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Background: Enhanced recovery after surgery (ERAS) protocols are known to potentially improve the management and outcomes of patients undergoing colorectal surgery, with limited evidence of their implementation in hospital networks and in a large population. We aimed to assess the impact of the implementation of an ERAS protocol in colorectal cancer surgery in the entire region of Piemonte, Italy, supported by an audit and feedback (A&F) intervention., Methods: A large, stepped wedge, cluster randomised trial enrolled patients scheduled for elective surgery at 29 general surgery units (clusters). At baseline (first 3 months), standard care was continued in all units. Thereafter, four groups of clusters began to adopt the ERAS protocol successively. By the end of the study, each cluster had a period in which standard care was maintained (control) and a period in which the protocol was applied (experimental). ERAS implementation was supported by initial training and A&F initiatives. The primary endpoint was length of stay (LOS) without outliers (>94th percentile), and the secondary endpoints were outliers for LOS, postoperative medical and surgical complications, quality of recovery and compliance with ERAS items., Results: Of 2626 randomised patients, 2397 were included in the LOS analysis (1060 in the control period and 1337 in the experimental period). The mean LOS without outliers was 8.5 days during the control period (SD 3.9) and 7.5 (SD 3.5) during the experimental one. The adjusted difference between the two periods was a reduction of -0.58 days (95% CI -1.07, -0.09; p=0.021). The compliance with ERAS items increased from 52.4% to 67.3% (estimated absolute difference +13%; 95% CI 11.4%, 14.7%). No difference in the occurrence of complications was evidenced (OR 1.22; 95% CI 0.89, 1.68)., Conclusion: Implementation of the ERAS protocol for colorectal cancer, supported by A&F approach, led to a substantial improvement in compliance and a reduction in LOS, without meaningful effects on complications. Trial registration number NCT04037787., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: A preliminary analysis from the COVID-Advanced Gastrointestinal Cancer Surgical Treatment (AGICT) study showed that the rate of minimally invasive surgery (MIS) for elective and urgent procedures did not decrease during the pandemic year. In this article, we aimed to perform a subgroup analysis using data from the COVID-AGICT study to evaluate the trend of MIS during the COVID-19 pandemic period in Italy. Methods: This study was conducted collecting data of MIS patients from the COVID-AGICT database. The primary endpoint was to demonstrate whether the SARS-CoV-2 pandemic scenario reduced MIS for elective treatment of gastrointestinal cancer (GIC) in Italy in 2020. The secondary endpoint was to evaluate the impact of the pandemic period on perioperative outcomes in the MIS group. Results: In the pandemic year, 62% of patients underwent surgery with a minimally invasive approach, compared to 63% in 2019 ( P  = .23). In 2020, the proportion of patients undergoing elective MIS decreased compared to the previous year (80% versus 82%, P  = .04), and the rate of urgent MIS did not differ between the 2 years (31% and 33% in 2019 and 2020 - P  = .66). Colorectal cancer was less likely to be treated with MIS approach during 2020 (78% versus 75%, P  < .001). Conversely, the rate of MIS pancreatic resection was higher in 2020 (28% versus 22%, P  < .002). Conversion to an open approach was lower in 2020 (7.2% versus 9.2% - P  = .01). Major postoperative complications were similar in both years (11% versus 11%, P  = .9). Conclusion: In conclusion, although MIS for elective treatment of GIC in Italy was reduced during the COVID-19 pandemic period, our study revealed that the overall proportion of MIS (elective and urgent) and postoperative outcomes were comparable to the prepandemic period. ClinicalTrial.gov (NCT04686747).

Background: This Italian multicentric retrospective study aimed to investigate the possible changes in outcomes of patients undergoing surgery for gastrointestinal cancers during the COVID-19 pandemic., Method: Our primary endpoint was to determine whether the pandemic scenario increased the rate of patients with colorectal, gastroesophageal, and pancreatic cancers resected at an advanced stage in 2020 compared to 2019. Considering different cancer staging systems, we divided tumors into early stages and advanced stages, using pathological outcomes. Furthermore, to assess the impact of the COVID-19 pandemic on surgical outcomes, perioperative data of both 2020 and 2019 were also examined., Results: Overall, a total of 8250 patients, 4370 (53%) and 3880 (47%) were surgically treated during 2019 and 2020 respectively, in 62 Italian surgical Units. In 2020, the rate of patients treated with an advanced pathological stage was not different compared to 2019 (P = 0.25). Nevertheless, the analysis of quarters revealed that in the second half of 2020 the rate of advanced cancer resected, tented to be higher compared with the same months of 2019 (P = 0.05). During the pandemic year 'Charlson Comorbidity Index score of cancer patients (5.38 ± 2.08 vs 5.28 ± 2.22, P = 0.036), neoadjuvant treatments (23.9% vs. 19.5%, P < 0.001), rate of urgent diagnosis (24.2% vs 20.3%, P < 0.001), colorectal cancer urgent resection (9.4% vs. 7.37, P < 0.001), and the rate of positive nodes on the total nodes resected per surgery increased significantly (7 vs 9% - 2.02 ± 4.21 vs 2.39 ± 5.23, P < 0.001)., Conclusions: Although the SARS-CoV-2 pandemic did not influence the pathological stage of colorectal, gastroesophageal, and pancreatic cancers at the time of surgery, our study revealed that the pandemic scenario negatively impacted on several perioperative and post-operative outcomes., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Evidence on the efficacy of minimally invasive (MI) segmental resection of splenic flexure cancer (SFC) is not available, mostly due to the rarity of this tumor. This study aimed to determine the survival outcomes of MI and open treatment, and to investigate whether MI is noninferior to open procedure regarding short-term outcomes., Methods: This nationwide retrospective cohort study included all consecutive SFC segmental resections performed in 30 referral centers between 2006 and 2016. The primary endpoint assessing efficacy was the overall survival (OS). The secondary endpoints included cancer-specific mortality (CSM), recurrence rate (RR), short-term clinical outcomes (a composite of Clavien-Dindo > 2 complications and 30-day mortality), and pathological outcomes (a composite of lymph nodes removed ≧12, and proximal and distal free resection margins length ≧ 5 cm). For these composites, a 6% noninferiority margin was chosen based on clinical relevance estimate., Results: A total of 606 patients underwent either an open (208, 34.3%) or a MI (398, 65.7%) SFC segmental resection. At univariable analysis, OS and CSM were improved in the MI group (log-rank test p = 0.004 and Gray's tests p = 0.004, respectively), while recurrences were comparable (Gray's tests p = 0.434). Cox multivariable analysis did not support that OS and CSM were better in the MI group (p = 0.109 and p = 0.163, respectively). Successful pathological outcome, observed in 53.2% of open and 58.3% of MI resections, supported noninferiority (difference 5.1%; 1-sided 95%CI - 4.7% to ∞). Successful short-term clinical outcome was documented in 93.3% of Open and 93.0% of MI procedures, and supported noninferiority as well (difference - 0.3%; 1-sided 95%CI - 5.0% to ∞)., Conclusions: Among patients with SFC, the minimally invasive approach met the criterion for noninferiority for postoperative complications and pathological outcomes, and was found to provide results of OS, CSM, and RR comparable to those of open resection., (© 2022. The Author(s).)

Early postoperative low compliance to enhanced recovery protocols has been associated with morbidity following colon surgery. The purpose of this study is to evaluate the possible causes of early postoperative low compliance to the enhanced recovery pathway and its relationship with morbidity following rectal surgery for cancer. A total of 439 consecutive patients who underwent elective surgery for rectal cancer have been included in the study. Compliance to enhanced recovery protocol on postoperative day (POD) 2 was evaluated in all patients. Indicators of compliance were naso-gastric tube and urinary catheter removal, recovery of both oral feeding and mobilization, and the stopping of intravenous fluids. Low compliance on POD 2 was defined as non- adherence to two or more items. One-third of patients had low compliance on POD 2. Removal of urinary catheter, intravenous fluids stop, and mobilization were the items with lowest adherence. Advanced age, duration of surgery, open surgery and diverting stoma were predictive factors of low compliance at multivariate analysis. Overall morbidity and major complications were significantly higher (p < 0.001) in patients with low compliance on POD 2. At multivariate analysis, failure to remove urinary catheter on POD 2 (OR = 1.83) was significantly correlated with postoperative complications. Low compliance to enhanced recovery protocol on POD 2 was significantly associated with morbidity. Failure to remove the urinary catheter was the most predictive indicator. Advanced age, long procedure, open surgery and diverting stoma were independent predictive factors of low compliance.

Background: While surgical treatment of Siewert I and III (S1,S3) Esophagogastric Junction (EGJ) cancer is codified, the efficay of transhiatal procedure with anastomosis in the lower mediastinum for Siewert II (S2) still remains a dibated topic., Methods: This is a large multicenter retrospective study. The results of 598 consecutive patients submitted to resection with curative intent from January 2000 to January 2017 were reported. Clinical and oncological outcomes of different procedures performed in S2 tumor were analyzed to investigate the efficacy of transhiatal approach., Results: The 5-year overall survival rate (OS) was poor (32%) for all Siewert types. The most performed operations in S2 cancer were proximal gastrectomy + transthoracic esophagectomy (TTE or Ivor-Lewis procedure, 60%), total gastrectomy + transhiatal distal esophagectomy with anastomosis in the chest (THE, 24%) and total gastrectomy + transthoracic esophagectomy (TGTTE, 15%). Cardiovascular and pulmonary complications were higher after TTE. On the contrary, surgical complications were significantly higher after THE. Postoperative mortality was similar. The distribution of TNM stages was different in the 3 types of procedures: patients submitted to THE had an earlier stage disease. With this bias, OS after THE was higher than after TTE but the difference was not significant (49.85% vs 28.42%, p = 0.0587)., Conclusions: Despite a higher rate of postoperative surgical complications, OS after total gastrectomy and transhiatal distal esophagectomy was at least comparable to that of transthoracic approach in less advanced S2 tumors. Therefore, THE with anastomosis in the chest could be a treatmen option in earlier S2 tumors., (Copyright © 2019. Published by Elsevier Ltd.)

EASL/AASLD guidelines clearly define indications for liver surgery for HCC: patients with single HCC and completely preserved liver function without portal hypertension. These guidelines exclude from operation many patients that could benefit from radical resection and that are daily scheduled for hepatectomy in surgical centers. Patients with large tumors or with portal vein thrombosis cannot be transplanted or treated by interstitial treatments. In selected cases liver resection may obtain good long-term outcomes, significantly better than non-curative therapies. In cases of multinodular HCC, liver transplantation is the treatment of choice within Milan criteria; patients beyond these limits can benefit from liver resection, especially if only two nodules are diagnosed: even if they have a worse prognosis, survival results after liver surgery are better than those reported after TACE or conservative treatments. EASL/AASLD guidelines excluded from operating patients with portal hypertension but data about this topic are not conclusive and further studies are necessary. Selected patients with mild portal hypertension could probably be scheduled for liver resection and, considering the shortage of donors, listing for transplantation could be avoided. In conclusion, guidelines for HCC treatment should consider good results of liver resection for advanced HCC, and indications for hepatectomy should be expanded in order not to exclude from radical therapy patients that could benefit from it.

Background: The future remnant liver (FRL) limit for safe major hepatectomy with low risk of postoperative liver failure has not yet been well defined., Methods: Between April 2000 and September 2004, every patient scheduled for major hepatectomy in our institution underwent CT-volumetry of FRL. Patients with FRL <25% underwent portal vein embolization (PVE). Exclusion criteria were PVE, associated vascular resection and liver cirrhosis. The FRL was correlated with short-term results in patients with normal liver (group A) and those with impaired liver function secondary to neoadjuvant chemotherapy or cholestasis (bilirubin >2 mg/100 ml) (group B). Liver dysfunction was defined as both PT <50% and serum bilirubin level >5 mg/100 ml for three or more consecutive days., Results: A total of 119 patients were analyzed, 72 in group A and 47 in group B. The FRL value was the only significant risk factor for postoperative liver dysfunction in the univariate and multivariate analysis (p = 0.009). The FRL did not correlate with postoperative mortality and morbidity. Bilirubin and prothrombin time (PT) on days 3 and 7 were significantly correlated to FRL in both groups. In group A, patients with postoperative liver dysfunction had a FRL<30% (3 versus 0; p = 0.005). According to receiving operator characteristic (ROC) curve analysis, a FRL value of 26.5% predicted postoperative liver dysfunction with 66.7% sensitivity, 97.1% specificity, 50% positive predictive value (PPV), and 98.5% negative predictive value (NPV). In group B, patients with postoperative liver dysfunction had a FRL <35% (4 versus 0; p = 0.027). According to ROC curve analysis, a FRL value of 31.05% predicted postoperative liver dysfunction with 75% sensitivity, 79.1% specificity, 25% PPV, and 97.1% NPV., Conclusions: Hepatectomy can be considered safe when FRL is >26.5% in patients with healthy liver and >31% in patients with impaired liver function.

We report a case of a 37-year-old woman who was referred to a peripheral hospital with severe abdominal pain, vomiting and hemorrhagic shock. Ultrasonography and CT scan showed a large ruptured adenoma of the right liver. Because of hemodynamic instability, she underwent laparotomy with gauze packing and then she was referred to our department with a bleeding persisting at a rate of about 100 mL per hour from the abdominal drain. She underwent relaparotomy and a ruptured liver cell adenoma with a huge hepatic hematoma completely involving the right liver and part of segment 4 was confirmed. Considering the size of the lesion and the presence of a large hematoma, a right hepatectomy with anterior approach was performed. In case of emergency liver resections, the anterior approach is preferable not only to avoid tumor manipulation and the risk of its rupture, but mainly to reduce liver bleeding and to prevent sudden fall of the blood pressure due to inferior vena cava twisting in a hemodynamically instable patient. Intraoperative blood loss was 1500 mL. The postoperative course was uneventful. The patient is doing well ten months after operation.

Background: Timing of hepatectomy for synchronous metastases of colorectal cancer is still debated. The aim of this retrospective study was to analyze prognostic factors after synchronous and delayed liver resections to define selection criteria for choosing timing of hepatectomy., Methods: The study was performed on 127 patients with synchronous metastases undergoing radical hepatectomy. We divided patients according to the timing of hepatectomy: 70 synchronous (group A) and 57 delayed (group B)., Results: Overall survival was similar between the two groups (5-year survival 30.8% vs. 32.0% A vs. B, P = .406). The multivariate analysis evidenced four independent prognostic factors in group A: male sex (P = .04), T4 (P = .0035), more than three metastases (P = .0001), and metastatic infiltration of nearby structures (P < .0001). There were no statistically significant prognostic factors in group B. Patients with more than three metastases had a significantly worse survival in group A than in group B (3-year survival, 15.0% vs. 34.3%, P = .007); similarly, borderline significant difference was encountered in patients with T4 primary tumor (3-year survival, 16.7% vs. 60%, P = .064), Conclusions: Patients with liver metastases synchronous with colorectal cancer with T4 primary tumor, metastasis infiltration of neighboring structures, and especially with more than three metastases should receive neoadjuvant chemotherapy before liver resection.

Background: Surgical strategy in liver metastases synchronous to colorectal cancer remains controversial. The aim of this study was to evaluate feasibility and short-term outcomes of major hepatectomies synchronous to colorectal surgery., Methods: Between January 1985 and December 2004, 79 patients underwent major hepatectomy for metastases synchronous to colorectal cancer; 31 underwent synchronous hepatectomy and colorectal surgery, and 48 underwent delayed liver resection., Results: The synchronous group had a higher rate of right colectomy (38.7% vs. 18.8%, P = .0499) and larger metastases (8 vs. 5.3 cm, P = .0032). Mortality (one patient in synchronous group), morbidity, and anastomotic leak rates were similar in the two groups. Colon-related morbidity did not cause adjunctive liver complications. Hospitalization in delayed hepatectomies was shorter (10.4 days vs. 13.9 days, P = .0021). Blood and plasma transfusions were higher in synchronous resections (41.9% vs. 16.7%, P = .0131 and 54.8% vs. 31.3%, P = .0370); no differences were found in the last 10 years. Considering both surgical procedures (colorectal + liver resection), in delayed hepatectomies, morbidity was higher (56.3% vs. 32.6%, P = .0369) and hospitalization was longer (20.5 vs. 13.9 days, P = .00001). Nine patients underwent major hepatectomy at the same time as anterior rectal resection with no mortality (morbidity 22.2%, mean hospitalization 12.4 days)., Conclusions: Major hepatectomies can be safely performed at the same time as colorectal surgery in selected patients with synchronous metastases with similar short-term results, even in the presence of rectal cancer.

Background/aims: Few reports have analyzed short- and long-term outcomes in the subset of patients with hepatocellular carcinoma (HCC) on non-cirrhotic liver., Methodology: From January 1985 to December 2002, 277 patients underwent liver resection for HCC; in only 47 the liver was normal or showed mild chronic hepatitis at histology., Results: A major hepatectomy (MHR) was accomplished in 37 cases (78.7%) including an extended hepatic resection in 18 (38.3%). In-hospital mortality was nil. The rate of complications was 40.4%. Overall and disease-free survival rates at 5 years were 30.9% and 33.9%. Fifteen patients are actually alive with a median survival of 33.3 months. By multivariate analysis, tumor size > 10cm and presence of satellite nodules were independent predictive factors of 5-year survival; median survival of thirteen patients with HCCs < or = 10cm and without daughter nodules was 60 months. Twenty-six patients had a margin less than 1cm and without cancer involvement; overall and recurrence-free survival rates were comparable to those of the patients with a > 1cm margin., Conclusions: In the treatment of HCC without cirrhosis, major hepatic resections are often needed. Tumors less than 10cm in size and without satellite nodes are the best candidates for operation. The width of the resection margin is unimportant provided that there is no microscopic infiltration.

Hypothesis: The knowledge of risk factors for bile leakage after liver resection could reduce its incidence., Design: Retrospective study., Setting: Tertiary care referral center., Patients: The study included 610 patients who underwent liver resection from January 1, 1989, through January 31, 2003., Interventions: Liver resections without biliary anastomoses., Main Outcome Measures: Bile leakage incidence and its correlation to preoperative and intraoperative patient characteristics., Results: Postoperative bile leakage occurred in 22 (3.6%) of 610 patients. Univariate analysis showed that cirrhosis (P = .05) or intraoperative use of fibrin glue (P = .01) was associated with a lower incidence of bile leakage. Moreover, the following factors were significant predictors of bile leakage: peripheral cholangiocarcinoma (P < .001), major hepatectomy (P = .03), left hepatectomy extended to segment 1 (P < .001), extension of transection out of the main portal scissure (P = .006), and hepatectomy including segment 1 (P = .001) or segment 4 (P = .003). At multivariate analysis, use of fibrin glue was an independent protective factor (relative risk = 0.38, P = .046), whereas peripheral cholangiocarcinoma (relative risk = 5.47, P = .02) and resection of segment 4 (relative risk = 3.10, P = .02) were independent risk factors for bile leakage., Conclusions: Hepatectomies including segment 4, especially if performed for peripheral cholangiocarcinoma, lead to a high risk for postoperative bile leakage. Intraoperative use of fibrin glue may reduce the risk of postoperative bile leakage.

Introduction: In recent decades liver resection has become a safe procedure, mainly because of better patient selection. Despite this progress, however, outcomes of hepatectomy in cirrhotic patients with portal hypertension are still uncertain. The aim of this study was to elucidate early and long-term outcomes of liver resection in these patients., Methods: Between 1985 and 2003, a total of 245 cirrhotic patients underwent hepatectomy for HCC. Altogether, 217 patients were eligible for this analysis and were divided into two groups according to the presence of portal hypertension at the time of surgery: 99 patients with portal hypertension and 118 without it., Results: Patients with portal hypertension had worse preoperative liver function (Child-Pugh A class patients: 66.7% vs. 94.9%; P<0.0001). No differences were encountered in terms of intraoperative and pathology data. Operative mortality was similar (11.1% vs. 5.1%; P=0.100), but patients with portal hypertension had higher morbidity (43.4% vs. 30.5%; P=0.049) and received a higher rate of blood and plasma transfusions (51.5% vs. 32.2%, P=0.004; 77.8% vs. 57.6%, P=0.0017). Considering only Child-Pugh A patients, short-term results were similar in the two groups in terms of mortality, morbidity, and transfusion rates. The 5-year survival rate was significantly higher in patients without portal hypertension (39.8% vs. 28.9%; P=0.020), although when considering only Child-Pugh A patients no difference of survival was encountered. Multivariate analysis identified Child-Pugh classification, tumor diameter, and vascular invasion as independent predicting factors for survival., Conclusions: Portal hypertension should not be considered an absolute contraindication to hepatectomy in cirrhotic patients. Child-Pugh A patients with portal hypertension have short- and long-term results similar to patients with normal portal pressure.

Aims: To evaluate short- and long-term results of liver resections and prognostic factors in cirrhotic patients with hepatocellular carcinoma., Study Design: A single-unit, retrospective study analyzing 216 patients with histologically confirmed cirrhosis who underwent hepatic resection for hepatocellular carcinoma. All clinico-pathologic and follow-up data were collected prospectively., Results: Child A patients had a significantly lower in-hospital mortality rate compared to Child B-C: 4.7 vs 21.3% (p=0.0003). Overall morbidity rate was 38.4%; multiple logistic regression analysis identified liver function, hepatic pedicle clamping time, number of nodes and transfusion rate as independent predictors for post-operative complications. Overall and disease-free 5-year survival rates were 34.1 and 25.2%. Multivariate analysis showed that Child A, radical resection, tumour size < or =5 cm and, absence of vascular invasion were independent prognostic factors for long-term survival. No significant differences in overall and disease-free survival were found according to the type of resection (anatomic vs non-anatomic)., Conclusions: Patients with preserved liver function and small-size, single-node hepatocellular carcinomas are the best candidates for hepatic resection.

In recent decades liver resection has become a safe procedure; however, the outcome of hepatectomies in aged cirrhotic patients is often uncertain. To elucidate early and long-term outcomes of hepatectomy for HCC in the elderly, we studied 241 cirrhotic patients who underwent liver resection for HCC between 1985 and 2003. According to their age at the time of surgery, patients were divided into two groups: aged > 70 years (64 patients) and aged < or = 70 years (177 patients). Operative mortality was 3.1% in the elderly and 9.6% in the younger group (p = 0.113). Postoperative morbidity and liver failure rates were higher in the younger group (42.4% versus 23.4%, p = 0.0073; 12.9% versus l.6%, p = 0.0065). Five-year survival rates are 48.6% in the elderly group and 32.3% in the younger group (p = 0.081). Considering only radical resections in Child-Pugh A patients, survival remains similar in the two groups (p = 0.072). Disease-free survival is not different in the two groups. A survival analysis performed according to the tumor diameter shows a better survival for elderly Child-Pugh A patients with HCC larger than 5 cm radically resected (50.8% versus 16.1% 5-year survival, p = 0.034). In univariate analysis, tumor size is not a prognostic factor in the elderly, whereas younger patients with large tumors have a worse outcome. Age by itself is not a contraindication for surgery, and selected cirrhotic patients with HCC who are 70 years of age or older could benefit from resection, even in the presence of large tumors. Long-term results of liver resections for HCC in the elderly may be even better than in younger patients.

Liver surgery for colorectal metastasis has moved toward a parenchymal sparing strategy in order to reduce postoperative liver failure, to resect an higher number of metastases and to allow a future re-resection. Patients undergone hepatectomy in our Department before and after 1999 were retrospectively compared. In the recent years surgery became more aggressive: a higher number of patients with multiple and bilateral lesions were treated. Short-term results improved in the recent series. After 1999, the rate of wedge resections was significantly increased with the same oncological radicality and with improved long-term results. Moreover, parenchymal sparing strategy allowed a higher re-resection rate in patients with liver recurrence.

Since the lack of donors, liver resections continue to be the treatment of choice for cirrhotic patients with good liver function and resectable hepatocellular carcinoma (HCC). Moreover, over the past 2 decades, an increasing number of major hepatic resections have been performed. The aim of this study is to evaluate short- and long-term outcomes of 55 cirrhotic patients undergoing major hepatic resection with particular attention to the survival of the patients with gross portal vein invasion or large size tumors. Twenty-two patients (40%) required intra- or post-operative blood transfusion. Medium tumor size was 66.6 +/- 29.2 mm; 7 patients had large size (>10 cm) HCCs. A single node was present in 38 cases (69.1%). There was a gross portal vein tumor thrombus (PVTT) in 13 patients (23.6%). Resection was non-curative in 4 cases. In-hospital mortality and morbidity rates were 5.5% and 30.9%, respectively. The overall and disease-free survival rates were 36.2% and 42.8%, respectively. Overall 5-year survival rates of patients with large size tumors was 17.1%. Ten patients with a gross PVTT had an R0 resection with a 26.6% 5-year survival rate. In conclusion, major hepatic resections for HCC can be performed with low mortality and morbidity rates. HCCs with PVTT or greater than 10 cm in size have very limited options of treatment; the favorable long-term results of our study suggest that they should undergo surgery if a radical resection can be achieved.

Background/purpose: Mortality and morbidity rates after liver resections have decreased with better surgical techniques and perioperative care. The aim of this study was to evaluate the short- and longterm results in patients who had undergone extensive hepatectomies., Methods: From January 1985 to December 2000, 237 patients underwent 275 liver resections for colorectal metastases. Extensive liver resections were defined as follows: technical reasons (extended hepatectomies, associated vascular resections); disease extent (diameter, >>10 cm; number, >>5; associated extrahepatic resection). The total number of extensive liver resections was 74. There were 51 radical resections (68.9%), while in the nonextensive resections group, 152 resections were radical (90.7%; P = 0.1)., Results: Postoperative mortality (60 days) was 1.6% (1.3% in the extensive resections group; P = 0.3), while morbidity was 22.7% (31% in the extensive resections group vs 19% in the nonextensive resections group; P = 0.1). One-, 3-, and 5-year overall actuarial survival rates were 91.8%, 44.9%, and 25.3%. The survival rates of patients who underwent an extensive resection were similar to those in the nonextensive resections group., Conclusions: Technical difficulties and neoplastic extension are not, nowadays, a contraindication for hepatectomy for colorectal liver metastases, unless a radical resection is performed. Mortality and morbidity rates after liver resections have decreased with better surgical techniques and perioperative care. The aim of this study was to evaluate the short- and longterm results in patients who had undergone extensive hepatectomies.

Background/aims: It has been shown that hepatic pedicle clamping is a safe and effective technique to control bleeding during liver resection. A major drawback can be the induction of liver ischemia and splanchnic venous stasis., Methodology: This randomized controlled clinical trial compared continuous and intermittent hepatic pedicle clamping during resection of the cirrhotic liver in order to determine which technique is more effective in reducing operative blood loss and producing less ischemic injury. In 18 patients we performed continuous portal triad clamping during liver transection while in 17 patients we performed intermittent clamping. The two groups matched for extent of resection. Serial hepatic function tests were performed on postoperative day 1, 3 and 7., Results: No significant difference was found between the two groups in terms of operative findings. Operative mortality was 5.7% (2 patients). Six patients (17.3%) had postoperative complications. There were no significant differences between the two groups with regard to postoperative liver function tests and coagulation profile., Conclusions: Continuous and intermittent clamping are both effective in reducing blood loss during hepatectomy in cirrhosis. The two techniques seem to be comparable in terms of ischemic injury. Our findings suggest that intermittent portal triad clamping may not be necessary. As this is contrary to the normal expectancy, additional studies may be needed.

Background: Extended surgical procedures are the only chance of longterm survival for patients with Klatskin tumors, but high mortality rates have been reported. The type of treatment for Bismuth type l-II carcinomas is still a matter of discussion., Study Design: We performed a single-unit, retrospective study analyzing 36 patients who underwent resectional surgery for Klatskin tumor., Results: An associated liver resection was performed in 88.9% of our patients; most of them had a major hepatectomy. The in-hospital mortality rate was 2.8%. Three- and 5-year survival rates were 40.8% and 27.2%, respectively. But the group of patients with Bismuth type I-II carcinomas undergoing hepatectomy had markedly better longterm outcomes than those undergoing hilar resection (p = 0.04): 54.5% versus 0% at 5 years, respectively; none of the patients who had only resection of bile duct confluence were alive at 2 years. Lymph node metastases were found in 38.8% of our patients; nodal involvement was not a major prognostic factor., Conclusions: Achievement of low in-hospital mortality rates is possible in specialized surgical departments. Aggressive surgical approaches can allow better longterm results in the subset of Bismuth type I-II carcinomas.

Background and Objectives: After curative resection of hepatic colorectal metastases, 10-20% of patients experience a resectable hepatic recurrence. We wanted to assess the expected risk-to-benefit ratio in comparison to first hepatectomy and to determine the prognostic factors associated with survival., Methods: Twenty-nine patients from a group of 152 patients resected for colorectal liver metastases underwent 32 repeat hepatectomies., Results: In-hospital mortality was 3.5% (1/29 patients); the morbidity after repeat hepatectomy was lower than that after first hepatic resection. Combined extrahepatic surgery was performed on 34.5% of repeat hepatectomies vs. 6.9% of first hepatectomies (P = 0.01). Overall actuarial 3-year survival was 35.1%: four patients have survived more than 3 years and one survived for more than 5 years. The number of hepatic metastases and the carcinoembryonic antigen (CEA) serum levels were significant prognostic factors on univariate analysis. The synchronous resection of hepatic and extrahepatic disease was not associated with a lower survival rate when compared with that of patients without extrahepatic localization: three patients of the former group are alive and disease-free at more than 2 years., Conclusions: Repeat hepatic resection can provide long-term survival rates similar to those of first liver resection, with comparable mortality and morbidity. The presence of resectable extrahepatic disease must not be an absolute contraindication to synchronous hepatectomy because long-term survival is possible.

Aims: Spontaneous rupture of hepatocellular carcinoma (HCC) is a life-threatening event, particularly in patients with associated cirrhosis. We present our experience of hepatic resection of ruptured HCC., Methods: We performed 199 resections of hepatocellular carcinoma between January 1984 and December 1999. Six (3%) of these patients were operated on as an emergency because of haemoperitoneum: in five the liver was cirrhotic., Results: The mean duration of the operation was 195+/-101 min; all the patients received blood transfusions. The overall morbidity was 50%, with a mortality rate of 16.5%. Three patients were alive at 50, 80 and 116 months respectively; two had an intrahepatic recurrence treated by chemoembolization., Conclusions: Non-surgical treatment of spontaneously ruptured hepatocarcinoma should be performed only in patients with contraindication to surgery. Hepatic resection should be the treatment of choice since, according to our experience, long-term results are similar to those of elective surgery., (Copyright 2000 Harcourt Publishers Ltd.)

Extended cholecystectomy is the only chance of a cure for patients with locally advanced cancer of the gallbladder. The aim of the study was to evaluate the short- and long-term results of surgical treatment and to define the prognostic factors associated with better survival. We conducted a retrospective study in 81 patients with gallbladder cancer admitted to our surgical department from 1985 to 1999. Radical surgery was performed on 39 patients. The type of surgical treatment was based on the TNM stage of the disease: all but stage I patients underwent extended cholecystectomy (resection of segment IVa-V, N1-2 lymph-node dissection). The mortality and morbidity rates were 5.1% and 28.2%, respectively. In the patients undergoing curative resection, the 5-year survival was 31.5% (75% in T1 patients, 57.1% in T2, 25.9% in T3 and 0% in T4. Long-term survival of patients with T1-2 tumours was significantly better than that of T3 (P = 0.02) or T4 patients (P = 0.0003); 53.6% of N0 patients were still alive at 5 years as against only 14.5% of N+ patients (P = 0.06). Depth of infiltration is an important prognostic factor. The presence of lymph-node metastases should not be a contraindication to surgery since long-term survival is possible.

Gallbladder carcinoma is the most common malignancy of the biliary tract. There are still many controversies regarding the type of curative surgical treatment for each stage of the disease. The staging system used is the TNM classification of the International Union Against Cancer. Different patterns of spread characterize gallbladder cancer but the two main types are direct invasion and lymph node metastases; since only the depth of invasion can be easily recognized by imaging techniques, it becomes the main variable in choosing the appropriate surgical treatment. Most Tis and T1 tumours are incidentally discovered after cholecystectomy for cholelithiasis and no further therapy is requested; for pT1b tumours, relaparotomy with hepatic resection and N1 dissection is associated with a better survival. For T2 tumours, cholecystectomy with hepatic resection and dissection of N1-2 lymph nodes is the standard treatment, with a 5-year survival of 60-80%. The only chance of long-term survival for patients with a T3-T4 tumour is an extended operation combining an hepatic resection with an N1-2 dissection with or without excision of the common bile duct. A subset of patients with peripancreatic positive nodes or invasion of adjacent organs seems to benefit from a synchronous pancreaticoduodenectomy.

Background: The aim of this study was to determine, in a prospective randomized clinical trial, whether the partial portacaval shunt offers any advantage in terms of liver function and encephalopathy rate when compared with direct side-to-side direct portacaval shunt., Methods: Forty-six "good risk" patients with cirrhosis and with documented variceal hemorrhage were randomly assigned to either a partial shunt procedure (achieved by 10-mm diameter interposition portacaval H-graft) or direct small-diameter side-to-side portacaval anastomosis., Results: Operative mortality was zero in both groups. During the follow-up period, encephalopathy developed in 3 patients in the partial shunt group and 9 in the direct shunt group (P =.04). Kaplan-Meier analysis demonstrated that encephalopathy-free survival was significantly longer in the partial shunt group (P =.025). Direct shunt patients had significant hepatic functional deterioration postoperatively compared with the partial shunt group., Conclusions: The partial portacaval shunt effectively controls variceal hemorrhage. Compared with direct side-to-side portacaval shunt, partial shunt preserves long-term hepatic function and minimizes postoperative encephalopathy. We conclude that the partial portacaval shunt is the preferred approach over direct shunts for patients with cirrhosis and with variceal bleeding.

Aims: Extended operations are the only chance of a cure for patients with advanced gallbladder carcinoma, but there is no consensus about which subset of patients can benefit. The aim of this retrospective study is to evaluate the results of surgical resection with special reference to the prognostic factors and to long-term survival., Methods: A retrospective review of 70 patients with a diagnosis of gallbladder cancer treated from 1985-1998 was performed: 33 patients had a curative resection and were included in this study. For stage I disease, simple cholecystectomy was considered curative; in most of the other cases, cholecystectomy was associated with lymph node dissection and liver resection., Results: Hospital mortality and morbidity were 6% and 33%, respectively. Curative resection was associated with an actuarial 5-year survival of 27.4%. Survival of pT1-2 patients was significantly better than that of pT3 (P=0.04) or pT4 patients (P=0.002). Patients with lymph node spread had a poorer prognosis (P=0.06) but four were alive and disease-free with a median survival of 22 months., Conclusions: Depth of the tumour and lymph node metastases are important prognostic factors. Patients with pT3-4 tumours or regional lymph node spread should be considered for curative resection because long-term survival is possible., (Copyright 2000 Harcourt Publishers Ltd.)