Is computed tomography volumetric assessment of the liver reliable in patients with cirrhosis?

OBJECTIVES: The estimation of liver volume (LV) has been widely studied in normal liver, the density of which is considered to be equivalent to 1 kg/l. In cirrhosis, volumetric evaluation and its correlation to liver mass remain unclear. The aim of this study was to evaluate the accuracy of computed tomography (CT) scanning to assess LV in patients with cirrhosis. METHODS: Liver volume was evaluated by CT (CTLV) and correlated to the explanted liver weight (LW) in 49 patients. Liver density (LD) and its association with clinical features were analysed. Commonly used formulae for estimating LV were also evaluated. The real density of cirrhotic liver was prospectively measured in explant specimens. RESULTS: Wide variations between CTLV (in ml) and LW (in g) were found (range: 3-748). Cirrhotic livers in patients with hepatitis B virus infection presented significantly increased LD (P = 0.001) with lower CTLV (P = 0.005). Liver volume as measured by CT was also decreased in patients with Model for End-stage Liver Disease scores of >15 (P = 0.023). Formulae estimating LV correlated poorly with CTLV and LW. The density of cirrhotic liver measured prospectively in 15 patients was 1.1 kg/l. CONCLUSIONS: In cirrhotic liver, LV assessed by CT did not correspond to real LW. Liver density changed according to the aetiology and severity of liver disease. Commonly used formulae did not accurately assess LV.

Cullin7: a new gene involved in liver carcinogenesis related to metabolic syndrome.

BACKGROUND: Metabolic syndrome (MS) is an emerging risk factor in hepatocellular carcinoma (HCC). HCC related to MS may occur either in advanced fibrosis or before the development of cirrhosis, suggesting involvement of different molecular pathways according to the features of background liver. OBJECTIVE: To investigate genomic aberrations in HCC related to MS in order to identify new target genes involved in liver carcinogenesis. METHODS: Chromosomal aberrations of HCC obtained from 20 patients with MS (HCC/MS) were studied by comparative genomic hybridisation and compared with HCC related to hepatitis C virus (HCV) infection (HCC/HCV, n=10) and, within the group of HCC with MS, according to the condition of the background liver (presence or absence of significant fibrosis). RESULTS: Among the most frequent chromosomal alterations observed in HCC, 6p21.1 amplification had a higher incidence in HCC/MS than in HCC/HCV (60% vs 20%, p<0.01). Advanced fibrosis/cirrhosis in the peritumoral liver was the only clinicopathological factor associated with the 6p21.1 amplicon in HCC/MS. Increased expression of cullin7 (CUL7), a gene located at the 6p21.1 locus, was demonstrated in HCC with the 6p21.1 amplicon, in parallel with a decrease in cyclin D1 expression. CUL7 downregulation using siRNA transfection in hepatoma cell lines induced significant cyclin D1 expression (by promoting its degradation), decreased cell proliferation and increased apoptosis. CONCLUSIONS: This study demonstrates specific genomic alterations in HCC/MS and points to CUL7 as a novel gene potentially involved in liver carcinogenesis associated with MS, the amplification of which might influence cell proliferation.

Removable intraductal stenting in duct-to-duct biliary reconstruction in liver transplantation.

Biliary reconstruction during liver transplantation (LT) is most oftenly performed by duct-to-duct biliary anastomosis. We hypothesized that the internal stenting might diminish the incidence and severity of biliary complications in patients receiving small duct size donor grafts. The purpose of this study was to report a technique of biliary reconstruction, including intraductal stent tube (IST) placement followed by postoperative endoscopic removal. A custom-made segment of a T-tube was placed into the bile in 20 patients in whom the diameter of the graft bile duct was smaller than 5 mm. The tube was removed endoscopically 4-8 months after LT, or in case of IST-related adverse events. After a median follow-up of 15.2 (range 2.5-27.5) months, endoscopic removal of the IST was performed in 17 patients. No technical failure and no procedure-related complications were recorded during drain removal. Biliary complications occurred in four patients, including one cholangitis, one hemobilia, one asymptomatic biliary leakage, and one anastomotic stricture. No biliary complication occurred in the group of patients who underwent deceased donor whole graft LT. IST is technically feasible and safe, and may help to prevent severe biliary complication when duct-to-duct biliary anastomosis is performed on small size bile ducts.

Feasibility of laparoscopic restorative proctocolectomy without diverting stoma.

AIM: Restorative proctocolectomy performed before the advent of laparoscopy had evolved to frequently omit a diverting stoma. Our aim was to assess the impact of a diverting stoma on postoperative outcomes following laparoscopic restorative proctocolectomy. METHOD: Data on all patients undergoing a laparoscopic restorative proctocolectomy at our institution were prospectively collated in a database. RESULTS: Between November 2004 and February 2010, 71 patients (38 females) underwent laparoscopic restorative proctocolectomy. Indications included familial adenomatous polyposis (n=34), ulcerative colitis (n=35), indeterminate colitis (n=1) and Lynch syndrome (n=1). Laparoscopic restorative proctocolectomy was performed as a one-stage procedure in 49 patients, and after a sub-total colectomy in 22. Seven patients in each group underwent the formation of a diverting stoma. Nine patients required conversion to open surgery. Sixteen patients experienced at least one postoperative complication. The postoperative morbidity was 29% (n=4/14) and 21% (n=12/21) in patients with and without a stoma (p=0.8), and the rate of fistula was 21% and 5%, respectively (p=0.08). Seven percent of patients with a stoma and 16% without stoma had an intra-abdominal collection (p=0.7). Nine patients required reoperation. The reoperation rate was not influenced by the presence or absence of a diverting stoma. CONCLUSION: Laparoscopic restorative proctocolectomy can be performed safely without a diverting stoma in selected patients.

Predicting high grade lesions of sinusoidal obstruction syndrome related to oxaliplatin-based chemotherapy for colorectal liver metastases: correlation with post-hepatectomy outcome.

BACKGROUND/OBJECTIVE: Oxaliplatin-based chemotherapy induces sinusoidal obstruction syndrome (SOS) lesions in the nontumorous liver parenchyma, which may increase the risk of liver resection for colorectal liver metastases. The objective of this study was to evaluate the accuracy of aspartate aminotransferase to platelet ratio index (APRI) and FIB-4 scoring systems to predict chemotherapy-associated liver injury and to correlate the severity of sinusoidal injury with postoperative outcome. METHODS: Between 1998 and 2007, 78 patients were operated for colorectal liver metastases after preoperative oxaliplatin-based chemotherapy. Grading of steatosis and SOS in the nontumorous liver parenchyma was obtained in these patients. Univariate analysis of 18 preoperative factors to predict SOS occurrence was performed as well as multivariate analysis. Relevance of preoperative platelet count level, transaminase levels, and fibrosis scoring systems were evaluated to predict high grade lesions of SOS using a receiving operative curve analysis. Ninety-day mortality and morbidity were studied according to SOS severity in 51 patients who underwent major liver resection. RESULTS: Overall, pathologic examination showed high-grade lesions of SOS (SOS 2/3) in 46 (59%) patients. Univariate analysis showed that a low preoperative platelet count, elevated preoperative aspartate aminotransferase, short interval between chemotherapy and surgery were significant factors associated with high-grade lesions of SOS. Multivariate analysis showed that only the APRI score was an independent predictive factor for severe SOS. Receiving operative curve analysis revealed that the cut-off value predicting high-grade lesions of SOS with the best accuracy was an APRI score of 0.36 (area under the curve, 0.85; sensitivity, 87%; specificity, 69%). After major liver resection (n = 51), SOS 2/3 (n = 38) was associated with postoperative hepatic dysfunction (26/38 in SOS 2/3 vs. 3/13 in SOS 0/1; P = 0.004) and ascites (P = 0.03). CONCLUSION: A low preoperative platelet count and high APRI score seem to be the most reliable indicators to predict SOS severity.

Preoperative radiotherapy is associated with worse functional results after coloanal anastomosis for rectal cancer.

PURPOSE: This study was designed to evaluate functional outcome in patients treated with preoperative radiotherapy after low anterior resection and a coloanal anastomosis for low rectal cancer. METHODS: Functional outcome data from patients enrolled in a prospective randomized trial comparing 3 reconstructive procedures were evaluated with respect to administration of preoperative radiotherapy. Incontinence was assessed with a questionnaire on bowel function including the Fecal Incontinence Severity Index; sexual function was assessed with the Sexual Health Inventory for Men and a gender-specific questionnaire for women. Quality of life was assessed with SF-36 scores. RESULTS: Of 364 patients enrolled, 153 (42%) had no radiotherapy or chemotherapy, and 211 (58%) had preoperative radiotherapy; 186 (51%) had chemotherapy in addition to radiotherapy. Comparison of irradiated vs. nonirradiated patients showed no significant differences in postoperative morbidity (29.9% vs. 35.3%; P = 0.27). Two-year follow-up of 297 patients showed greater impairment of bowel function in irradiated patients (n = 170) vs. nonirradiated patients (n = 127): e.g., mean number of daily bowel movements at 12 months, 4.2 +/- 3.5 vs. 3.5 +/- 2.6, P = 0.032; urgency, 85% vs. 67%, P = 0.002). Antidiarrheal use was significantly higher in irradiated patients vs. nonirradiated patients at 4 (P = 0.043), 12 (P = 0.002), and 24 (P = 0.001) months. Sexual Health Inventory for Men scores indicated poorer function in irradiated patients at 24 months (P = 0.039). Preoperative radiotherapy had no deleterious effects on quality of life. Multivariate analyses showed that negative effects of preoperative radiotherapy on urgency at 4 months (P = 0.002) and antidiarrheal use at 24 months were independent of reconstruction technique, but a positive effect of reconstruction with a J-pouch was still observed in patients who received radiotherapy. CONCLUSION: Preoperative radiotherapy does not increase overall morbidity but is associated with poorer functional outcome after low anterior resection with coloanal anastomosis. Preoperative radiotherapy and the J-pouch are nonconfounding predictors of functional outcome up to 24 months after surgery.

Hepatic resection for gastrointestinal stromal tumor liver metastases.

Liver resection is the preferred treatment for gastrointestinal stromal tumor liver metastases (GIST LMs) when complete resection can be achieved. Major and extended hepatic resections can be safely performed, and using modern techniques, an increasing proportion of patients with GIST LMs are candidates for potentially curative therapy. The combination of tyrosine kinase inhibitor therapy (eg, imatinib) with surgery seems to improve outcome, and although prospective data are lacking, a short neoadjuvant course (6 months) of imatinib therapy followed by resection may improve patient selection for surgery and outcome from treatment. Postoperative therapy with imatinib is generally advised, although the duration of such therapy is not yet clearly defined. These questions may formulate the basis for future prospective studies of imatinib with complete resection of GIST LMs.

A marking technique for intraoperative localization of small liver metastases before systemic chemotherapy.

Preoperative chemotherapy is increasingly used prior to resection of colorectal liver metastases (CLM). Since some of these lesions may disappear or may be hardly detectable with intraoperative ultrasound (IOUS), we describe herein a new technique to mark small lesions with coils before chemotherapy. This technique facilitates the resection of small lesions likely to disappear after preoperative chemotherapy.

Liver recurrence of a subcutaneous temporal hemangiopericytoma: the index case.

INTRODUCTION: Hemangiopericytoma is an uncommon soft tissue vascular neoplasm. Intraperitoneal hemangiopericytomas such as primary or secondary liver location have been exceptionally described. Its natural history is mostly benign, but recurrences may occur and determining if these late-discovered tumors are distant metastases or synchronous slow and silent-growing locations is sometimes challenging. The histopathological diagnosis and definition of hemangiopericytoma is based on its distinction with solitary fibrous tumors. Liver resection to treat liver hemangiopericytoma seems to be supported by various published experiences. CASE PRESENTATION: We herein report the first case of liver metastases from a subcutaneous temporal hemangiopericytoma. The patient was treated by a liver resection. CD34 Immunostaining was negative, but strong expression of Bcl2 and CD99 was found in the neoplastic cells. After 1 year of follow-up, the patient is alive without recurrence. CONCLUSION: To date, published data, including the case herein reported, support the need for a prolonged follow-up and the role of liver resection to treat liver metastases of hemangiopericytomas. Complete resection of all gross disease appears to be the most significant prognostic factor.

Hepatocellular carcinomas in patients with metabolic syndrome often develop without significant liver fibrosis: a pathological analysis.

UNLABELLED: Metabolic syndrome (MS) is a newly identified risk factor in chronic liver disease (CLD) and hepatocellular carcinoma (HCC). The aim of this study was to analyze the pathological characteristics of HCC and nontumoral liver in patients with MS as the only risk factor for liver disease in comparison with those that developed in the course of other CLDs in order to provide further insight into the physiopathology of HCC associated with MS. HCC patients with features of MS as the only risk factor for liver diseases (MS group, n = 31) were compared to HCC patients with overt causes of CLD (CLD group, n = 81) or without causes of CLD (cryptogenic group, n = 16) who underwent surgical resection during the same period of time. Among the patients of the MS group, there were 30 males and 1 female. In comparison with the patients with HCC of the CLD group, the patients with MS were older (mean age: 67+/- 7 versus 59 +/- 14 years, P < 0.01), and the background liver was significantly more often free of significant fibrosis (F0-F2: 65% in the MS group versus 26% in the CLD group, P < 0.001). In addition, HCCs associated with MS were more often well differentiated (65% versus 28%, P < 0.001). Five HCCs, all from the MS group, developed on a preexisting liver cell adenoma, with three of them showing typical histological features of telangiectatic adenoma. CONCLUSION: This study shows that HCCs in patients with features of MS as the only risk factor for liver disease have distinct morphological characteristics and mainly occur in the absence of significant fibrosis in the background liver. In addition, some of them arise through malignant transformation of a preexisting liver cell adenoma.

Complete hepatocellular carcinoma necrosis following sequential porto-arterial embolization.

Most patients with hepatocellular carcinoma (HCC) are not eligible for curative treatment, which is resection or transplantation. Two recent series have emphasized the potential benefits of preoperative arterio-portal embolization prior to surgical resection of such tumours. This preoperative strategy offers a better disease free survival rate and a higher rate of total tumor necrosis. In case of non resectable HCC it is now widely accepted that transarterial chemoembolization (TACE) leads to a better survival when compared to conservative treatment. Thus, the question remains whether combined portal vein embolization (PVE) may enhance the proven efficiency of TACE in patients with unresectable HCC. We herein report the case of a 56-year-old cirrhotic woman with a voluminous HCC unsuitable for surgical resection. Yet, complete tumour necrosis and prolonged survival could be achieved after a combined porto-arterial embolization. This case emphasizes the potential synergistic effect of a combined arterio-portal embolization and the hypothetical survival benefit of such a procedure, in selected patients, with HCC not suitable for surgery or local ablative therapy.

Laparoscopic division of a portosystemic shunt to treat chronic hepatic encephalopathy.

In the event of liver cirrhosis with severe portal hypertension, voluminous portosystemic shunt may lead to refractory encephalopathy. Obliteration of the shunt has been described as a satisfactory therapeutic solution, and reported procedures are mainly endovascular embolization and surgical shunt ligation through laparotomy. The former procedure is less invasive and seems to be as efficient. Laparoscopy, which is widely recognized to minimize mortality and morbidity in cirrhotic patients undergoing surgery, has never been used for such a procedure. Shunt division can therefore be considered using this modern approach to good effect and reduced morbidity. In support of this view, we report a case of severe chronic encephalopathy cured by laparoscopic surgical division of a large shunt after failure of the percutaneous technique.

Hepatocellular carcinoma developed on compensated cirrhosis: resection as a selection tool for liver transplantation.

The objective of this study was to evaluate the histological profile obtained from primary resection of hepatocellular carcinoma (HCC) as a selection tool for liver transplantation (LT). The natural history of HCC depends on its histological features. The clinical effectiveness of resection as a selection tool for salvage or de principe LT has been previously advocated. Between 1987 and 2006, 20 patients underwent a resection prior to LT. Long-term survival of these 20 patients was compared to that of 73 patients who underwent primary LT. Histological features of the resected specimen were compared to those of the recurrences. Feasibility, morbidity, and mortality of LT following primary resection were also analyzed. Mean follow-up was 3.8 +/- 4.4 and 2.7 +/- 4.5 years from resection and LT, respectively; 6 patients died. The mean 1-, 3-, 5-, and 10-year overall survival rates were 71%, 61%, 55%, and 45% and 74%, 66%, 66%, and 40% after primary transplantation and primary resection, respectively (not significant). At LT, 14 patients had a recurrence, but histological study of the recurrence was not possible in 2 (complete necrosis). For 9 patients (75%), histological features of both primary and recurrent tumors were exactly the same. Four patients had recurrence following LT; in each case, primary and recurrent nodules shared the same histological markers of poor prognosis. De principe transplantation was proposed to 6 patients because of poor prognosis histological features on the resected specimen. All these patients are alive without recurrence with a mean follow-up of 55 months. In conclusion, the natural history of HCC can be predicted on the basis of the histological profile of the resected specimen, which may be used as a selection tool for LT. De principe LT in patients within Milan criteria with poor prognosis histological features may be an optimal strategy.

Laparoscopic colorectal surgery in elderly patients: a matched case-control study in 178 patients.

BACKGROUND: We conducted a prospective case-matched study to compare outcomes of laparoscopic colorectal surgery in elderly (>or= 70 years) and younger (< 70 years) patients. STUDY DESIGN: Among 506 consecutive patients who underwent 536 colorectal resections supervised by 1 colorectal surgeon (YP), 75 elderly patients (>or= 70 years)were matched with 103 younger patients (< 70 years), according to gender, body mass index, pathology, and surgical procedure. Postoperative mortality and morbidity were defined as in-hospital deaths and complications. RESULTS: One hundred seventy-eight patients (95 men and 83 women) underwent laparoscopic colorectal resection for colorectal carcinoma (40%) or benign diseases (60%). Laparoscopic surgical procedures included left colectomy (43%), rectal resection (34%), right colectomy (12%), subtotal colectomy (6%), and rectopexy (5%). Cardiopulmonary comorbidities were significantly more frequent in elderly compared with young patients (80% versus 33%, p < 0.001). Mean operating times were similar between elderly and young patients (244+/-89 minutes versus 242+/-80 minutes, NS). Thirty-two patients (18%, 16 in each group) required conversion to laparotomy. There was no mortality. Overall postoperative complications were comparable between groups (32% versus 26%, NS). Sixteen patients (9%, 5 elderly and 11 young) required reoperation. Mean hospital stay was comparable between groups (11+/-8 days versus 10+/-9 days, NS). CONCLUSIONS: This large case-matched study suggested that laparoscopic colorectal surgery may be proposed in elderly patients, with similar postoperative outcomes as this surgery has in young patients, despite significantly more frequent cardiorespiratory comorbidities.