Department of Surgery - Liver Unit, Scientific Institute San Raffaele, Via Olgettina 60, 20132, Milan, Italy. Tel: +39-02-2643-7808; Fax: +39-02-26437807.
pulitano.carlo@hsr.it
Carlo Pulitanò, M.D
I. PERSONAL INFORMATION
Date of Birth: 29/11/1977 Place of Birth: Reggio Calabria, Italy Citizenship: Italian Marital status: Single Home address and telephone: Via Palmanova n.28, 20132, Milan,Italy. Tel: +39-02-2822305; Fax: +39-02-26437807; E-mail: pulitano.carlo@hsr.it Professional address Royal Prince Alfred Hospital, Sydney, Australia
II. EDUCATION 1997-1998 University of Messina, Medical School, Messina, Italy. 1998-1999 Boston University, Department of Biology, Boston, MA, USA 1999-2004 Vita-Salute San Raffaele University, Medical School, Milan, Italy. 20- 7-2004 Medical Doctor (M.D) with honours, Vita-Salute San Raffaele University. 2005-Present Resident in General Surgery (Director. Prof. Valerio Di Carlo M.D). Vita-Salute San Raffaele University, Medical School, Milan, Italy.
III. HONORS AND AWARDS 2006 Finalist Young Investigators Award, 7th World Congress of the International Hepato- Pancreato-Biliary Association (IHPBA). Edinburgh, Scotland, September 3-7. 2006 Poster of Distinction, Annual Meeting of the American Hepato-Pancreato-Biliary Association (AHPBA). Miami, Florida, USA, March 9-12. 2005 Finalist Young Investigators Award, Congress of the American Hepato-Pancreato-Biliary Association (AHPBA). Ft. Lauderdale FL, USA, April 14-17. 2004 Best Presentation Award of the Session. 106° Congress of the Italian Society of Surgery. Rome, Italy, October 17-20. 1997 Young scientist award, 9th European Union Contest for Young Scientist. Milan, Italy, September 9-12.
IV. PROFESSIONAL EXPERIENCE 2006-Present Member of the organ harvest team, Center for Kidney and Pancreas Transplantation and Islet Transplant Program of Scientific Institute San Raffaele, Milan, Italy. 2005-Present Department of Surgery, Division of Hepatobiliary Surgery-Liver Unit, Scientific Institute San Raffaele, Milan, Italy (Director: Prof. Gianfranco Ferla M.D), under the supervision of Luca Aldrighetti M.D., Ph.D (Head of Liver Unit). Aug-Sep. 2003 Clinical Clerkship at Memorial Sloan-Kettering Cancer Center, NY, USA. Hepatobiliary Service (Director: Leslie. H. Blumgart). 2002-2005 Clinical Clerkship at I° Division of Surgery – Liver Unit, Scientific Institute San Raffaele, Milan, Italy (Director: Prof. Gianfranco Ferla), under the supervision of Luca Aldrighetti M.D., Ph.D. 1998-1999 Undergraduate Medical Research Fellow, Boston University, Department of Biology, Boston, MA, USA. V. EDITORIAL BOARD CONTRIBUTIONS 2005-Present Thrombosis and Haemostasis (reviewer) 2007-Present American Journal of Transplantation (reviewer)
VI. PRESENTATIONS AT SCIENTIFIC MEETINGS : N = 14 2004-Present 7 oral presentation in national meetings 2005-Present 7 oral presentation in international meetings (2 finalist young investigator award)
VII. RESEARCH INTERESTS Colorectal liver metastases (Prognostic factors; Hepatic arterial infusion chemotherapy; Neoadjuvant chemotherapy). Development of prognostic score systems in surgery Systemic reactions to operation (Use of corticosteroids in surgery; Coagulation Homeostasis in liver surgery). Liver surgery (Technique of liver transection; Laparoscopic liver surgery). Pathophysiology and modulation of hepatic ischemia/reperfusion Injury (Mediators of I/R injury; Role of I/R in promoting colorectal carcinoma micrometastases. Primitive liver tumors (Cholangiocarcinoma; Hepatocellular Carcinoma)
VIII. BIBLIOGRAPHY (2005-Present) Published Articles or In Press in Peer-Review Journals: 23 (Mean Impact factor 3.3) Reviews : 1 Books chapters : 1 Articles Submitted or in Preparation : 5 Abstracts: 41
Five most relevant articles for impact factor: 1. Aldrighetti L., Pulitanò C., Catena M., Arru M., Guzzetti E., Ferla G. Liver resection with Portal Vein Thrombectomy for HCC with Vascular Invasion. Ann Surg Oncol 2007: (In press) [Impact factor 3.329] 2. Pulitanò C., Arru M., Bellio L., Rossini S., Ferla G., Aldrighetti L. A risk score system for predicting perioperative blood transfusion in liver surgery. Br J Surg 2007 Jul;94(7):860-5. [Impact factor 4.092] 3. Pulitanò C., Aldrighetti L., Arru M., Finazzi R., Catena M., Guzzetti E., Comotti L., Soldini L., Ferla G. Preoperative Methylprednisolone Administration Maintains Coagulation Homeostasis in Patients Undergoing Liver Resection: Importance of Inflammatory Cytokine Suppression. Shock. 2007 Jun 14. [Impact factor 3.318] 4. Pulitanò C., Aldrighetti L., Arru M., Vitali G., Ronzoni M., Catena M., Finazzi R., Villa E., Ferla G. Influence of preoperative chemotherapy on the risk of major hepatectomy for colorectal liver metastases. Ann Surg 2006 Nov; 244(5):833-835. [Impact Factor 7.678] 5. Aldrighetti L., Pulitanò C., Arru M., Finazzi R., Catena M., Soldini L., Comotti L., Ferla G. Impact of preoperative steroids administration on ischemia-reperfusion injury and systemic responses in liver surgery: a prospective randomized study. Liver Transplant 2006; 12: 941-949 [Impact Factor 4.629]
IX. CAREER INTENTIONS:
I am determined to follow a career in Hepato-Pancreato-Biliary surgery. Once completed the residency in general surgery, I wish to obtain additional training and experience in the surgical management of HPB disease. I would like to find an accademic centre where I will be able to devote a significant portion of my professional practice to HPB research.
Abstract: BACKGROUND: Laparoscopy is considered the "gold standard" to perform left-lateral sectionectomy with results identical to those of open surgery, yielding decreased postoperative pain and disability, reduced hospital stay, and shortened patient recovery time. As the emphasis on minimizing the invasiveness of surgical techniques continues, laparoendoscopic single site (LESS) surgery is quickly evolving. The purpose of this study was to compare the results of laparoscopic left-lateral sectionectomy performed using the traditional approach or LESS approach with a case-matched analysis for tumor size, type of resection, and surgical indications. METHODS: Thirteen patients who underwent LESS left-lateral sectionectomy are considered the study group (LESS group) and compared with 13 patients who underwent left-lateral sectionectomy with traditional laparoscopic approach (conventional group). RESULTS: There were no significant differences between groups for length of surgery (165Â min in conventional group vs. 195Â min in LESS group), blood loss (150Â mL in conventional group vs. 175Â mL in LESS group), conversion to open surgery, histological tumor exposure, and requirements of postoperative analgesics. One patient in the LESS group died of cardiac failure due to an unknown severe aortic valve stenosis. No differences were recorded for postoperative complications (23.1% in both groups) and median length of postoperative stay (4Â days in both groups). CONCLUSIONS: For left-lateral hepatic sectionectomy, LESS surgery is technically feasible and as safe as traditional laparoscopic surgery in terms of intraoperative and postoperative results, even though requiring both hepatobiliary and laparoscopic technique experience.
Abstract: For patients with colorectal liver metastasis (CLM), the presence of concomitant perihepatic/para-aortic lymph node metastasis (LNM) is considered a contraindication to liver resection. We sought to determine the benefits of liver resection among patients with CLM + LNM by examining long-term outcomes among a large cohort of patients.
Abstract: Concomitant injury to the bile duct and hepatic artery is an increasingly recognized complication of laparoscopic cholecystectomy (LC). The impact of a concomitant arterial injury in patients with a bile duct injury (BDI) remains debatable. Early reports described a high incidence of septic complications, difficulty of biliary repair, and increased the risk of recurrent stricture.
Abstract: Hepatic resection for colorectal liver metastasis (CLM) with concomitant extrahepatic disease (EHD) is a controversial topic. We sought to evaluate the long-term outcome of patients undergoing liver resection for CLM in presence of EHD and identify factors associated with prognosis.
Abstract: Management of patients with neuroendocrine liver metastasis (NELM) remains controversial. We sought to examine the relative efficacy of surgical management versus intra-arterial therapy (IAT) for NELM and determine factors predictive of survival.
Abstract: To identify factors associated with outcome after surgical management of intrahepatic cholangiocarcinoma (ICC) and examine the impact of lymph node (LN) assessment on survival.
Abstract: Management of neuroendocrine tumor liver metastasis (NELM) remains controversial, with some advocating an aggressive surgical approach while others have adopted a more conservative strategy. We sought to define the efficacy of the surgical management of NELM in a large multicenter international cohort of patients.
Abstract: Laparoscopy is gaining acceptance as a safe procedure for resection of liver neoplasms. The aim of this study is to evaluate surgical results and mid-term survival of minor hepatic resection performed for HCC.
Abstract: Traditionally, survival estimates have been reported solely as survival from the time of surgery, but future survival probability likely changes based on the survival time already accumulated after therapy-otherwise known as conditional survival (CS). We sought to assess the comparative performance of various colorectal liver metastasis prognostic scoring systems, as well as to investigate the CS of patients who underwent resection of colorectal liver metastasis.
Abstract: During the last two decades, resection of colorectal liver metastases (CLM) in selected patients has become the standard of care, with 5-year survival rates of 25-58%. Although a substantial number of actual 5-year survivors are reported after resection, 5-year survival rates may be inadequate to evaluate surgical outcomes because a significant number of patients experience a recurrence at some point.
Abstract: To evaluate the impact of liver ischemia from hepatic pedicle clamping (HPC) on long-term outcome after hepatectomy for colorectal liver metastases (CRLM).
Abstract: 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.
Abstract: Although 5-year survival approaches 55% following resection of colorectal liver metastasis, most patients develop recurrent disease that is often isolated to the liver. Although repeat curative intent surgery (CIS) is increasingly performed for recurrent colorectal liver metastasis, only small series have been reported. We sought to determine safety and efficacy of repeat CIS for recurrent colorectal liver metastasis as well as determine factors predictive of survival in a large multicenter cohort of patients.
Abstract: Hepatocellular carcinoma (HCC) tends to invade the intrahepatic vasculature, especially the portal vein. The presence of portal vein tumor thrombus (PVTT) in patients with HCC is one of the most significant factors for a poor prognosis. The presence of macroscopic PVTT in patients with HCC is also a significant factor for poor prognosis, with a median survival of <3 months without treatment. In surgically resected series, in patients with gross PVTT (PVTT in the portal trunk, its first-order branch, or its second-order branch), the 3-year and 5-year survival rates are reportedly 15% to 28% and 0% to 17%, respectively.
Abstract: Several staging systems for patients with hepatocellular carcinoma (HCC) have been proposed, but studies of their prognostic accuracy have yielded conflicting conclusions. Stratifying patients with early HCC is of particular interest because these patients may derive the greatest benefit from intervention, yet no studies have evaluated the comparative performances of staging systems in patients with early HCC.
Abstract: Liver ischemia-reperfusion injury occurs in a number of clinical settings, including liver surgery, transplantation, and circulatory shock, leading to significant morbidity and mortality. There is a substantial evidence that hepatic ischemia-reperfusion injury results from an intense inflammatory response initiated by oxidative stress in the liver parenchyma during reperfusion. The anti-inflammatory effects of glucocorticosteroids (GCs) have been known for decades and have found extensive therapeutic use in a wide range of clinical situations associated with organ ischemia. Based on their biological effects, routine perioperative GCs administration has been advocated to reduce hepatic ischemic injury. However, the use of GCs in hepatic surgery remains controversial and clinical benefits are still uncertain. The aim of this review is to present the experimental and clinical evidence about the role of GCs in modulating hepatic ischemia-reperfusion injury.
Abstract: Laparoscopic liver resection (LLR) represents a natural extension of minimally invasive surgery. Several case-control studies have demonstrated that LLR is safe and feasible in carefully selected patients. LLR is associated with reduced operative blood loss and earlier recovery when compared with open surgery. In addition, oncologic clearance achieved with LLR is comparable to that achieved with open surgery. Improved cosmesis and postoperative patient comfort also argue in favor of LLR compared with open surgery. When considering whether a patient is suitable for LLR, the size and location of the neoplasm must be taken into account. Operator experience must also be considered as LLR is technically demanding and requires experience in conventional hepatobiliary surgery and advanced laparoscopy. The main indication for LLR is limited resection of superficial or peripherally located tumors. In the case of malignant tumors, LLR should be indicated only if a safe and effective oncologic resection can be performed, and the availability of laparoscopy should not change the indications for benign lesions. Ultimately, the future application of LLR will depend on how easily liver surgeons can master the technique and whether the long-term results of LLR can match those achieved with open resection.
Abstract: Previous comparative studies have demonstrated that laparoscopic liver resection is associated with more frequent use and longer duration of portal camping than open liver resection, a fact that may partially explain the improvement in operative blood loss reported by most series of laparoscopic liver resection. The aim of this prospective study was to evaluate the real need for portal clamping in laparoscopic liver surgery.
Abstract: Wedge resection (WR) for colorectal liver metastases (CLM) has become more common in an attempt to preserve liver parenchyma. However, some investigator have reported that WR is associated with a higher incidence of positive margin and an inferior survival compared with anatomic resection (AR) 1.
Abstract: Although hepatic artery infusion chemotherapy (HAIC) of floxuridine (FUDR) for colorectal liver metastases (CLM) can produce high response rates, data concerning preoperative HAIC are scarce. The aim of this study was to assess the feasibility and results of liver resection after preoperative HAIC with FUDR.
Abstract: Parenchymal liver transection represents a fundamental phase of liver surgery. Several devices have been described for safe and careful dissection of the liver parenchyma during laparoscopic liver surgery, but the ideal technique has not yet been defined. This report describes the combined use of ultrasonic dissector and the ultrasonic coagulating cutter for laparoscopic liver resection. The ultrasonic dissector is used to fracture the parenchyma along the line of proposed division, and the uncovered bridging structures are sealed using the ultrasonic coagulating cutter. The combined use of ultrasonic dissector and harmonic scalpel allows liver resection to be safely performed, with the advantage of minimal surgical complication and low blood losses.
Abstract: BACKGROUND: The aim of this study was to analyze the prognostic factors associated with long-term outcome after liver resection for colorectal metastases. The retrospective analysis included 297 liver resections for colorectal metastases. METHODS: The variables considered included disease stage, differentiation grade, site and nodal metastasis of the primary tumor, number and diameter of the lesions, time from primary cancer to metastasis, preoperative carcinoembryonic antigen (CEA) level, adjuvant chemotherapy, type of resection, intraoperative ultrasonography and portal clamping use, blood loss, transfusions, complications, hospitalization, surgical margins status, and a clinical risk score (MSKCC-CRS). RESULTS: The univariate analysis revealed a significant difference (p < 0.05) in overall 5-year survival rates depending on the differentiation grade, preoperative CEA >5 and >200 ng/ml, diameter of the lesion >5 cm, time from primary tumor to metastases >12 months, MSKCC-CRS >2. The multivariate analysis showed three independent negative prognostic factors: G3 or G4 grade, CEA >5 ng/ml, and high MSKCC-CRS. CONCLUSIONS: No single prognostic factor proved to be associated with a sufficiently disappointing outcome to exclude patients from liver resection. However, in the presence of some prognostic factors (G3-G4 differentiation, preoperative CEA >5 ng/ml, high MSKCC-CRS), enrollment of patients in trials exploring new adjuvant treatments is suggested to improve the outcome after surgery.
Abstract: The surgical management of hepatocellular carcinoma in patients with well-compensated cirrhosis is controversial. The purpose of the current study was to compare the outcome of patients with well-compensated cirrhosis and early stage hepatocellular carcinoma treated with initial hepatic resection versus transplantation.
Abstract: Secondary scrotal lymphedema is an infrequent complication of radical cystectomy assiociated with pelvic lymphadenectomy. We report a case of secondary lymphedema of male genitalia presenting more than 4 years after a radical cystectomy with extended pelvic lymphadenectomy for adenocarcinoma of the bladder. Microsurgical lymphovenous anastomoses are usually performed using only the scrotal lymphatics excluding the testicular lymphatics drainage. We have experimented a new microsurgical technique based on lymphovenous anastomosis between the collectors of the spermatic funiculus and the veins of the pampiniform plexus, allowing the testicular lymphatic drainage. (c) 2007 Wiley-Liss, Inc. Microsurgery, 2007.
Abstract: BACKGROUND: Left lateral sectionectomy is one of the most commonly performed laparoscopic liver resections, but limited clinical data are actually available to support the advantage of laparoscopic versus open-liver surgery. The present study compared the short-term outcomes of laparoscopic versus open surgery in a case-matched analysis. MATERIALS AND METHODS: Surgical outcome of 20 patients who underwent left lateral sectionectomy by laparoscopic approach (LHR group) from September 2005 to January 2007 were compared in a case-control analysis with those of 20 patients who underwent open left lateral sectionectomy (OHR group). Both groups were similar for: tumor size, preoperative laboratory data, presence of cirrhosis, and histology of the lesion. Surgical procedures were performed in both groups combining the ultrasonic dissector and the ultrasonic coagulating cutter without portal clamping. RESULTS: Compared with OHR, the LHR group had a decreased blood loss (165 mL versus 214 mL, P = 0.001), and earlier postoperative recovery (4.5 versus 5.8 days, P = 0.003). There were no significant differences in terms of surgical margin and operative time. Morbidity was comparable between the two groups, but two cases of postoperative ascites were recorded in two cirrhotic patients in the OHR. Major complications were not observed in either groups. CONCLUSIONS: Laparoscopic resection results in reduced operative blood loss and earlier recovery with oncologic clearance and operative time comparable with open surgery. Laparoscopic liver surgery may be considered the approach of choice for tumors located in the left hepatic lobe.
Abstract: BACKGROUND: It would be desirable to predict which patients are most likely to benefit from preoperative autologous blood donation. This aim of this study was to develop a point scoring system for predicting the need for blood transfusion in liver surgery. METHODS: The medical records of 480 consecutive patients who underwent hepatic resection were analysed. The data set was split randomly into a derivation set of two-thirds and a validation set of one-third. Univariable analysis was carried out to determine the association between clinicopathological factors and blood transfusion. Significant variables were entered into a multiple logistic regression model, and a transfusion risk score (TRS) was developed. The accuracy of the system was validated by calculating the area under the receiver-operator characteristic (ROC) curve. RESULTS: Factors associated with blood transfusion in multivariable analysis included preoperative haemoglobin concentration below 12.5 g/dl, largest tumour more than 4 cm, need for exposure of the vena cava, need for an associated procedure, and cirrhosis. Each variable was assigned one point, and the total score was compared with the transfusion status of each patient in the validation set. The TRS accurately predicted the likelihood of blood transfusion. In the validation set the area under the ROC curve was 0.89. CONCLUSION: Use of the TRS could lead to substantial saving by improving the cost-effectiveness of the autologous blood donation programme.
Abstract: Several techniques have been described for safe dissection of the liver parenchyma. The aim of this study was to evaluate the feasibility and effectiveness of combining two different electronic devices, the ultrasonic dissector and the harmonic scalpel, during hepatic resection. One hundred consecutive patients who underwent liver resection between January and December 2004 were enclosed in the study. Patients requiring concomitant colic resection or biliary-enteric anastomosis were excluded from the study. Operative variables (type of procedure, operating time, Pringle time, blood losses, transfusions, and histological tumor exposure at the transection surface), hospital stay, and complications were recorded. The extent of hepatic resection was a minor resection in 31 and major in 69 cases. Median blood loss was 500 mL (range, 100-2000 mL) and the Pringle maneuver was used in 58 patients. Median operative time was 367 minutes (range, 150-660 minutes). Hepatic resection was performed in 32 cirrhotic livers. Surgical complications included one postoperative hemorrhage and two bile leaks. The overall morbidity and mortality rate was 14 and 1 per cent, respectively. In conclusion, the combined use of these electronic devices allows liver resection to be safely performed, even in cirrhotic patients, with the advantage of reducing surgical complications. A prospective randomized trial is needed to clarify the clinical benefits of liver resections performed combining these two devices.
Abstract: Hepatic injury secondary to warm ischemia and reperfusion (I/R) remains an important clinical issue following liver surgery. The aim of this prospective, randomized study was to determine whether steroid administration may reduce liver injury and improve short-term outcome.
Abstract: Alterations in hemostatic parameters are a common finding after major hepatic resection. There is growing evidence that inflammation has a significant role in inducing coagulation disarrangement that follows major surgery. To determine whether preoperative methylprednisolone administration has a protective effect against the development of coagulation disorders, we evaluated the effect of preoperative steroids administration on changes in hemostatic parameters and plasma levels of inflammatory cytokines in patients undergoing liver surgery. Seventy-three patients undergoing liver resection were randomized to a steroid group or to a control group. Patients in the steroid group received 500 mg of methylprednisolone preoperatively. Serum levels of coagulation parameters (prothrombin time, platelets, fibrinogen, plasma fibrin degradation products [D-dimer], antithrombin III) and inflammatory mediators (IL-6 and TNF-alpha) were measured before and immediately after the operation and on postoperative days 1, 2, and 5. Multivariate analysis was performed to identify factors related to the characteristics of the patients and surgery affecting coagulation parameters between the two groups. Decreases in antithrombin III, platelet count and fibrinogen levels, prolongation of prothrombin time, and increases in the plasma fibrin degradation products were significantly suppressed by the administration of methylprednisolone. Cytokines production was also significantly suppressed by the administration of methylprednisolone, and there was significant correlation between plasma levels of cytokines and coagulation alterations. These findings suggest that preoperative methylprednisolone administration inhibits the development of coagulation disarrangements in patients undergoing liver resection, possibly through suppressing the production of inflammatory cytokines.
Abstract: BACKGROUND: Based on previous studies in experimental models, pro-inflammatory Th1 cytokines (i.e. TNF-alpha and IFN-gamma) are thought to play a pathogenic role in hepatic ischemia/reperfusion injury, while anti-inflammatory Th2 cytokines (i.e. IL-4 and IL-10) have been associated with reduced liver disease severity. To test the relevance of these concepts in humans, cytokine expression profiles were characterized in liver biopsies from patients undergoing hepatic resection following intermittent portal clamping. METHODS: Twelve patients were analyzed for the intrahepatic expression of TNF-alpha, IFN-gamma, IL-4 and IL-10 before and about 90min after the last reperfusion. In addition, parameters of liver damage including sALT and serum levels of TNF-alpha were analyzed at 2, 24 and 48h after surgery. RESULTS: When compared with pre-reperfusion liver specimens, all post-reperfusion biopsies showed significantly increased levels of TNF-alpha and IFN-gamma mRNAs. Conversely IL-4 and IL-10 mRNA levels were significantly increased in only seven patients. A negative correlation was observed between Th2 cytokines (IL-4, IL-10) and ALT and serum levels of TNF-alpha. Furthermore, the presence of hepatic steatosis was significantly associated with lower intrahepatic contents of IL-4 and IL-10. CONCLUSIONS: The results suggest that the local early expression of Th2 cytokines may contribute to attenuate liver injury following ischemia reperfusion in humans. The early imbalance between pro- and anti-inflammatory cytokines seen in steatotic liver subjected to I/R could explain, at least partially, the decreased tolerance of steatotic livers to I/R injury.
Abstract: INTRODUCTION: The aim of this study was to assess the safety and the efficacy of hepatic resective surgery in the treatment of single lobe hepatolithiasis. PATIENTS AND METHODS: Retrospective analysis and comparison between hepatic resections in patients with hepatolithiasis (hepatolithiasis group [HG]) and liver masses (control group [CG]). Seventeen consecutive Caucasian patients with single lobe hepatolithiasis (HG) and 30 patients with liver masses without chronic liver disease and previous chemotherapy (CG), were operated during the 5-year period 2000-2005, inclusive. Major hepatic resections including 4 right hepatectomies, 10 left hepatectomies, and 3 left lateral sectionectomy in HG, and 12 right hepatectomies, 3 extended right hepatectomy, 5 left hepatectomies, 4 left lateral sectionectomy, 5 bisegmentectomy, and 1 mesohepatectomy in CG. The main outcome measures were: type and length of surgical procedures, intra- and postoperative blood losses and transfusions (packed red blood cells [PRBC] and fresh frozen plasma [FFP]), intra- and postoperative course and complications (within 30 days of the operation), length of hospitalisation, histopathology, and recurrence of hepatolithiasis. RESULTS: Mean operation time was 6.21 +/- 2.38 h in HG versus 7.10 +/- 2.21 h in CG (P = 0.33). Mean intra-operative blood loss in CG was higher than in HG (1010 +/- 550 ml versus 560 +/- 459 ml; P = 0.035). The other variables considered in the two groups were not statistically different. Intra-operative transfusion were 0.50 +/- 0.85 units in HG versus 1.35 +/- 2.25 units of PRBC in CG (P = 0.06), and 0.66 +/- 1.34 units in HG versus 0.68 +/- 1.20 units of FFP in CG (P = 0.44), respectively. No cases of death were registered. Postoperative complications occurred in 12 patients (25.5%) - 5 cases (10.6%) in HG and 7 cases (14.8%) in CG (P = 0.18). Mean postoperative transfusions were 0.47 +/- 1.24 units in HG versus 1.10 +/- 1.18 units of PRBC in CG (P = 0.35), and 0.65 +/- 1.40 units in HG versus 0.46 +/- 0.82 units of FFP in CG (P = 0.25), respectively. Difference in median hospitalisation was not statistically significant (14 +/- 10 days versus 12 +/- 9 days; P = 0.28). Histopathology showed cholangiocarcinoma in 2 cases (11.7%). During the follow-up period (range, 5-127 months; mean, 50.4 +/- 41.9 months), 1 patient had lithiasis recurrence and 1 patient died for the co-existing cholangiocarcinoma. CONCLUSIONS: Hepatic resection is the treatment of choice in patients with single lobe hepatolithiasis. An early indication for surgery may reduce the mortality/morbidity rates of hepatic resection for hepatolithiasis.
Abstract: We evaluated the feasibility and effectiveness of combining two different electronic devices, the ultrasonic dissector (UD) and the harmonic scalpel (HS), during hepatic resection. One hundred consecutive patients underwent liver resection using UD plus HS between January and December 2004 (UD + HS group). The ultrasonic dissector was used to fracture liver parenchyma and the uncovered vessel was sealed using the HS. Surgical outcomes were compared with 100 consecutive patients who underwent liver resection using the clamp crushing method. Operative variables, postoperative liver function, hospital stay, and type and number of complications were compared. The two groups were equivalent in term of demographic and pathologic variables. The UD + HS group had a decreased blood loss (500 ml versus 700 ml, P = 0.005), number of patients transfused (22 versus 39, P = 0.009), tumor exposure at the transection surface (4 versus 12, P = 00.012), and hospital stay (7 versus 8.5 days, P = 0.020). Postoperative major complications, in particular, fluid collection and biliary fistula, were significantly less frequent in the UD + HS group (2 versus 9, P = 0.030). A longer operative time was recorded in the UD + HS group (385 versus 330 minutes, P = 0.001). The combined use of UD with HS allows liver resection to be safely performed, with the advantage of reducing blood losses and surgery-related complications. The only major disadvantage may be a longer transection time.
Abstract: Hepatic injury secondary to warm ischemia-reperfusion (I/R) injury and alterations in haemostatic parameters are often unavoidable events after major hepatic resection. The release of inflammatory mediator is believed to play a significant role in the genesis of these events. It has been suggested that preoperative steroid administration may reduce I/R injury and improve several aspects of the surgical stress response. The aim of this prospective randomized study was to investigate the clinical benefits on I/R injury and systemic responses of preoperatively administered corticosteroids. Seventy-six patients undergoing liver resection were randomized either to a steroid group or to a control group. Patients in the steroid group received preoperatively 500 mg of methylprednisolone. Serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, coagulation parameters, and inflammatory mediators, interleukin 6 and tumor necrosis factor alpha were compared between the 2 groups. Length of stay, and type and number of complications were recorded as well. Postoperative serum levels of ALT, AST, total bilirubin, and inflammatory cytokines were significantly lower in the steroid than in the control group at postoperative days 1 and 2. Changes in hemostatic parameters were also significantly attenuated in the steroid group. In conclusion, the incidence of postoperative complications in the steroid group tended to be significantly lower than the control group. It is of clinical interest that preoperative steroids administration before major surgery may reduce I/R injury, maintain coagulant/anticoagulant homeostasis, and reduce postoperative complications by modulating the inflammatory response.
Abstract: BACKGROUND: The role of surgery in the treatment of rectal cancer has been demonstrated worldwide. Moreover, curative liver resection of colorectal liver metastases is the only treatment offering a chance of long-term survival. Unfortunately, the liver resection can be performed in only 10% of the patients. AIM: In order to extend the frontiers of surgical indications in the treatment of liver metastases from colorectal cancer, we describe, in the video, a multimodal approach to rectal cancer with liver metastasis in the right lobe. Patient and methods. A 51 years old woman was admitted to our Department for adenocarcinoma of the distal rectum and a resectable solitary synchronous liver metastasis located across the right and the middle hepatic vein. Unfortunately, the future remnant liver was too small, risking severe post-operative liver failure. For this reason, a portal vein embolization or occlusion has been proposed. First of all, the patient has been submitted to laparoscopic low anterior resection with simultaneous right portal vein ligature. Two months later, after a CT estimation of liver volume in vivo, she was submitted to right hepatectomy (open surgery). RESULTS: Both postoperative courses were uneventful. CONCLUSIONS: As a preparation for large hepatic resection for liver rectal metastasis the laparoscopic ligature of the right portal vein performed simultaneously to the laparoscopic low anterior resection is feasible and safe.
