Left Hepatectomy Through Double Approach and Total Vascular Exclusion for Giant Left Lobe Hepatocarcinoma.

BACKGROUND/AIM: Hepatocellular carcinoma represents the most frequently encountered liver malignancy worldwide; however the dimensions of these lesions rarely surpass 20 cm. In such cases surgical treatment might encounter significant technical difficulties. CASE REPORT: We present the case of a 49-year-old patient diagnosed with a 22/25/21 cm left lobe hepatocellular carcinoma. RESULTS: In order to achieve a safe and effective resection total vascular exclusion was needed. Moreover, due to the anatomical relationship between the tumor and the cava vein, an intrathoracic approach of the inferior cava vein was the option of choice. The time of total vascular exclusion was of 26 minutes while the length of surgery was of 210 minutes; meanwhile the estimated blood loss was of 650 ml, while the postoperative outcome was uncomplicated. CONCLUSION: Total vascular exclusion by double approach might be a safe alternative in order to minimize the risks of severe intraoperative and postoperative complications.

Heterogeneity of antigenic constellation in human hepatocellular carcinoma.

Hepatocellular carcinoma is one of the primary liver malignancies responsible for over a million deaths per year worldwide (approximately 10% of all deaths in the adult age range). The diagnosis of HCC can be difficult and often requires the use of more than one microscopic technique. A retrospective study was performed on a study batch of 42 cases that died of HCC due to metastasis or other secondary complications. Tissue samples were taken in order to investigate the tumour antigenic constellation by means of IHC method using a large variety of antibodies. In situ hybridization was also performed for albumin mRNA to assess the albumin expression in some selected cases. Telomerase activity was investigated using IHC method for the hTERT catalytic subunit. A cocktail of hepatic cytokeratins (CK8, 18) combined with Hep Par-1 and associated to albumin proved to be more powerful than albumin alone in differentiating HCC and increased the value of tumour diagnosis. hTERT expression was proportionally reverse to the tumour degree of differentiation, but was independent from the expression of tumour-proliferating indexes. The heterogeneity of the antigenic constellation in hepatocellular carcinoma suggests an antigenic mosaicism, which can be expressed a synchronous or metachronous manner, depending on the tumour degree of differentiation.

Possible Influence of Weight Gain and Creatinine Levels in Predicting Response to Nivolumab: A Multicenter Analysis.

BACKGROUND: Literature suggests that high body mass index can be correlated with better response to immune checkpoint inhibitors. On the other hand, sarcopenia seems to be a negative predictive marker. Materials and methods: The present analysis is a retrospective, multicenter trial that included patients with metastatic melanoma, non-small cell lung cancer (NSCLC), and renal cell carcinoma treated with nivolumab between 2018 and 2020. Patients were stratified by creatinine levels both at treatment initiation and at first follow-up (at three months) and by BMI for the same intervals, as recorded in the patients' charts. Creatinine was considered a surrogate marker for sarcopenia. IBM SPSS version 20 was used for statistical analysis. Results: A total of 57 (n = 57) patients were included in the trial. Overall response rate (ORR) for the entire population was 38.59% (p = 0.02). Patients with BMI lower than 25 had an ORR of 28.5% (p = 0.003), whereas patients with BMI higher than 25 had an ORR of 42.3% (p = 0.002). Patients who gained weight during treatment had a lower probability of having progressive disease (OR = 0.4 [95% CI; 0.4-1.2]), as did patients with creatinine higher than 0.9 (OR = 0.39 [95% CI: 0.13-1.14]). No superiority was found in progression-free survival (PFS) when patients were dichotomized for BMI = 25 or BMI = 18.5. Mean PFS in the BMI under 18.5 group was 10.2 months [95% CI: 5.8-23.1], versus 11.2 for BMI over 18.5 [95% CI: 5.3-25.3], p < 0.03. Mean PFS for the BMI under 25 was 11.2 months [95% CI: 7.2-20.1], vs. 13.3 months [95% CI: 6.4-22] for the BMI over 25, p < 0.001. There were also differences in PFS in the patients with baseline creatinine over 0.9 when compared with under 0.9 values. Mean PFS in the first group was 19.78 months [95% CI: 16.23-22.9] vs. 16.1 [95% CI: 12.2-20.3], p < 0.001. Conclusion: Patients treated with nivolumab who have weight gain during treatment have a better PFS than the ones who do not. Creatinine levels of over 0.9 at treatment initiation also have positive predictive value.

When is Laparoscopy Avoided in the Treatment of Surgical Complications due to Crohn Disease.

Introduction: Crohn disease (CD) has seen a steady increase in incidence over the years in Romania. Laparoscopy had a slow evolution as a feasible therapeutic option for patients with CD. Material and Method: The study is retrospective. The period on which the data was gathered spread over 8 years (01.01.2011-01.01.2019). Data was retrieved from three Clinical Hospitals in Bucharest, Romania Results: the preoperative diagnosis of an intestinal fistula (p = 0,02), sepsis (p = 0.01 ) or increased age should be regarded as a limitation for a laparoscopic approach in CD complications. Also in emergency settings an open approach should be the mainstay treatment (approach p = 0.000001). Conclusion: Laparoscopy is a feasible surgical option in the treatment of surgical complication in CD. In order to increase the safety of the intervention, correct selection of patients is important.

Watch and Wait Strategy for Rectal Cancer: 15 Years After the First Published Study. Are We any Closer to the Non-operative Management of Rectal Cancer?

Introduction: Over time, the management of rectal cancer has undoubtedly evolved with the use of neoadjuvant radiochemotherapy. Material and method: The P.I.C.O.S guidelines were used to structure the questions and the research topic as to attain clinical validity. The results of the research were filtered in accordance with the PRISMA checklist. Results: We identified 42 papers. After screening 27 papers were used to complete the analysis. Discussion: There is an increased interest towards the non-operative management of rectal cancer, as up to 25% of patients with preoperative radiochemotherapy have demonstrated complete pathological response (absence of tumor cells on the operative specimens). This information leads to the tantalizing idea that in some cases, surgery can be avoided. Unfortunately, there is a lack of quality data to support this view. Due to increased interest in this subject, an international database in which patients with w w therapy can be enrolled and monitored. Up to now, the database contains over 900 patients. Also, quality prospective trials are emerging. Conclusion: Even with all these recent efforts, the wide-use of this therapy is precluded due to the absence of a standardized evaluation of these patients in the follow-up period.

TAAP vs. TEP in Inguinal Hernia Repair - What is the Evidence? A Single Center Experience.

GOALS: To evaluate the indications of TAAP vs TEP in the treatment of unilateral inguinal hernia and the limitations of each technique using the experience of our clinic. MATERIAL AND METHOD: The study is retrospective, extends over 4 years and includes patients with unilateral inguinal hernia operated using either TAAP or TEP technique. Results: We identified a number of 40 patients of which 25 were treated with the TAPP and 15 with the TEP technique. The mean age in the TAAP group was 42 years and 38 years in the TEP group. Mean surgery time for TAAP was 52 min; for TEP it was 62 min. Large inguinoscrotal hernias were operated with the TAAP technique. Conversion from TEP to TAAP was encountered in 2 cases, while conversion to open a hernia was encountered in 3 cases. No deaths were recorded in the follow-up time. Conclusions: Both TAAP and TEP are feasible surgical options to treat an inguinal hernia. The use of the TEP technique is limited by the size of the hernia defect while the TAAP technique has the advantage of larger intraoperative field, and an increased risk of injury to major abdominal organs.

Clinical Pattern of Surgical Crohn Disease Patients.

Backround/Objective: The aim of investigation was to evaluate if there is a pattern regarding the anatomical location of the disease and type of surgery performed/surgical indication. Also a analysis was performed regarding the complication rate in two subgroups deriving from urban and rural environments. Methods: Data was obtained from the medical records of patients with CD and centralized. Tests of statistical analysis included the CHY-SQUARE test and the results were presented as a retrospective, longitudinal study. Results: The group was formed of 60 patients. Patients with ileocolic disease were frequently diagnosed with obstruction and benefited from an enterectomy with anastomosis. Patients with colonic disease were frequently diagnosed with perforation and benefited from colectomy and stomy. Patients from rural areas had a milder evolution when compared with patients from urban enviroments. Conclusions: Although most patients with CD eventually require surgery, the indication could be anticipated by recognition of the concept of clinical patterns, and type of surgery required could be predicted if the clinical aspect of the patient/disease were identified.

Reintervention Rate Following Emergency Surgery for Crohn Disease.

Backround/Objective: To assess the impact of emergency surgery and postoperative recurrence in Crohn's disease (CD) and to evaluate the disease course while observing different factors that may influence it. Methods: Information on 37 consecutive patients which were diagnosed and operated in emergency for CD complications and the the relapse rate (regarded as a second surgery) were retrospectively evaluated. Results: The risk of relapse and second surgery was increased in males under 50 years and in those who benefited from an anastomosis during the first invervention while stomy seemed to reduce the rate of surgical relapse. The median duration until relapse was 2,3 years while a percentage of 33% required reintervention. Conclusions: The majority of patients with CD will undergo at least one surgical intervention during their lifetime and one third of them will relapse requiring a second intervention. Although medical treatment has seen great advancements, surgery requirements have remained unchanged as the mainstay treatment in emergent complications of CD. The age of the patients, smoking status and the postoperative medication influence the rate of postoperative recurrence.