The Italian Consensus on minimally invasive simultaneous resections for synchronous liver metastasis and primary colorectal cancer: A Delphi methodology.

At the time of diagnosis synchronous colorectal cancer, liver metastases (SCRLM) account for 15-25% of patients. If primary tumour and synchronous liver metastases are resectable, good results may be achieved performing surgical treatment incorporated into the chemotherapy regimen. So far, the possibility of simultaneous minimally invasive (MI) surgery for SCRLM has not been extensively investigated. The Italian surgical community has captured the need and undertaken the effort to establish a National Consensus on this topic. Four main areas of interest have been analysed: patients' selection, procedures, techniques, and implementations. To establish consensus, an adapted Delphi method was used through as many reiterative rounds were needed. Systematic literature reviews were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses instructions. The Consensus took place between February 2019 and July 2020. Twenty-six Italian centres participated. Eighteen clinically relevant items were identified. After a total of three Delphi rounds, 30-tree recommendations reached expert consensus establishing the herein presented guidelines. The Italian Consensus on MI surgery for SCRLM indicates possible pathways to optimise the treatment for these patients as consensus papers express a trend that is likely to become shortly a standard procedure for clinical pictures still on debate. As matter of fact, no RCT or relevant case series on simultaneous treatment of SCRLM are available in the literature to suggest guidelines. It remains to be investigated whether the MI technique for the simultaneous treatment of SCRLM maintain the already documented benefit of the two separate surgeries.

Two-stage hepatectomy in two regional district community hospitals: perioperative safety and long-term survival.

INTRODUCTION: Surgical resection offers the best chance of cure for patients with colorectal liver metastases (CRLMs). Two-stage hepatectomy (TSH) has been demonstrated to be safe and effective to obtain curative resection in patients with multiple, bilobar CRLMs that are unresectable in a single procedure. Up to now TSH has been the prerogative of dedicated liver surgery centers. The aim of this study was to assess the safety and effectiveness of TSH also in community hospitals. METHODS: Of 294 patients operated on for CRLMs between September 1997 and June 2012 in 2 district community hospitals (belonging to the same regional healthcare district), 43 (14.6%) were scheduled for TSH. Thirty-eight/43 received neoadjuvant and/or bridge chemotherapy (2 neoadjuvant only, 4 neoadjuvant and bridge, 32 bridge only). RESULTS: The mean follow-up was 35.74 ± 29.53 months. Five-year overall survival (OS) was 31.4%, with a median survival time of 31 months. Twenty-nine patients completed the planned procedure (OS: 42.9%; median 47 months), while 14 did not because of disease progression (OS: 0%; median 13 months). No operative mortality occurred within the first 90 days either after the first or second stage. CONCLUSIONS: Our results suggest good efficacy and safety of TSH even when performed in a community hospital setting. Shifting patient selection from neoadjuvant to bridge chemotherapy had no impact on outcome once the clearing of the liver had been achieved. In patients presenting with synchronous CRLMs, simultaneous colorectal resection and clearing of the less involved hemiliver as the first surgical step is feasible without any negative impact on outcome.

Improvement in perioperative and long-term outcome after surgical treatment of hilar cholangiocarcinoma: results of an Italian multicenter analysis of 440 patients.

OBJECTIVE: To evaluate improvements in operative and long-term results following surgery for hilar cholangiocarcinoma. DESIGN: Retrospective multicenter study including 17 Italian hepatobiliary surgery units. PATIENTS: A total of 440 patients who underwent resection for hilar cholangiocarcinoma from January 1, 1992, through December 31, 2007. MAIN OUTCOME MEASURES: Postoperative mortality, morbidity, overall survival, and disease-free survival. RESULTS: Postoperative mortality and morbidity after liver resection were 10.1% and 47.6%, respectively. At multivariate logistic regression, extent of resection (right or right extended hepatectomy) and intraoperative blood transfusion were independent predictors of postoperative mortality (P = .03 and P = .006, respectively); in patients with jaundice, mortality was also higher without preoperative biliary drainage than with biliary drainage (14.3% vs 10.7%). During the study period, there was an increasingly aggressive approach, with more frequent caudate lobectomies, vascular resections, and resections for advanced tumors (T stage of 3 or greater and tumors with poor differentiation). Despite the aggressive approach, the blood transfusion rate decreased from 81.0% to 53.2%, and mortality slightly decreased from 13.6% to 10.8%. Median overall survival significantly increased from 16 to 30 months (P = .05). At multivariate analysis, R1 resection, lymph node metastases, and T stage of 3 or greater independently predicted overall and disease-free survival. CONCLUSIONS: Surgery for hilar cholangiocarcinoma has improved with decreased operative risk despite a more aggressive surgical policy. Long-term survival after liver resection has also increased, despite the inclusion of cases with more advanced hilar cholangiocarcinoma. Preoperative biliary drainage was a safe strategy before right or right extended hepatectomy in patients with jaundice. Pathologic factors independently predicted overall and disease-free survival at multivariate analysis.

Laparoscopic cholecystectomy can be performed safely with only three ports in the majority of cases.

Reducing the number of ports used to perform laparoscopic cholecystectomy (LC) is indicated as means of further minimising postoperative pain, allowing a rapid return to activity and work, and obtaining patient satisfaction and better cosmetic results. It is still debatable whether the three-port technique is comparably safe. Since 2001, 374 consecutive patients underwent laparoscopic cholecystectomy in elective and emergency surgery. Three ports were routinely positioned and the need for a fourth cannula was evaluated during the surgical procedure. Of the 374 consecutive cholecystectomies performed, 204 were completed with three ports and 161 needed a fourth port to be completed, while 9 required conversion to laparotomy. Patients who were operated on with just three ports were significantly younger and mostly female. Complications of procedures completed with three ports were negligible and those of procedures completed with four ports were in line with the recent literature. Our experience shows that the three-port technique is always a good initial option when performing laparoscopic cholecystectomy. It is safe and requires conversion to four-port placement in only a minority of cases overall.

Impact of radiofrequency assisted hepatectomy for reduction of transfusion requirements.

BACKGROUND: Liver parenchyma transection technique using heat coagulative necrosis induced by radiofrequency (RF) energy is evaluated in this series. METHODS: Between January 2000 and October 2004, 156 consecutive patients underwent liver resection with the RF-assisted technique. Data were collected prospectively to assess the outcome, including intraoperative blood loss, blood transfusion requirement, and morbidity and mortality rates. RESULTS: There were 30 major hepatectomies and 126 minor resections. While total operative time was 241 +/- 89 minutes, the actual resection time was 75 +/- 51 minutes. Intraoperative blood loss was 139 +/- 222 mL. Nine patients (5%) received blood transfusion, predominantly those receiving major hepatectomy (P = .006). Thirty-six patients (23%) developed postoperative complications, and the mortality rate was 3.2%. Mean hospital stay was 12 +/- 12 days. CONCLUSION: The RF-assisted technique is associated with minimal blood loss, a low blood transfusion requirement, and reduced mortality and morbidity rates and can be used for both minor and major liver resections.

Hydatid cyst of the liver: spontaneous rupture with peritoneal and thoracic involvement. Report of a case.

Hydatidosis due to Echinococcus granulosus is an endemic parasitic disease in Mediterranean countries. The most frequent anatomical locations are the liver and lung and the most significant complication of liver hydatidosis is rupture into the biliary tract. Spontaneous rupture into the free peritoneal cavity associated with thoracic involvement is an unusual complication accompanied by a high mortality rate. An isolated abdominal approach is necessary when peritoneal cavity drainage is required and may be sufficient in cases of contamination of the pleural cavity by scolices without suppurative involvement. An unusual case of spontaneous rupture of a hydatid cyst of the liver into the free peritoneal cavity associated with diaphragmatic and pleural involvement is reported. This complication requires immediate surgical treatment consisting in a combined thoracic and abdominal approach. The isolated abdominal approach not requiring thoracotomy may be satisfactory if there is no intrathoracic damage due to the chronic presence of scolices. Intrabdominal and intrathoracic cyst rupture still remains a serious complication because of the complexity of the lesions which are often difficult to treat in a one-stage operation. The mortality remains high in various series.

Prevention of hepatocellular carcinoma recurrence with alpha-interferon after liver resection in HCV cirrhosis.

Tumor recurrence after resection of hepatocellular carcinoma (HCC) can occur early (<2 years) or late (>2 years) as metastases or de novo tumors. Interferon (IFN) has the potential for chemoprevention against hepatitis C virus (HCV)-related cirrhosis. A predetermined group of 150 HCV RNA-positive patients undergoing resection of early- to intermediate-stage HCC was stratified into 80 HCV-pure (hepatitis B anticore antibody [anti-HBc]-negative) and 70 mixed HCV+hepatitis B virus (HBV) (anti-HBc-positive) groups, then randomized to IFN-alpha (3 million units 3 times every week for 48 weeks [n = 76]) versus control (n = 74). The primary end point was recurrence-free survival (RFS); secondary end points were disease-specific and overall survival. Intention-to-treat and subgroup analysis on adherent patients were conducted. Treatment effects on early/late recurrences were assessed using multiple Cox regression analysis. No patient experienced life-threatening adverse events. There were 28 adherent patients (37%). After 45 months of median follow-up, overall survival was 58.5%, and no significant difference in RFS was detectable between the two study arms (24.3% vs. 5.8%; P = .49). HCC recurred in 100 patients (48 IFN-treated, 52 controls), with a 50% reduction in late recurrence rate in the treatment arm. HCC multiplicity and vascular invasion were significantly related to recurrence (P = .01 and .0003). After viral status stratification, while no treatment effect was apparent in the mixed HCV+HBV population and on early recurrences (72 events), there was a significant benefit on late recurrences (28 events) in HCV-pure patients adherent to treatment (HR: 0.3; 95% CI: 0.09-0.9; P = .04). In conclusion, IFN does not affect overall prevention of HCC recurrence after resection, but it may reduce late recurrence in HCV-pure patients receiving effective treatment.

Laparoscopic treatment of Morgagni-Larrey hernia: technical details and report of a series.

Three patients with Morgagni-Larrey hernia were admitted to the surgical department between August 2000 and September 2003 with slight chest pain and dyspnea. Laparoscopic repair of the diaphragmatic hernia was performed using a tension-free closure of the defects with either Vicryl-Prolene or dual facing mesh fixed by Prolene extracorporeal knots and Endostitch devices. The patients were discharged on postoperative day 5 without complications. Mean follow-up has been 23 months (range, 15-36 months) and no recurrence or morbidity related to the procedure has been seen. Laparoscopic repair of Morgagni-Larrey hernia represents an attractive alternative to open surgery. The benefits are gentle and easy manipulation of the content of the sac, reduced surgical trauma, and rapid and uneventful recovery.

Conservative management of a spleen trauma using radiofrequency.

AIM OF THE STUDY: Conservative operative management of a splenic injury has become more and more employed in order to preserve the immune function of the organ. CASE REPORT: A case of a rupture of the spleen successfully treated with the use of a radiofrequency thermal energy generator is eported. The parenchymal tear was coagulated by a one cooled tip needle electrode. There were no postoperative complications and the function of the spleen was preserved. CONCLUSIONS: The technique cannot be applied in case of lesion of the major vessels or in case of avulsion of the hilum. This technique integrates to the others to make the operative conservative management of a splenic injury more and more feasible.

Radiofrequency-assisted liver resection.

Radiofrequency (RF)-assisted thermal ablation has been used with increasing frequency for unresectable hepatic tumors. This new approach employs RF energy to coagulate the liver at the hepatic resection line after which hepatic resection is performed with the use of a common scalpel. This procedure was used in three patients with hepatocellular carcinoma and in five patients with colorectal metastasis to the liver. These eight patients underwent a total of two left bisegmentectomies, three segmentectomies, and seven wedge resections. Mean operative time was 220 minutes. A mean of 78 sessions of RF-assisted ablation were required for these resections. Mean blood loss was 46 ml; no device other than RF ablation was required to obtain hemostasis. None of the patients needed a blood transfusion. Preoperative hemoglobin was 12.8 gm/dl and postoperative hemoglobin was 11.3 gm/dl. There were no perioperative deaths. Postoperative complications occurred in two patients: a liver abscess in one and heart failure in the other. The mean hospital stay was 9.4 days. This new approach, integrated with other techniques, reduces blood loss and coagulates the margins of resection during liver surgery. This new technique has two limitations: (1) it cannot be applied near main portal pedicles, and (2) it requires a long operative time. The best indication for this technique is when segmentectomy is required in patients with cirrhosis. Its role in major hepatic resections has yet to be determined. Further progress in the development of thermal ablation techniques and experience gained during the learning curve should help reduce the operative time, thereby improving the safety and efficacy of this procedure.