Abstract: BACKGROUND AND AIM: to identify the factors that could influence the outcome of the old aged patients underwent liver resection for hepatocellular carcinoma (HCC) or colorectal liver metastases (LMCRC). PATIENT AND METHODS: the Authors identified 51 patients older 70 years-old over 12-years period underwent resection for HCC (n 26) or for LMCRC (n 25). This group was compared with a cohort of 93 patients younger than 70 years who underwent resections in the same period. We have evaluated the results in terms of peroperative morbidity and mortality. RESULTS: the mean age of 51 elderly patients was 74 years-old. Thirty-five were treated with anatomical resection. Cirrhosis was present in 26 patients while 27 had co-morbidities. Thirteen patients developed complications and the mean age of these were 76 years compared with 73 of the patients who have not (p= .01). No mortality was registered. The cirrhosis, blood transfusions, anatomical resection and diameter of the lesion did not influence the outcome. CONCLUSIONS: our results indicate the age per se should not be considered a contraindication for surgery, that proved to be safe and curative therapy, but showed that old age, using 75 years as a cut-off, in association with at least one comorbid medical condition could be considered as relevant factor of morbidity.
Abstract: BACKGROUND/PURPOSE: The role of computer-assisted surgery (CAS) is still debated and not clearly defined. METHODS: The authors report their initial experience with CAS, comparing 29 patients submitted to cholecystectomy, using a Zeus remote-controlled robot and an Aesop remote voice-activated endoscope robot, with 29 patients submitted to standard laparoscopic cholecystectomy (LC). The surgical field and the arms of the robot were under the direct and real-time control of the surgeon, who stayed at the workstation and maneuvered the Zeus, using joysticks. The workstation was in the same room as the patient. RESULTS: Twenty-nine patients underwent telerobotic-assisted cholecystectomy (TLAC); 1 procedure was converted to standard LC and 1 to open cholecystectomy. The conversions were due to choledocholithiasis and cholecystitis. During TLAC, the mean operating time and transition time (from the induction of anesthesia to incision of the skin) were, respectively, 75 min (range, 60-170 min) and 45 min (range, 25-60 min). We did not observe any complications related to TLAC. The limitations of TLAC were the lack of tactile feedback, the increase in surgical time, and the expensive cost of the procedure to reach the same result as that of LC. CONCLUSIONS: After this initial experience, we believe that TLAC could be considered only for training in CAS, but that it is without advantages in terms of its higher cost compared with LC.
Abstract: BACKGROUND/PURPOSE: We evaluated the role of operative cholangiography and of conversion to decrease major bile duct injuries. METHODS: We report 1074 patients who underwent laparoscopic cholecystectomy, out of a total of 1195 patients who underwent laparoscopy, over an 8-year period. The planned laparoscopic operative procedure in all the patients was the standard four-port technique with the operator on the left side of the patient. Operative cholangiography was performed with Olsen's pliers. RESULTS: We performed 993 (83%) operative cholangiographies; 121 (10.1%) patients were converted from laparoscopic to open cholecystectomy. Despite a prolonged time of dissection, 54 (4.5%) patients were converted because of unclear anatomy of Calot's triangle. One hundred and ninety patients suffered acute cholecystitis and, of those, 52 (27.3% of 190 patients) were converted. Fifteen patients showed intraoperative biliary duct stones and they were converted. Seven (0.58%) bile duct injuries (one stricture and six fistulas) are reported. CONCLUSIONS: The low number of major bile duct injuries reported in our study showed the value of operative cholangiography during laparoscopic cholecystectomy. Moreover, another important factor found to reduce major bile duct injuries was conversion when, despite accurate dissection, the anatomy of Calot's triangle remained unclear.
Abstract: Amoebic liver abscess is the most common extra-intestinal manifestation of amebiasis with approximately 10% of the world's population infected by this parasite. Actually, incidence of this infection is also increasing in industrialized countries, as a consequence of the more frequent immigration or travelling. Only 3-10% of patients with intestinal amebiasis develop liver abscess. A clinical case of suprainfection of amoebic liver abscess consequent on acute appendicitis is presented.
Abstract: BACKGROUND: Spontaneous rupture is a life-threatening complication of HCC, occurring in 4.8-26% of cases. Liver failure is the main cause of death. Debates still remain on the most appropriate treatment in such patients because of the high operative mortality of emergency surgery and the high risk of rebleeding and less satisfying mid- and long-term results of nonoperative procedures like angiographic embolization. Early and long-term results of a surgically oriented treatment, based on prompt evaluation of the functional liver reserve and tumor resectability was retrospectively review-ed. METHODS: From January 1994 to December 2000, 11 patients (7 males and 4 female, mean age 66.2 (11.86 years) were treated for ruptured HCC, in 10 cases involving a cirrhotic liver. Seven patients underwent emergency surgery and 4 patients transcutaneous arterial embolization (TAE). Liver resection was performed in patients with preserved liver function, after ultrasonography and/or CT scan demonstrated hemoperitoneum and a single resectable liver tumour (5 cases). In one patient with cirrhosis, ultrasonography showed only hemoperitoneum. A bleeding nodule was discovered intraoperatively and resected in a liver with a multinodular HCC. Another patient under-went emergency resection after referral at our Unit with a surgical packing. In 4 cases with poor liver function and/or unresectable tumour TAE of the neoplasm was performed, in one case after surgical packing. Mortality, morbidity and patients survival after treatment were analyzed. All patients had at least 1 year follow-up. RESULTS: All patients underwent minor resection; 2 left lobectomies, 1 segmentectomy (VII), 1 bisegmentectomy (VII-VIII), and 3 wedge resections. Postoperative course was complicated by ascites in 5 cases and subphrenic abscess in one case. Four patients died 3, 4, 6 and 62 months after surgery; 3 patients are actually alive 22, 25, and 89 months after surgery. Four patients were submitted to TAE: all patients died within 6 months. CONCLUSIONS: When ruptured HCC is suspected, preserved liver function (Child A-B7) and a resectable hepatic tumour are considered clear indications to surgery. Emergency liver resection achieved good early and long-term results. In cases of advanced liver disease or multinodular HCC a non-operative approach, like TAE, must be attempted. Surgical direct hemostasis or hepatic artery ligation must be reserved for patients with uncontrollable o recurrent bleeding after TAE.
Abstract: Conservative treatment of hepatic trauma is currently implemented in 80-90% of cases with a success rate of 92.5% and is mainly based on the haemodynamic status of the patients. We conducted a retrospective study of 71 patients with hepatic trauma from January 1993 to April 2001 and reviewed our experience with surgical and conservative treatment, also considering associated extrahepatic lesions. Fifty-three (74.6%) patients with liver trauma underwent celiotomy and 18 (25.3%) were treated conservatively. Haemodynamic instability was the most common indication for surgery (34 patients). Eighteen (52.9%) patients required an extrahepatic surgical procedure. Nineteen (35.8%) patients were haemodynamically stable and the indications for surgery in these cases were penetrating trauma in 6, large haemoperitoneum in 12, and diaphragmatic rupture in 1. The overall mortality in the operated group was 15%, but the liver-related mortality rate was 7.5%. The success rate for conservative management was 88.8%, with mortality 0% and morbidity 11%. The patients managed conservatively had grades of injury (I-III) similar to the haemodynamically stable operated patients (94.4% vs 94.7%), whereas the haemoperitoneum was larger in the operated group (63.1% vs 11.1%). Non-operative management is the preferred treatment option in haemodynamically stable patients with limited haemoperitoneum, regardless of the grade of the hepatic lesion, and without severe intra-abdominal injuries.
Abstract: Squamous cell liver cancer (SCLC) arising from an epidermoid intestinal cyst is rare. Only 65 cases of this cyst have been reported since 1850, with 2 reported cases of squamous cell cancer. We describe here the case of a 21-year-old man who complained of mild pain, a feeling of fullness in the right upper quadrant of the abdomen, and fever and weight loss, who developed SCLC arising from an epidermoid intestinal cyst. The clinical presentation, management, and pathological findings are discussed.
Abstract: In view of the proven efficacy of endoscopic sclerotherapy and the even improving results of liver transplantation, the present role of porto-systemic shunt should be reconsidered. From 1986 (when our liver transplant program began), to March 1994, 59 cirrhotic patients (males = 40, females = 19, mean age 53.17 +/- 12.04) underwent a porto-systemic shunt, 22 under emergency conditions and 37 in an elective setting. Patients were subdivided according to age, emergency or elective surgery, type of operation, and liver function. In the emergency procedures previous sclerotherapy and time between admission and surgery were also considered in the assessment. Mean follow-up was 46.49 +/- 31.48 months. Overall 5-year actuarial survival was 62.5%. In the emergency porto-systemic shunts the worst short-term results were obtained in patients over 55 years of age (p < 0.05) and when operations were performed within the first 24 hours after admission (p < 0.005). Long-term survival was not significantly influenced by the variables considered although patients over 55 years of age and patients with reduced liver function (Child B and C) seemed to have a more dismal outcome. Those patients under 55 years of age, with no portal thrombosis, considered as potential liver transplant candidates, had a better short-term survival rate (p < 0.05) than that of the rest of the patient population studied, mainly because of the better outcome after emergency surgery. Our data confirm the efficacy of porto-systemic shunt procedures in preserving the patient from variceal bleeding. They have a definite role in the complex treatment strategy of portal hypertension, and they must not be considered only a rescue procedure. However, liver transplantation remains the best option to resolve both portal hypertension and the underlying liver disease.
