Minimally invasive liver resection for primary and metastatic liver tumors: influence of age on perioperative complications and mortality.

BACKGROUND: As minimally invasive technique becomes more popular, an increasing number of elderly patients were considered for minimally invasive liver resection (MILR). Limited physiologic reserve remains a major concern, which frequently leads surgeons to recommend nonresectional alternatives. We sought to evaluate complications and outcomes of elderly patients undergoing MILR. METHODS: Eight hundred and thirty-one patients who underwent MILR were classified into groups A, B, and C based on age [(< 70, n = 629), (70-79, n = 148), (≥ 80, n = 54) years old, respectively]. RESULTS: Gender distribution, BMI, and cirrhotic status were comparable among all groups. Groups B and C had higher MELD (p = 0.047) and ASA (p = 0.001) scores. Operative time (170, 157, 152 min; p = 0.64) and estimated blood loss (145, 130, 145 ml; p = 0.95) were statistically equal. Overall postoperative complications were greater in groups B and C (12.9 and 9.3 vs. 6.5%, respectively). Complications in group C were all minor. Clavien-Dindo grade III-IV complications were higher in group B when compared to group A (6.8 vs. 2.7%, p = 0.43). There was no significant difference in cardiopulmonary complications, thromboembolic events, ICU admissions, and transfusion rates seen in groups B and C when compared to group A. Duration of hospital stay was statistically longer in groups B and C (3.6, 3.5 vs. 2.5 days, p = 0.0012). 30- and 90-day mortality rates were comparable among the groups, irrespective of age. CONCLUSIONS: In spite of greater preoperative comorbidities and ASA score, there was no significant increase in postoperative morbidity after minimally invasive liver resection in patients ≥ 70 years of age.

Hand-assisted laparoscopic left hepatectomy: how I do it.

Laparoscopic liver resection has been adopted slowly due to concerns for bleeding and oncologic outcomes. Currently, over 9,500 laparoscopic liver resections have been performed and reported worldwide. Numerous studies have shown the safety and oncologic equivalence of laparoscopic liver resection when compared to open resection. Pure laparoscopic and hand-assisted laparoscopic liver resection are the two most commonly used techniques for minimally invasive liver resection surgery. Advantages of the hand-port include tactile feedback, facilitation of liver mobilization, and ease of ability to control bleeding. We present a case report with video of a hand-assisted laparoscopic left liver resection for a hepatocellular carcinoma in a non-cirrhotic patient.

Longterm survival outcomes of patients undergoing treatment with radiofrequency ablation for hepatocellular carcinoma and metastatic colorectal cancer liver tumors.

BACKGROUND: We aim to investigate long-term survival outcomes in patients undergoing radiofrequency ablation (RFA), based on our longitudinal 5 and 10 year follow-up data. METHODS: All patients who underwent RFA for hepatocellular carcinoma (HCC) and colorectal liver metastasis (CLM) between 1999 and 2010. RESULTS: 320 patients were included with oncologic diagnoses of HCC in 122 (38.1%) and CLM in 198 (61.9%). The majority of patients had a single tumor ablation (71% RFA 1 lesion). Minimum 5 year follow-up information was available in 89% patients, with a median follow-up of 115.3 months. In patients with HCC, disease eventually recurred in 73 (64%) patients. In patients with CLM, disease recurrence was ultimately seen in 143 (84.1%) patients. In the HCC group, the 5- and 10-year overall survivals were 38.5% and 23.4%, while in the CLM group, the 5- and 10-year overall survivals were 27.6% and 15%, respectively. CONCLUSIONS: The use of RFA as a part of treatment strategy for primary and metastatic liver tumors imparts 10-year overall survivals of >23% and 15%, respectively. This study indicates that long-term survival is possible with RFA treatment.

T2 Gallbladder Cancer-Aggressive Therapy Is Warranted.

Treatment of gall bladder cancer (GBC) has traditionally been viewed with pessimism and lymph node positivity has been associated with worse prognosis. The aim of this study is to analyze the role of radical cholecystectomy in T2 tumors. All patients who underwent surgery for GBC between September 2005 and June 2014 were identified retrospectively. Data collected included clinical presentation, operative findings, and histopathological data. Twenty-five patients had incidental GBC diagnosis after cholecystectomy. Ten patients were T2 on initial cholecystectomy pathology and all underwent radical resection. Two patients were N1 on initial cholecystectomy pathology. Four were upstaged to N1 and two patients were upstaged to T3 after further surgery. Overall, 60 per cent patients with T2 disease had node positivity and 60 per cent were upstaged by further surgery. Eleven patients were diagnosed on imaging. Four of these patients were unresectable and six were either stage T3 or higher or node positive. Sixty per cent of T2 GBC was node positive and 60 per cent were upstaged with radical cholecystectomy. This finding supports the call for radical resection in patients with incidental diagnosis of T2 tumor on cholecystectomy. This study also emphasizes the role of radical surgery in accurate T staging.

Duodenal Neuroendocrine Tumors: Location Matters!

Duodenal neuroendocrine tumors (NETs) are rare. Historically, when feasible a less aggressive surgical approach is considered. The aim of this study was to identify factors associated with prognosis and the necessity for more aggressive surgical procedures. All patients who underwent surgery for duodenal NETs between September 2005 and June 2014 were identified retrospectively. Data collected included clinical presentation, operative findings, and histopathological data. Eighteen patients underwent surgical management for duodenal NETs. Two patients underwent transduodenal excision (11%), two patients had partial duodenal resection (11%), two patients had antrectomy including 1st part of duodenum (D1) resection (33%), and eight underwent pancreaticoduodenectomy [PD (44%)]. On analysis, 2nd part of duodenum (D2) location was the most common site of duodenal NETs (n = 9, 50%). The odds of having a PD were 10 times higher when the lesion was in D2 location. The odds of having a positive lymph node are nine times higher when the lesion is in D2 region. The odds of having a positive lymph node are three times higher when lesion is greater than T1. D2 location of NETs is associated with higher odds of lymph node positivity and need for more extensive procedures like PD.

Evidence supporting laparoscopic major hepatectomy.

Laparoscopic liver resection (LLR) has been increasing in frequency with over 9,000 cases done worldwide. Benefits of laparoscopic resection include less blood loss, smaller incisions, decreased postoperative morbidity, and shorter length of stay compared to open liver resection. With increased experience, several centers have reported series of laparoscopic major hepatectomy, although this represents only about 25% of total LLR performed. Evidence is accumulating to support laparoscopic major hepatectomy with the understanding that there is a steep learning curve, and surgeons should begin with minor LLR before moving on to laparoscopic major hepatectomy. Controversy still remains concerning indications, techniques, learning curve, risks, and long-term cancer outcomes with laparoscopic major hepatectomy.

MRI with gadoxetate disodium for colorectal liver metastasis: is it the new "imaging modality of choice"?

BACKGROUND: Accurate detection of colorectal liver metastasis is paramount in the role of management. This study aims to compare magnetic resonance imaging (MRI) with gadoxetate disodium (a hepatocyte-specific agent-Eovist®) to triple-phase enhanced computed tomography in detecting colorectal liver metastases. METHODS: A retrospective chart analysis of 30 patients from 2011 to 2013 with colorectal liver metastases was performed. Patients with more than 6 weeks or two cycles of chemotherapy between the two imaging modalities were excluded. The number of lesions identified on triple-phase enhanced computed tomography vs. MRI with Eovist® was compared. RESULTS: Of the 30 patients that met the inclusion criteria, 12 (40 %) patients had more lesions identified on MRI with Eovist® compared to triple-phase enhanced computed tomography. Eighteen (60 %) had no change in the number of lesions identified. When MRI with Eovist® detected more lesions, the mean number of additional lesions detected was 1.5. Eovist® MRI changed the surgical management in 36.7 % of patients. CONCLUSION: MRI with Eovist® is superior to enhanced computed tomography in identifying colorectal liver metastases. The increased number of lesion identified on MRI with Eovist® can profoundly change the surgeon's management. It should be considered the "imaging modality of choice" in preoperative imaging for liver metastases in these patients.

Driving intoxicated: is hospital admission protective against legal ramifications?

BACKGROUND: According to the US National Highway Traffic Safety Administration, in 2010, 10,228 people were killed in alcohol-impaired driving crashes. Daily, intoxicated drivers are seen in trauma centers across the country. At our trauma center, we sought to determine the number of drivers who had a documented elevation in their blood alcohol content (BAC) and compare this with county police records to evaluate how many charges for driving while intoxicated (DWI) were issued. METHODS: A retrospective chart review was performed for trauma admissions during a 3-year period. Patients with a BAC of less than 0.08 g/dL were excluded. Only documented drivers were included. This group of intoxicated drivers was then compared against public records from the Dallas County for any record of a charge of DWI. RESULTS: During a 3-year period, from 2009 to 2011, 118 drivers had a confirmed BAC above the legal limit of 0.08 g/dL. Average BAC level was 0.218 g/dL. Injuries varied widely between patients with an average Injury Severity Score (ISS) of 11. Extremity fractures were seen in 27%, facial fractures were seen in 16%, and intracranial hemorrhage was seen in 7%. Forty-eight percent of the patients were admitted to the intensive care unit initially, with an average length of intensive care unit stay of 1.5 days (range, 0-25 days). Only 18% of our patients (21) received a charge of DWI. Four patients were charge with related offenses. CONCLUSION: A motor vehicle accident may be protective against the legal ramifications of drinking and driving. Less than 20% of patients who were driving under the influence incurred any legal repercussion. Deterrents that prevent law enforcement from being able to obtain evidence needed for prosecution should be eliminated. Health care providers and law enforcement agencies should work as a team to help mitigate the incidence of drunk driving and its burden on society. LEVEL OF EVIDENCE: Epidemiologic study, level III.

De novo exon duplication in a new allele of mouse Glra1 (spasmodic).

The novel neurological mutant Cincinatti arose by genomic duplication of exon 5 in the glycine receptor gene Glra1. The mutant transcript results in premature protein truncation. A direct repeat of the pentamer GGGGC is present adjacent to the breakpoints and may have mediated the duplication event by a replication slippage mechanism.

Phenolic compounds in red oak and sugar maple leaves have prooxidant activities in the midgut fluids of Malacosoma disstria and Orgyia leucostigma caterpillars.

Phenolic compounds are generally believed to be key components of the oxidative defenses of plants against pathogens and herbivores. However, phenolic oxidation in the gut fluids of insect herbivores has rarely been demonstrated, and some phenolics could act as antioxidants rather than prooxidants. We compared the overall activities of the phenolic compounds in red oak (Quercus rubra) and sugar maple (Acer saccharum) leaves in the midgut fluids of two caterpillar species, Malacosoma disstria (phenolic-sensitive) and Orgyia leucostigma (phenolic-tolerant). Three hypotheses were examined: (1) ingested sugar maple leaves produce higher levels of semiquinone radicals (from phenolic oxidation) in caterpillar midgut fluids than do red oak leaves; (2) O. leucostigma maintains lower levels of phenolic oxidation in its midgut fluids than does M. disstria; and (3) phenolic compounds in tree leaves have overall prooxidant activities in the midgut fluids of caterpillars. Sugar maple leaves had significantly lower ascorbate: phenolic ratios than did red oak leaves, suggesting that phenolics in maple would oxidize more readily than those in oak. As expected, semiquinone radicals were at higher steady-state levels in the midgut fluids of both caterpillar species when they fed on sugar maple than on red oak, consistent with the first hypothesis. Higher semiquinone radical levels were also found in M. disstria than in O. leucostigma, consistent with the second hypothesis. Finally, semiquinone radical formation was positively associated with two markers of oxidation (protein carbonyls and total peroxides). These results suggest that the complex mixtures of phenolics in red oak and sugar maple leaves have overall prooxidant activities in the midgut fluids of M. disstria and O. leucostigma caterpillars. We conclude that the oxidative defenses of trees vary substantially between species, with those in sugar maple leaves being especially active, even in phenolic-tolerant herbivore species.

Genetic interaction between Wnt7a and Lrp6 during patterning of dorsal and posterior structures of the mouse limb.

Wnt7a and the Wnt coreceptor Lrp6 are both required for development of posterior digits and dorsal structures of the limb. We report that Lrp6 null mice lack Lmx1b expression in the distal mesenchyme, as previously described for Wnt7a mutants. The loss of Lmx1b expression in Wnt7a-/-Lrp6+/- double mutants did not differ from that in Wnt7a-/- mice. These data suggest that Wnt7a acts through Lrp6 to regulate Lmx1b expression during dorsal specification. The loss of posterior skeletal elements in the Wnt7a-/-Lrp6+/- double mutant was much more severe than in Wnt7a-/- mice, suggesting that the Wnt7a-/- limb is protected by the action of other Lrp6 ligands. The data are consistent with the view that Wnt7a acts through Lrp6 and the canonical Wnt signaling pathway during dorsal and posterior limb development in the mouse.