Survival benefit of second line therapies for recurrent hepatocellular carcinoma: repeated hepatectomy, thermoablation and second-line transplant referral in a real life national scenario.

BACKGROUND: Despite second-line transplant(SLT) for recurrent hepatocellular carcinoma(rHCC) leads to the longest survival after recurrence(SAR), its real applicability has never been reported. The aim was to compare the SAR of SLT versus repeated hepatectomy and thermoablation(CUR group). METHODS: Patients were enrolled from the Italian register HE.RC.O.LE.S. between 2008 and 2021. Two groups were created: CUR versus SLT. A propensity score matching (PSM) was run to balance the groups. RESULTS: 743 patients were enrolled, CUR = 611 and SLT = 132. Median age at recurrence was 71(IQR 6575) years old and 60(IQR 53-64, p < 0.001) for CUR and SLT respectively. After PSM, median SAR for CUR was 43 months(95%CI = 37 - 93) and not reached for SLT(p < 0.001). SLT patients gained a survival benefit of 9.4 months if compared with CUR. MilanCriteria(MC)-In patients were 82.7% of the CUR group. SLT(HR 0.386, 95%CI = 0.23 - 0.63, p < 0.001) and the MELD score(HR 1.169, 95%CI = 1.07 - 1.27, p < 0.001) were the only predictors of mortality. In case of MC-Out, the only predictor of mortality was the number of nodules at recurrence(HR 1.45, 95%CI= 1.09 - 1.93, p = 0.011). CONCLUSION: It emerged an important transplant under referral in favour of repeated hepatectomy or thermoablation. In patients with MC-Out relapse, the benefit of SLT over CUR was not observed.

The albumin-bilirubin score stratifies the outcomes of Child-Pugh class A patients after resection of hepatocellular carcinoma.

BACKGROUND: The albumin-bilirubin (ALBI) score is a mathematical model including serum albumin and bilirubin, recently proposed as an alternative prognostic tool in patients with hepatocellular carcinoma (HCC). The aims of this study were to provide evidence that the ALBI score can identify different prognostic groups in Child-Pugh (CP) class A patients undergoing liver resection with curative intent and to verify the ability of the ALBI score to predict short-term and long-term outcomes. METHODS: We performed a retrospective analysis on patients classified as class A according to the CP score who underwent liver resection with curative intent for HCC between 2006 and 2016 in the Division of Hepatobiliary Surgery at the University of Verona. Patients were divided according to the ALBI score and the presence or absence of preoperative clinically significant portal hypertension (CSPH). RESULTS: Among the 187 CP class A patients, 125 patients (66.8%) were ALBI 1 and 62 patients (33.2%) were ALBI 2. The 5-year overall survival (OS) was 49.2% in the entire cohort and was 57.1% and 33.5% for ALBI 1 and ALBI 2, respectively (P=0.0014). ALBI 2 patients showed a higher rate of post-hepatectomy liver failure (PHLF), 9.7% vs. 2.4% for ALBI 1 (P=0.027). In the multivariate analysis, the ALBI score [hazard ratio (HR) 1.9, P=0.026], stage of fibrosis (HR 2.0, P=0.02) and vascular invasion (HR 3.1, P<0.001) were the independent factors associated with OS. CSPH was identified in 60 (32.1%) patients. Of the patients with CSPH, the 5-year OS was 44.6% and 25.2% for ALBI 1 and ALBI 2, respectively (P=0.031). Of the patients without CSPH, the 5-year OS was 62.5% and 37.6% for ALBI 1 and ALBI 2, respectively (P=0.021). CONCLUSIONS: The ALBI score represents a simple tool to stratify the risk of PHLF and OS in CP class A HCC patients undergoing surgery and to evaluate the prognosis in patients with CSPH. This study justifies the use of the ALBI score in clinical practice to better select patients before surgery.

Inguinal Bladder and Ureter Hernia Permagna: Definition of a Rare Clinical Entity and Case Report.

BACKGROUND: Inguinoscrotal herniation of the bladder is a rare clinical entity, with a frequency between 0.5% and 4% of all inguinal hernias. The bladder can partially or entirely herniate into the inguinal canal; when the whole bladder and ureters migrate into the scrotum, it may cause urinary disorders. CASE PRESENTATION: A 62-year-old male patient presented with urinary disorders and right-sided inguinoscrotal hernia. Under clinical suspicion of bladder involvement in the inguinal canal, abdominal and pelvic computed tomography (CT) scan with endovenous contrast was performed, revealing a right inguinoscrotal hernia, containing the whole urinary bladder and the right pelvic ureter. Without violating the urinary bladder wall integrity, the content of the hernial sac was reduced into the abdominal cavity. Hernioplasty was performed by means of Lichtenstein's method. CONCLUSIONS: Ureteral involvement should be suspected when a clinical inguinal hernia is diagnosed concurrently with unexplained hydronephrosis, renal failure, or urinary tract infection, as in the case described. When suspected, the preoperative diagnosis, particularly with CT scan, is essential to avoid complications and to reduce risk of bladder and ureter injuries during hernia repair.

Amyand's Hernia, State of the Art and New Points of View.

BACKGROUND: Amyand's hernia (AH) is an inguinal hernia containing the vermiform appendix, with an incidence between 0.4% and 1% of all inguinal hernias. Acute or perforated appendicitis can complicate AH. CASE PRESENTATION: A 75-year-old Caucasian man presented with incarceration of vermiform appendix in inguinal hernia sac. Diagnosis was posed preoperatively with computed tomography (CT) scan. Patient underwent urgent surgery and simultaneous appendectomy and hernia repair by Bassini's technique were performed. CONCLUSIONS: Preoperative diagnosis of AH is rare; however it could be useful for surgeon to choose operative approach. Treatment of AH depends on grade of appendix inflammation and/or perforation. The technique utilized to repair hernia depends largely on surgeon's preferences; the presence of inflamed or perforated appendix is not an absolute contraindication for using a prosthetic mesh.

Impact of age on short-term outcomes of liver surgery: Lessons learned in 10-years' experience in a tertiary referral hepato-pancreato-biliary center.

We investigate the surgical outcomes of patients undergoing hepatectomy according to different age intervals, identify the clinical factors related to surgical outcomes, and propose clinical risk scores for severe morbidity and mortality based on the clinical factors.Eight hundred three patients undergoing liver resection were divided into 3 groups: young patients (YP), <65 years (n = 387), elderly patients (EP), from 65 to 74 years (n = 279); very-elderly patients (VEP), ≥75 years (n = 137).Severe morbidity was 10.6%, 12.2%, and 17.5% (P = .103), and mortality was 0.3%, 1.4%, and 4.4% (P = .002) in group YP, EP, and VEP, respectively. Ischemic heart disease, cirrhosis, major hepatectomy, biliary tract-associated procedure, and red blood cells (RBC) transfusion ≥3 U were related with severe morbidity. Ischemic heart disease, cirrhosis, major hepatectomy, and RBC transfusion were independent risk factors for postoperative mortality. Age did not result an independent factor related to mortality and severe morbidity. Two different scores were developed and have proved to be statistically related with severe morbidity and mortality. Moreover, in patients with score ≥2, severe morbidity increased from 24.2% in YP, to 29.3% in EP, and to 40.0% in VEP, P = .047. Likewise, mortality increased from 2.3% in YP, to 7.0% in EP, and to 22.7% in VEP, in patients with score ≥2, P = .017.Age alone should not be considered a contraindication for hepatectomy. We identified factors and proposed 2 scores that can be useful to stratify the risk of morbidity and mortality after hepatectomy. Moreover, severe morbidity and mortality increases according to the different age intervals in patients with scores ≥2.

Management of pancreatic trauma: A pancreatic surgeon's point of view.

BACKGROUND: Pancreatic trauma occurs in 0.2% of patients with blunt trauma and 1-12% of patients with penetrating trauma. Traumatic pancreatic injuries are characterised by high morbidity and mortality, which further increase with delayed diagnoses. The diagnosis of pancreatic trauma is challenging. Signs and symptoms can be non-specific or even absent. METHODS: A critical review of studies reporting the management and outcomes of pancreatic trauma was performed. RESULTS: The management of pancreatic trauma depends on the haemodynamic stability of the patient, the degree and location of parenchymal injury, the integrity of the main pancreatic duct, and the associated injuries to other organs. Nevertheless, the involvement of the main pancreatic duct is the most important predictive factor of the outcome. The majority of pancreatic traumas are managed by medical treatment (parenteral nutrition, antibiotic therapy and somatostatin analogues), haemostasis, debridement of devitalised tissue and closed external drainage. If a proximal duct injury is diagnosed, endoscopic transpapillary stent insertion can be a viable option, while surgical resection by pancreaticoduodenectomy is restricted to an extremely small number of selected cases. Injuries of the distal parenchyma or distal duct may be managed with distal pancreatectomy with spleen preservation. At the pancreatic neck, when pancreatic transection occurs without damage to the parenchyma, a parenchyma-sparing procedure is feasible. CONCLUSION: The management of pancreatic injuries is complex and often requires a multidisciplinary approach. Here, we propose a management algorithm that is based on parenchymal damage and the site of duct injury.

Hepatocellular carcinoma: surgical perspectives beyond the barcelona clinic liver cancer recommendations.

The barcelona clinic liver cancer (BCLC) staging system has been approved as guidance for hepatocellular carcinoma (HCC) treatment guidelines by the main Western clinical liver associations. According to the BCLC classification, only patients with a small single HCC nodule without signs of portal hypertension or hyperbilirubinemia should undergo liver resection. In contrast, patients with intermediate-advanced HCC should be scheduled for palliative therapies, even if the lesion is resectable. Recent studies report good short-term and long-term outcomes in patients with intermediate-advanced HCC treated by liver resection. Therefore, this classification has been criticised because it excludes many patients who could benefit from curative resection. The aim of this review was to evaluate the role of surgery beyond the BCLC recommendations. Safe liver resection can be performed in patients with portal hypertension and well-compensated liver function with a 5-year survival rate of 50%. Surgery also offers good long-term result in selected patients with multiple or large HCCs with a reported 5-year survival rate of over 50% and 40%, respectively. Although macrovascular invasion is associated with a poor prognosis, liver resection provides better long-term results than palliative therapies or best supportive care. Recently, researchers have identified several genes whose altered expression influences the prognosis of patients with HCC. These genes may be useful for classifying the biological behaviour of different tumours. A revision of the BCLC classification should be introduced to provide the best treatment strategy and to ensure the best prognosis in patients with HCC.

Usefulness of contrast-enhanced intraoperative ultrasonography (CE-IOUS) in patients with colorectal liver metastases after preoperative chemotherapy.

AIMS: The aim of this study was to evaluate the ability of contrast-enhanced intraoperative ultrasonography to detect colorectal liver metastases after preoperative chemotherapy compared with intraoperative ultrasound and preoperative imaging techniques. METHODS: From January 2010 to December 2011, 28 patients with colorectal liver metastases underwent intraoperative ultrasonography and contrast-enhanced intraoperative ultrasonography during hepatectomy following preoperative chemotherapy. The findings were compared to preoperative imaging using contrast-enhanced ultrasonography, computed tomography, magnetic resonance imaging, and/or fluorodeoxyglucose positron emission tomography. RESULTS: Preoperative imaging techniques detected 58 metastatic lesions in 28 patients. In 32 % of patients (n = 9), intraoperative ultrasound detected 24 missed hepatic nodules. In 14 % of patients (n = 4), contrast-enhanced intraoperative ultrasonography detected an additional six nodules and change in operative management occurred in 18 % of patients. Using univariate analysis, we found three factors significantly related to detection of additional metastases with contrast-enhanced intraoperative ultrasonography: three or more metastases before chemotherapy (p = 0.047), resolution of at least one metastasis (p = 0.011), and small liver metastases (largest lesion size ≤20 mm) after chemotherapy (p = 0.007). CONCLUSION: In patients undergoing surgery for colorectal liver metastases after chemotherapy, contrast-enhanced intraoperative ultrasonography improved both the sensitivity of intraoperative ultrasonography to detect liver metastases and the R0 hepatic resection rate.