma (n=23), focal nodal hyperplasia (n=2) and intrahepatic cholangiocarcinoma (ICC) (n=2). Hepatic inflow occlusion was not used. RESULTS: No perioperative death was documented. Median blood loss was 100ml (range 30-300cm(3)). Blood transfusion was required postoperatively in one patient. Median transection time was 35min (15-60min). Three patients developed biliary fistulas, four patients pleural effusions, one patient hyperbilirubinemia, two pneumonia and four wound infection. The median postoperative hospital stay was 6 days (range 4-10 days). In a median 12 month follow-up (range 3-24 months), four patients with colorectal metastases (CRM) and one patient with ICC developed recurrence. CONCLUSIONS: Cool-Tip RF device provides a unique, simple and safe method of bloodless liver resections and is indicated in cirrhotic patients with challenging hepatectomies (segment VIII, central resections).