Matteo Barabino, MD Date of birth 03-04-1973 Nationality: Italian Address: via Gb Barinetti 1 Milan Zip code 20145 Mobile +39335211091 Post Graduate Degree in General Surgery 09-11-2004 Main occupation field: HPB Surgery Work's location:HPB Surgical Unit San Paolo Hospital - Milan - Chief Prof. E. Opocher
Main interests in these years have been the study and application of intraoperative laparoscopic and laparotomic ultrasonography in the staging and treatment of hepatobiliary tumours. At regards he attended to 2 courses of ultrasonographic techique in HPB surgery in Turin and Rome (2008) and recently he partecipated to the organization of a Course in HPB laparoscopic ultrasound in Milan (march 2009). In 2007 he attended to the italian Course of HPB surgery directed by Dr Capussotti in Turin and during this period he made a stage at the Transplantation HPB Surgical Unit directed by Dr. Mazzaferro in Milan. . Moreover in the summer 2007 he made a stage at the Centre Hepato-Biliaire dell’Hopital Paul Brousse directed by Prof Castaing. From July 2009 to October 2009 he also attended as visiting fellow to Department of HPB Of Red Cross Medical Hospital Tokyo, directed by Prof. Masatoshi Makuuchi
Abstract: PURPOSE: This study was designed to compare our laparoscopic ultrasonography (LUS) experience in the resectability evaluation of pancreatic or periampullary cancers (PAC) in two different periods: before and after the introduction of multidetector CT (MDCT). METHODS: We prospectively enrolled 104 CT-resectable patients with PAC. During Step 1 (1995-1999), we performed LUS on all patients, whereas during Step 2 (2002-2007), LUS was performed selectively according to Pisters' criteria. RESULTS: LUS was satisfactorily performed in all cases. At Step 1 accuracy of LUS in predicting pancreatic resectability was high (96%) but it was markedly lower in a subgroup of patients with close contact between tumor and portal vein (sensibility of 57%). At Step 2, selective LUS was performed on 9 of 64 patients (14%). LUS confirmed the MDCT finding of unresectability in 8 of 9 cases, and allowed curative resection in 1 case. Only 1 of 55 of the patients who did not undergo LUS would have benefited from the procedure. The yield of LUS decreased from 45% before to 1.8% after MDCT. CONCLUSIONS: In resectable-MDCT patients, routine LUS is unjustified. However, in doubtful MDCT cases, LUS has yet a good yield. In the event of close vascular contact, neither MDCT nor LUS seem to be conclusive, and laparotomy is still the only solution.
Abstract: BACKGROUND: Laparoscopic surgery has gained growing acceptance, but this does not hold for laparoscopic surgery of the liver, above all for patients with hepatocellular carcinoma (HCC) and cirrhosis. This approach mainly includes diagnostic procedures and interstitial therapies. However, we believe there is room for laparoscopic liver resections in well-selected cases. The aim of this study is to assess: (a) the risk of intraoperative bleeding and postoperative complications, (b) the safety and the respect of oncological criteria, and (c) the potential benefit of laparoscopic ultrasound in guiding liver resection. METHODS: A prospective study of laparoscopic liver resections for hepatocellular carcinoma was undertaken in patients with compensated cirrhosis. Hepatic involvement had to be limited and located in the left or peripheral right segments (segments 2-6), and the tumor had to be 5 cm or smaller. Tumor location and its transection margins were defined by laparoscopic ultrasound. RESULTS: From January 1997, 22 out of 250 patients with HCC (9%) underwent laparoscopic liver resections. The mean patient age was 61.4 years (range, 50-79 years). In three patients, conversion to laparotomy was necessary. The laparoscopic resections included five bisegmentectoies (2 and 3), nine segmentectomies, two subsegmentectomies and three nonanatomical resections for extrahepatic growing lesions. The mean operative time, including laparoscopic ultrasonography, was 199 +/- 69 min (median, 220; range, 80-300). Perioperative blood loss was 183 +/- 72 ml (median, 160; range, 80-400 ml). There was no mortality. Postoperative complications occurred in two out of 19 patients: an abdominal wall hematoma occurred in one patient and a bleeding from a trocar access in the other patient requiring a laparoscopic re-exploration. Mean hospital stay of the whole series was 6.5 +/- 4.3 days (median, 5; range, 4-25), while the mean hospital stay of the 19 laparoscopic patients was 5.4 +/- 1 (median, 5; range, 4-8). CONCLUSION: Laparoscopic treatment should be considered in selected patients with HCC and liver cirrhosis in the left lobe or segments 5 and 6 of the liver. It is clear that certain types of laparoscopic resection are feasible and safe when carried out by adequately skilled surgeons with appropriate instruments.
Abstract: BACKGROUND: The optimal treatment for hepatocellular carcinoma (HCC) is surgical resection. However, only a small percentage of patients are operative candidates. The authors aimed to assess a novel operative combination of laparoscopic radiofrequency (LRF) with a selective intrahepatic vascular occlusion (SIHVO) to obtain an increased rate of total necrosis and a reduced rate of local HCC recurrences. METHODS: For this study, 37 patients with HCC in liver cirrhosis were submitted to LRF with SIHVO. An LRF was indicated for patients not amenable to liver resection who evidenced at least one of the following criteria: severe impairment of the coagulation tests, large tumors (but <5 cm) or multiple lesions requiring repeated punctures, superficial lesions adjacent to visceral structures, deep-sited lesions with a very difficult or impossible percutaneous approach, and short-term recurrence of HCC after percutaneous loco-regional therapies. RESULTS: Laparoscopic ultrasound identified seven new malignant lesions (19%) undetected by preoperative imaging. There was no operative mortality. Of the 37 patients, 31 experienced no complications (84%). Computed tomography (CT) evaluation 1 month after treatment showed that a complete response with 100% necrosis had been achieved for all the patients (100%). During the follow-up period (mean, 11.8 +/- 8.2 months), new malignant nodules developed in 14 patients (42%), and 36% of these recurrences were located in the same treated segment of the HCC. CONCLUSIONS: The combined LRF and SIHVO procedure proved to be a safe and effective technique at least in the short and mid term. In fact, it permitted the treatment of lesions not treatable using the percutaneous approach with a complete clearance, and it had a low morbidity rate.
Abstract: BACKGROUND: Laparoscopic surgery has gained growing acceptance, but this does not hold for laparoscopic surgery of the liver. This mainly includes diagnostic procedures, interstitial therapies, and treatment of liver cysts. However, the authors believe there is room for a laparoscopic approach to the liver in selected cases. METHODS: A prospective study of laparoscopic liver resections was undertaken with patients who had preoperative diagnoses of benign lesion and hepatocellular carcinoma with compensated cirrhosis. The inclusion criteria required that hepatic involvement be limited and located in the left or peripheral right segments (segments 2-6), and that the tumor be 5 cm or smaller. The location of the tumor and its transection margin were defined by laparoscopic ultrasound (LUS). RESULTS: From December 1996, 17 (5%) of 313 liver resections were included in the study. There were 5 benign lesions and 12 hepatocellular carcinomas in cirrhotic patients. The mean age of the study patients was 59 years (range, 29-79 years). The LUS evaluation identified the presence of new hepatocellular carcinoma nodules in two patients (17%). The resections included 1 bisegmentectomy, 8 segmentectomies, 3 subsegmentectomies, and 3 nonanatomic resections. The mean operative time, including laparoscopic ultrasonography, was 156 +/- 50 min (median, 150 min; range, 60-250 min), and the perioperative blood loss was 190 +/- 97 ml. There was no mortality. Conversion to laparotomy was necessary for two patients. Postoperative complications were experienced by 3 of 15 patients, all of them cirrhotics. One of the patients had a wall hematoma, and the remaining two patients had bleeding from a trocar access requiring a laparoscopic reexploration. The mean hospital stay for the whole series was 6.9 +/- 4.9 days (median, 6 days; range, 2-25 days) and 5.6 +/-1.4 days (median, 6 days; range, 2-8 days) for the 15 laparoscopic patients. CONCLUSION: Laparoscopic treatment should be considered for selected patients with benign and malignant lesions in the left lobe or frontal segments of the liver. Evaluation by LUS is indispensable to guarantee precise determination of the segmental tumor location and the relationship of the tumor to adjacent vascular or biliary structures, excluding adjacent or adjunctive new lesions. The evolution of laparoscopic hepatectomies probably will depend on the development of new techniques and instrumentations.
Abstract: Background: An aggressive surgical approach combined with chemotherapy (CHT) is the best way to prolong survival in patients with colorectal cancer and synchronous resectable metastatic disease. Reintervention followed by systemic CHT is often a safe and effective procedure for fit patients with metastatic liver recurrence. Methods: Patients with resectable metastatic liver disease who underwent at least two surgical operations were included in the study. At diagnosis they had a median number of 6 measurable liver metastases (range 1–16), and median sum of largest diameters of lesions was 35 mm (range 10–70) from CT scan. Hepatic resection was followed each time by systemic CHT. Radiofrequency (RF) was added as needed to reach a curative intent . The aim of our study was to evaluate DFS and OS combining surgery, RF and CHT in this high-risk group. Results: Between November 2003 and July 2006 13 patients (median age 52 yrs, range 36–73; PS 0) with metastatic colorectal cancer underwent surgery on primary tumour and liver metastases followed by adjuvant CHT consisting of FOLFOX4 (oxaliplatin 85 mg/m2 and LV5FU) or FOLFIRI (irinotecan 180 mg/m2 and LV5FU) for 6 months. Free margins were obtained in 12 patients (92.3%). The second relapse was treated by liver surgery and systemic CHT (either FOLFIRI or FOLFIRI + Cetuximab in EGFR expressing tumours). Eight patients were offered concomitant radiofrequency (RF) for smaller lesions. Five patients (38.5%) underwent a third operation + RF followed by third-line CHT consisting of capecitabine alone or associated to oxaliplatin. After second and third hepatectomy there was no intraoperative or early postoperative mortality. With a median follow-up of 24 months (range 6–37) 6 patients are free of disease and all patients are still alive. Two-year DFS and OS are 46.2% and 100% respectively. Conclusions: Patients with metastatic colorectal cancer should be treated aggressively by surgery and CHT. In a small group of fit patients operated at least two times we obtained excellent 2-year DFS and OS. The benefit of adding adjuvant CHT as second-line or even third-line treatment seems to be justified by good long-term results. Our promising data from a single institution prompt further evaluation for aggressive surgery associated to CHT and new target molecules.
No significant financial relationships to disclose.
Abstract: We report three cases of intraductal papillary-mucinous tumour of the pancreas, occurring over a brief period in our surgical unit. Symptoms were aspecific in two cases, while only one of the patients presented a picture of acute pancreatitis. Preoperative investigations included ultrasonography, abdominal CT-scan and endoscopic ultrasonography (EUS) with guided fine needle aspiration biopsy (EUS-FNAB) of the cyst. EUS furnished invaluable data about the neoplasm and pancreatic duct morphology, while EUS-FNAB was crucial in revealing cytological features highly suggestive of intraductal papillary-mucinous tumour. All three patients underwent surgical resection, (two pylorus-preserving pancreatico-duodenectomies and one total pancreatectomy). The histological features of the resected specimen confirmed the preoperative EUS-FNAB diagnosis. After a medium-term follow-up, patients have been free of abdominal symptoms with no evidence of recurrence at CT-scan. In the present study we analyse the feasibility and effectiveness of EUS and EUS-FNAB in diagnosing intraductal papillary-mucinous tumours and in predicting their malignancy.
Abstract: PURPOSE: This article reports the results of a prospective trial of the feasibility of Longo's procedure under local anesthesia in day surgery. METHODS: From April 2002 to May 2003, 66 patients (42 males and 24 females) were enrolled in the study; the mean age was 47.5 (range, 23-65) years. Thirty-six patients (55 percent) had prolapsed third-degree hemorrhoids, while 30 (45 percent) had fourth-degree hemorrhoids. All patients were operated on under local infiltration of the anorectal region by injecting ropivacaine 7.5 mg/dl using a Quadrijet. During the surgical procedure, blood pressure and heart rate were always monitored and the level of pain was checked using a visual analog scale. Hospital discharge was programmed for 6:00 p.m. Any immediate complications, such as bleeding, urinary retention, or pain, were also recorded. RESULTS: It was possible to perform the procedure under local anesthesia in all patients, and the anesthesiologist did not need to intervene at any time. No vagal reaction was observed; the transient reduction of blood pressure and heart rate, which occurred in four patients (6 percent),was controlled with an analgesic drug. In 96 percent of the cases the mean intraoperative visual analog score was not higher than four. Fifty-six patients were discharged at 6:00 p.m., while only 10 percent required an overnight stay. CONCLUSIONS: The stapled prolapsectomy procedure is feasible and can be performed safely under local anesthesia and as day surgery. This procedure provides good pain control and results in a minimal number of complications.
Abstract: BACKGROUND: Hepatobiliary cystadenoma is a rare tumour that can be clinically 'silent' and only discovered as an incidental finding on ultrasonography (US). It can also be symptomatic with abdominal pain and jaundice or develop internal bleeding and (exceptionally) malignant degeneration. Therefore the treatment of choice is liver resection. CASE OUTLINE: A 77-year-old woman was admitted with mild jaundice and right hypochondrial pain. For 7 years she had been known to have a silent liver lesion, always considered to be a simple cyst on US. US and CT scan revealed a multi-septate mass involving segments IV, V and VIII of the liver, with thick walls, no calcifications and no contrast enhancement. US-guided aspiration showed the presence of old blood-stained material. The patient was operated with a suspected diagnosis of bleeding into a simple cyst. A Lin fenestration was performed with wide excision of the anterior wall of the cyst. Pathological examination demonstrated a mucinous hepatobiliary cystadenoma. The postoperative course was uneventful, and follow-up at 2 years confirmed no recurrence. DISCUSSION: Imaging will normally help to distinguish the occasional hepatobiliary cystadenoma from the common simple cyst. Otherwise, when a complication occurs, preoperative differentiation may become impossible, and requires histological examination of the cyst after surgical removal.
Abstract: Delayed gastrojejunocolic fistulas in patients previously operated for gastric cancer are often caused by local recurrence of the tumour. We present two cases of delayed gastrojejunocolic fistula without neoplastic recurrence. Both patients had been operated for adenocarcinoma several months earlier; a gastric Billroth 2 resection was performed in both cases. The first patient arrived at our hospital for chest pain, dyspepsia, weight loss, vomiting and diarrhoea. Blood tests showed low levels of vitamin B, proteins and cholesterol. The second patient was admitted for lipothymia, hyporexia, proctorrhagia, diarrhoea and weight loss. Blood tests showed macrocytic anaemia and hypoproteinaemia. The radiological and endoscopic examinations revealed a gastrojejunocolic fistula in both cases. Since gastrojejunocolic fistulas are rarely resolved by conservative treatment, we performed a gastric resection with a histological examination to exclude tumour recurrence in both patients. The aetiopathogenesis of gastrojejunocolic fistulas is unknown. It is conceivable that some agents (such as bile) may damage a mucosa that has been weakened by nutritional deficiency and/or postsurgical microvascular damage. Early and delayed gastrojejunocolic fistulas present the same clinical manifestations, namely, diarrhoea, abdominal pain, weight loss and hypoproteinaemia.
Abstract: Enteral feeding by jejunostomy is one of the main surgical procedures used to supply the proteins and calories necessary in the early postoperative period after major surgery of the upper digestive tract. The complications associated with early postoperative enteral feeding may vary from signs of gastrointestinal intolerance such as nausea, emesis, diarrhoea and cramp-like abdominal pain to hypotension and hypovolaemic shock, and also to the development of small bowel ischaemia and necrosis. Ischaemic intestinal involvement with progression towards necrosis is fortunately a rare event. The cause is not well known. A multifactorial pathogenesis of the mucosal damage has been proposed, where hyperosmolarity of feeding and bacterial overgrowth, due to excessive fermentation of carbohydrates, a decreased mesenteric blood flow and a lowering of peristalsis have been adduced as causes of mucosal injury. We report a case of intestinal necrosis following a jejunostomy procedure, which led to ileal resection.
Abstract: BACKGROUND: The surgical management of primary hyperparathyroidism is changing both in terms of the extent of cervical exploration and in technique. There are many new mini-invasive procedures for neck surgery. We describe our preliminary experience with a technique that combines two mini-invasive procedures--radio-guided and video-assisted parathyroidectomy. METHODS: Six consecutive patients with no recurrent or persistent primary hyperparathyroidism, no previous cervical operations, and no thyroid pathologies were selected to undergo radio-guided video-assisted parathyroidectomy. RESULTS: One case was converted. There was no morbidity or mortality in the postoperative period. Six parathyroids were removed; the histological diagnosis was adenoma in all cases. All patients were discharged on the 1st postoperative day. Calcium serum levels normalized in all cases, with only one case of transient postoperative hypocalcemia. All patients were normocalcemic after 6 months. CONCLUSION: Radio-guided video-assisted parathyroidectomy is feasible in selected patients. However, longer follow-up and more cases are necessary before this procedure can be applied routinely.
