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In the context of spreading interest in textbook outcome (TO) evaluation in different fields, we aimed to investigate an uncharted procedure, that is, laparoscopic microwave ablation (MWA) for hepatocellular carcinoma (HCC). Absence of post-MWA complications, a hospital stay of three days, no mortality nor readmission within 30 days, and complete response of the target lesion at post-MWA CT scan defined TO achievement. Patients treated between January 2014 and March 2021 were retrospectively reviewed, and of the 521 patients eligible for the study, 337 (64.7%) fulfilled all the quality indicators to achieve the TO. The absence of complications was the main limiting factor for accomplishing TO. At multivariable analysis, Child–Pugh B cirrhosis, age of more than 70 years old, three nodules, and MELD score ≥ 15 were associated with decreased probabilities of TO achievement. A score based on these factors was derived from multivariable analysis, and patients were divided into three risk groups for TO achievement. At survival analysis, overall survival (OS) was significantly (p = 0.001) higher in patients who achieved TO than those who did not. Moreover, OS evaluation in the three risk groups showed a trend coherent with TO achievement probability. The present study, having assessed the first TO for laparoscopic MWA for HCC, encourages further broader consensus on its definition and, on its basis, on the development of clinically relevant tools for managing treatment allocation.

In resected perihilar cholangiocarcinoma (PHC), positive ductal margin (DM) is associated with poor survival. There is currently little knowledge about the impact of positive radial margin (RM) when DM is negative. The aim of this study was to evaluate the incidence and the role of positive RM. Patients who underwent surgery between 2005 and 2017 where retrospectively reviewed and stratified according to margin positivity: an isolated RM-positive group and DM ± RM group. Of the 75 patients identified; 34 (45.3%) had R1 resection and 17 had positive RM alone. Survival was poorer in patients with R1 resection compared to R0 (p = 0.019). After stratification according to margin positivity; R0 patients showed better survival than DM ± RM-positive patients (p = 0.004; MST 43.9 vs. 23.6 months), but comparable to RM-positive patients (p = 0.361; MST 43.9 vs. 39.5 months). Recurrence was higher in DM ± RM group compared to R0 (p = 0.0017; median disease-free survival (DFS) 15 vs. 30 months); but comparable between RM and R0 group (p = 0.39; DFS 20 vs. 30 months). In univariate and multivariate analysis, DM positivity resulted as a negative prognostic factor both for survival and recurrence. In conclusion, positive RM resections appear to have different recurrence patterns and survival rates than positive DM resections.

Liver metastases development in colon rectal cancer has a strong impact on patient overall survival, with a 5-years survival of 5% with palliative treatment. Surgical resection combined with pharmacological treatment can achieve a 5-year overall survival of 31–58%. However, in only 20% of patients with colon rectal liver metastases (CRLM) liver resection is feasible. In highly selected patients, recent trials and studies proved that liver transplantation for non-resectable CRLM is a surgical option with an excellent long term overall survival. The aim of this paper is to review the indications and outcome of liver transplantation for CRLMs, with a special focus on the immunosopressive therapy and the management of local and extra hepatic recurrence after liver transplantation.

Liver transplantation (LT) is an established treatment for patients with end-stage liver disease. The significant advances in surgical technique, immunosuppression therapy, and anesthesiological management have dramatically improved short- and long-term outcomes. The aim of this study is to correlate specific surgical and anesthesiological variables with causes of early death in LT recipients.A retrospective observational analysis of adult patients who underwent LT in the period 2012 to 2016 and died within 90 days following LT was conducted. Exclusion criteria were intraoperative death, split liver, and domino transplant. Death was considered a dependent variable and classified into 3 different groups: death by sepsis, vascular events not related to the graft, and primary non-function. Donor and recipient variables were considered and analyzed using Fisher's exact test.Statistically significative associations (P value .05) were found between renal function support, retransplantation, and the number of fresh frozen plasma units transfused in one group and early death due to sepsis in the other.This study identified some risk factors associated with the specific cause of early death in liver transplantation. The clinical implications of these findings are the ability to stratify patients at high risk of early death by planning more intensive and accurate management for them.

Liver transplantation with left split liver is an excellent alternative to whole liver transplantation to respond to demand for organs in the pediatric population. In the face of a complex surgical technique that requires specific liver transplantation expertise, skills in resection and anatomical and pathophysiological knowledge deriving from deep hepatobiliary experience are of great relevance. Results in terms of outcome are now almost comparable to the use of whole liver. Limited space is still reserved to the use of split liver for two adults (full-right full-left) to meet the demands of the adult waiting list as well, because it is a technically challenging surgical procedure. The surgical technique is diversified and in continuous refinement, and now includes the possibility of applying dynamic preservation devices to reduce organ injury and ischemia time.

Background and aim: Liver transplantation (LT) is a validated treatment for hepatocellular carcinoma (HCC). HCC recurrence occurred between 8 and 20% of patients and lung is the most frequent site. Pulmonary metastases resection (PMR) prolongs survival, however in LT-setting the impact on survival is unclear. To give new lights on this issue, we report the experience of three Italian LT Centers. Methods: All consecutive HCC transplanted patients in three Italian LT Centers, who developed pulmonary metastasis from HCC (PM-HCC), as first metastasis, from 2008 to 2018, were included whenever treated with PMR. Results: Twenty-five patients were enrolled (median age 58 yrs, 84% male, 3% cirrhotics). HCC recurred after 34 months (9–306) since LT and PMR was performed after 2.4 months (0–43.1). A total of 28 PMR (19 single resections; 9 multiple resections; 16 right; 2 left) have been performed on 24 patients while in one case percutaneous microwave ablation (MWA) was preferred. Four patients have been re-operated due to pulmonary HCC-recurrence after surgery. The majority of surgical resection type was wedge resection (26, 89%). Surgical access was: video-assisted thoracic surgery (VATS) in 17 cases (59%); thoracotomy in 11 (38%); MWA in 1 (3%). The 48% of nodule was in right lower lobe. Perioperative in-hospital mortality and 30 days mortality were nil; median surgical time 90 min (50–365); median post-operative overall stay 5 days (2–11). Post-operative ICU treatment was necessary in 1 case (3%) for 3 days; blood transfusions in 2 cases (7%). Overall, 5 complications (2 bleeding; 1 AKI; 1 major cardiac; 1 wound dehiscence) occurred, with an overall complications rate of 23%. Eight (32%) patients died during a follow-up after HCC recurrence of 32 months (7–213): 7 for HCC progression, 1 for severe liver failure due to chronic rejection. The 1 and 5 year cumulative probability of OS from recurrence were 100 and 43% (95%CI 12–74), respectively, with a median OS of 51 months (95%CI 24–78). Conclusion: Selected patients with isolated pulmonary HCC-recurrence after LT and with preserved hepatic function showed that a pulmonary metastasectomy could be efficacious in managing a PM-HCC and could give an opportunity for long-term survival.

Carbon dioxide embolism during laparoscopic surgery is a serious and life-threatening complication. The overall incidence of embolism during laparoscopic surgery is low (0.15%). Although the potential fatal consequences of this complication are reported in literature, a well-documented report of the effect of massive CO2 embolism during laparoscopic liver resection on cardiovascular, respiratory and encephalographic parameters does not exist. The authors describe a well-documented case of massive carbon dioxide embolism during laparoscopic liver resection suspected by both hemodynamic instability and elevation of EtCO2 and confirmed by arterial blood gas. The surgeon's rapid closure of the vascular breach resulted in an overall improvement of the patient’s vital signs without further consequences. Our case report shows the cardiovascular, respiratory and encephalographic effects of a massive carbon dioxide embolism and highlights the importance of a strict cooperation between the surgeon and the anesthesiologist and the importance for a prompt treatment when massive carbon dioxide embolism occurs.

BACKGROUND Hepatic resection represents the best treatment for primary and metastatic liver tumors but is not always feasible. In early 1980, Piclmayr described a complex liver resection technique, termed "ex vivo liver resection," for the treatment of locally advanced tumors not conventionally resectable. The authors approached this technique with translational research in a preclinical setting and then similarly reproduced it in human patients. METHODS In the swine median xyphopubic laparotomy, the liver was mobilized to expose the vena cava. A temporary porto-caval shunt was previously prepared on the back table using a segment of thoracic aorta, and a vascular anastomosis between the supra-hepatic vena cava and a caval graft was quickly performed. The liver was placed in a machine perfusion system and continuously perfused for 2 h for its final implantation orthotopically in the same animal. The anastomoses were performed as usual. Based on this experience, the intervention was reproduced in the human model of a 39-year-old woman affected by large intrahepatic cholangiocarcinoma considered unresectable.' RESULTS All animals survived the procedure. The peak aspartate aminotransferase level (460 ± 87 U/L) was recorded 60 min after reperfusion. Lactate levels flared up for 120 min (3.6 ± 0.2 mmol/L). In the clinical case, the postoperative period was uneventful, and the patient was discharged on day 22. CONCLUSIONS The described procedure is feasible only for surgeons with a transplantation background. The study showed that this translational approach enhances the surgeon's ability to perform the intervention systematically in a shorter time and with a good outcome.

Background Although post–liver transplantation pain is not as severe as expected from the size of the surgical incision, optimal pain control becomes crucial to aid compliance with the ventilator, improve respiratory function, and facilitate an early weaning from mechanical ventilation. Methods Because the majority of analgesics are primarily metabolized and excreted by the hepatobiliary system, a poor recovery of graft function will result in a decrease in clearance and reduced elimination of the drug. On the other hand, if the liver is working well, the metabolism of analgesics improves significantly with minimal accumulation. Morphine-based analgesia has been associated with a higher risk of sedation and respiratory depression compared with major abdominal surgical procedures. Fentanyl and sufentanil in continuous intravenous infusion may be preferred in the presence of hemodynamic instability or bronchospasm. Sufentanil produces shorter-lasting respiratory depression and long-lasting analgesia than does fentanyl. Results The provision of potent continuous analgesia, independent of the duration of infusion, and the unique pharmacokinetics, not significantly affected by the functional status of the graft, make remifentanil appropriate for the majority of liver-transplanted patients. Unlike for patients with very severe pain after major abdominal surgery, liver transplant recipients usually benefit from tramadol, either in repeated intravenous boluses or continuous intravenous infusion. Paracetamol has been included as adjuvant (or sole agent, rarely) in the analgesic treatment of mild to moderate postoperative pain. The combination treatment (paracetamol plus tramadol) is a reasonable, safe option with improved analgesia and concurrent reduction in the incidence of some opioid-related side effects. Conclusions Frequent review of the patient's response is mandatory when potent opioids are used because dose-dependent respiratory depression is a serious and potentially life-threatening adverse effect. The benefits provided by epidural analgesia in this particular setting should be weighed against the risks because in the presence of markedly deranged perioperative blood clotting, the development of epidural hematoma represents a disastrous complication.

A 50-year-old woman was referred to our tertiary Hepato-Pancreato-Biliary (HPB) Surgery Center two years after undergoing a complex cholecystectomy (Mirizzi Syndrome Type 2) with T-Tube placement in the common bile duct after an episode of mild cholangitis. Cross-sectional imaging revealed sectoral dilatation of the right posterior bile duct. Focal intrahepatic strictures often present with vague symptoms such as fever, jaundice, or abdominal pain. A differential diagnosis based on the patient’s clinical history and basic imaging data should take into consideration iatrogenic and non-iatrogenic causes of segmental cholangiectasia. Given the difficulty in ruling out malignancy (which occurs in 50–70% of the cases of isolated cholangiectasia) a liver resection should be considered, since it can provide both the data necessary for a definitive diagnosis allowing an oncologically correct treatment plan.

Noninvasive positive-pressure ventilation (NIV), which represents a consolidated treatment of both acute and chronic respiratory failure, is increasingly being used to maintain spontaneous ventilation in lung transplant patients with impending pulmonary complications. Adding a noninvasive inspiratory support plus positive end-expiratory pressure (PEEP) has proven to be useful in preventing endotracheal mechanical ventilation, airway injury, and infections. Lung recipients with closure of the small airways in the dependent regions may also benefit from the prone position, which is helpful to promote recruitment of nonaerated alveoli and faster healing of consolidated atelectatic areas. In patients with localized or diffuse lung infiltrates, high-frequency percussive ventilation (HFPV), by either an invasive airway or a facial mask, has been adopted as an alternative ventilatory mode to enhance airway opening, limit potential respirator-associated lung injury, and improve mucus clearance. In nonintubated lung recipients at risk for volubarotrauma with conventional mechanical ventilation, it allows oxygen diffusion into the distal airways at lower mean airway pressures while avoiding repetitive cyclical opening and closing of the terminal airways. We summarize the clinical course of 3 patients with post-lung transplantation respiratory complications who were noninvasively ventilated with HFPV in the prone position. Major advantages of this treatment included gradual improvement of spontaneous clearance of bronchial secretions, significant attenuation of graft infiltrates and consolidations, a reduction in the number of bronchoscopies required, a decrease in spontaneous respiratory rate and work of breathing, and a significant improvement in gas exchange. The patients found HFPV with either standard facial mask or total mask interface to be comfortable or only mildly uncomfortable, and after the sessions they felt more restored. HFPV by facial mask in the prone position may be an interesting and attractive alternative to standard NIV, one that is more useful when implemented before full-blown respiratory failure is established.

Ex situ ex vivo liver surgery represents a method to expand the surgical indications to treat otherwise unresectable liver tumors. We report the case of a 38-year old woman with hepatic metastasis from a pancreatoblastoma that was judged to be unresectable due to the involvement of the three hepatic veins. To treat the primary tumor, she underwent a pancreaticoduodenectomy, adjuvant chemotherapy, and thermal ablation of a liver metastasis. After appropriate preoperative study and with the permission of the ethics committee, she underwent ex situ ex vivo liver resection. The hepatectomy was performed by removing the whole liver en bloc with the retrohepatic vena cava. The inferior vena cava was reconstructed by interposition of a prosthetic graft. The ex situ ex vivo hepatic resection, a left hepatic lobectomy included the lesion in segments 1-5-7-8. The two hepatic veins were reconstructed using patches of saphenous vein. The organ was preserved continuously for 6 hours using hypothermic perfusion with 4°C Celsior solution. The liver was then reimplanted performing an anastomosis between the reconstructed hepatic veins and the caval prostheses. The patient was discharged at postoperative day 22 and is currently disease-free at 8 months after surgery and 44 months after the initial diagnosis. Ex situ, ex vivo liver surgery offers an additional option for patients with both primary and secondary liver tumors considered to be unresectable using traditional surgical approaches.

Background Liver transplantation (LT) for hepatocellular carcinoma (HCC) can be used for tumor recurrence after liver resection (LR) both for initially transplant-eligible patients as conventional salvage therapy (ST) and for non–transplant-eligible patients (beyond Milan criteria) with a goal of downstaging (DW). The aim of this study was to compare the intention-to-treat (ITT) survival rates of patients who are listed for LT, according to these two strategies. Methods We analyzed a prospective database of 399 consecutive patients who underwent hepatic resection for HCC from 2002 to 2011 to identify patients included in the waiting list for tumor recurrence. Intention-to-treat (ITT) survivals were compared with those of patients resected for HCC within and beyond Milan criteria in the same period and not included in the LT waiting list. Results The study group consisted of 42 patients, 28 in the ST group (within Milan) and 14 in the DW group (beyond Milan). The 5-year ITT survival rate was similar between the 2 groups, being 64% for ST and 60% for DW (P = .84). Twenty-five patients (15 ST and 10 DW) underwent LT, 13 (10 ST and 3 DW) were still awaiting LT, 4 (3 ST and 1 DW) dropped out of the waiting list because of tumor progression, and 7 (5 ST [33%] and 2 DW [20%]) had tumor recurrence. The 5-year ITT survival of ST patients was similar to that of 252 in-Milan HCC patients resected only (P = .3), whereas 5-year ITT survival of DW patients was significantly higher (P Conclusions LR seems to be a safe and effective therapy both as alternative to transplantation and as downstaging strategy for intermediate-advanced HCC. The survival benefit of salvage LT, however, seems to be higher in the 2nd than in the 1st group.

This work is the first report of vacuum-assisted closure (VAC) therapy applied as a life-saving surgical treatment for severe acute pancreatitis occurring in a sequential liver- and kidney-transplanted patient who had percutaneous biliary drainage for obstructive "late-onset" jaundice. Surgical exploration with necrosectomy and sequential laparotomies was performed because of increasing intra-abdominal pressure with hemodynamic instability and intra-abdominal multidrug-resistant sepsis, with increasingly difficult abdominal closure. Repeated laparotomies with VAC therapy (applying a continuous negative abdominal pressure) enabled a progressive, successful abdominal decompression, with the clearance of infection and definitive abdominal wound closure. The application of a negative pressure is a novel approach to severe abdominal sepsis and laparostomy management with a view to preventing compartment syndrome and fatal sepsis, and it can lead to complete abdominal wound closure.

The aim of this prospective study was to analyze the impact of different surgical techniques on patients undergoing intestinal surgery for Crohn's disease (CD) in terms of recovery, quality of life, and direct and indirect costs.Forty-seven consecutive patients admitted for intestinal surgery for CD were enrolled in this prospective study. Surgical procedures were evaluated as possible predictors of outcome in terms of disability status (Barthel's Index), quality of life (Cleveland Global Quality of Life score), body image, disease activity (Harvey-Bradshaw Activity Index), and costs (calculated in 2008 Euros). Univariate and multivariate analyses were performed.Significant predictors of a long postoperative hospital stay were the creation of a stoma, postoperative complications, disability status on the third post-operative day, and surgical access (R (2) = 0.59, p0.01). Barthel's index at discharge was independently predicted by laparoscopic-assisted approach, ileal CD, and colonic CD (R (2) = 0.53, p0.01). The disability status at admission showed to be an independent predictor of quality of life score at follow-up. The overall cost for intestinal surgery for CD was 12,037 (10,117-15,795) euro per patient and stoma creation revealed to be its only predictor (p = 0.006).Laparoscopy was associated with a shorter postoperative length of stay; stoma creation was associated with a long and expensive postoperative hospital stay, and stricturoplasty was associated with a slower recovery of bowel function.

Aim Diverting loop ileostomy is used to minimize the impact of anastomotic complication after restorative proctocolectomy (RPC). However, the ileostomy itself may have complications and therefore affect quality of life (QOL). The aim of this study was to analyse the predictors of complications of the ileostomy formation and closure and of the QOL of these patients. Method Forty-four consecutive patients who underwent RPC were enrolled. Records of the ileostomy follow-up were retrieved from a prospectively collected database and QOL was assessed with the Stoma-QOL questionnaire. Ileostomy site coordinates were measured. Univariate and multivariate analysis were performed. Results In this series, three patients experienced peristomal herniae, two ileostomy stenosis, seven ileostomy retraction and fourteen peristomal dermatitis. Emergency surgery was the only predictor of parastomal hernia (P = 0.017). Stenosis correlated with the distance from the umbilicus (τ = 0.24, P = 0.021). Use of standard rod and retraction were independent predictors of peristomal dermatitis (P = 0.049 and P = 0.001). Stoma-QOL was directly correlated to the age of the patients and to the occurrence of parastomal hernia (P = 0.001 and P = 0.021, respectively). After stoma closure, two patients reported wound sepsis and seven suffered obstructive episodes. Conclusion The predictors of negative outcome after construction of a diverting loop ileostomy after RPC were urgent surgery, use of standard rod, the distance of the stoma site from the umbilicus, parastomal herniae and the older age of patients.

Liver cancer is the fifth most commonly diagnosed malignancy and the second most frequent cause of cancer death in men worldwide. Amongst liver cancers, hepatocellular carcinoma (HCC) represents the major histological subtype and it is one of the most common malignant human tumors worldwide. Research into the molecular biology of hepatocarcinogenesis has identified several biomarkers, which could provide additional informations in order to better understand the biology of HCC. A large number of biomarkers have been shown to have potential predictive significance and a wide variety of molecular markers have been proven to be excellent diagnostic tools for HCC but it is difficult to characterize HCC with a single biomarker. Thus, signatures of a combination of biomarkers may be more valuable for the diagnosis, staging and prognosis of HCC. Specifically, a correlation of HCC-CSCs phenotype to specific hepatic cancer subtypes and to specific clinical and pathological features has not yet been reported in human liver tumors. In this view we will first discuss the possible sources of liver stem cells and their relation with liver cancer development and we will secondly focus on the prognostic significance of clinical and pathological features of HCC.

Liver transplant is the preferred treatment for hepatocellular carcinoma in patients with cirrhosis, as both neoplastic and cirrhotic liver tissue can be removed. Treatment of recurring neoplasms is a difficult issue, especially in long-term survivors of liver transplant. No consensus has been reached on the treatment of recurrent hepatocellular carcinoma. Although patients with extrahepatic metastases are generally not candidates for local therapy, successful multimodal salvage therapy including resection or ablation can be achieved in liver transplant recipients with local recurrence of hepatocellular carcinoma. Microwave ablation is safe and effective for treating unresectable hepatocellular carcinoma, achieving excellent results in local disease down-staging or as a “bridge” to liver transplant, with no significant differences in local recurrence and complications compared with the more commonly used radiofrequency ablation. A patient with local recurrence of hepatocellular carcinoma 36 months after liver transplant for multifocal hepatocellular carcinoma and cirrhosis due to hepatitis C was successfully treated with laparoscopic microwave ablation without any postoperative complications. The patient is disease free 24 months after microwave ablation.

The hepatic caudate lobe (S1), or Spiegel lobe, has been widely considered a “nonlaparoscopic” segment due to its particular anatomical location between the hilar plate and inferior vena cava, which technically restricts the use of a conventional laparoscopic approach when treating segment 1 primitive and metastatic lesions. Since the early 2000s, the increasing detail in understanding liver segmental anatomy, improved preoperative imaging and intraoperative anesthesiologic management, as well as improvements in laparoscopic surgical skills and equipment, have allowed a significant increase in the adoption of minimally invasive procedures. Initially confined to wedge resections and segmentectomies of the anterior liver (laparoscopic segments), more advanced minimally invasive liver resections, such as in left and right sections, are now extensively performed and attain acceptable morbidity and mortality rates, with 3- and 5-year survival rates reported for hepa- tocellular carcinoma (HCC) and colorectal metastases comparable with those of open procedures [1]. Even though extremely rare, isolated laparoscopic resection of hepatic segment 1 (S1) has also been reported in the context of technically dyshomogeneous series. With the exception of a couple of reports, there is substantial lack, however, of a systematic technical description of the procedure.

Adrenalectomy represents the definitive treatment in clinically evident Cushing's syndrome; however, the most appropriate treatment for patients with subclinical Cushing's syndrome (SCS) with an adrenal incidentaloma remains controversial. This study was aimed to assess whether adrenalectomy may improve cardiovascular and metabolic impairment and quality of life compared with conservative management.Twenty patients with adrenal incidentaloma underwent laparoscopic adrenalectomy for SCS, whereas 15 were managed conservatively. Hormonal laboratory parameters of corticosteroid secretion, arterial blood pressure (BP), glycometabolic profile, and quality of life (by the SF-36 questionnaire) were compared at baseline and the end of follow-up.The 2 groups were equivalent concerning all the examined parameters at baseline. In the operative group, laboratory corticosteroid parameters normalized in all patients but not in the conservative-management group (P.001). In operated patients, a decrease in BP occurred in 53% of patients, glycometabolic control improved in 50%, and body mass index decreased; in contrast, no improvement or some worsening occurred in the conservative-management group (P.01). SF-36 evaluation improved in the operative group (P.05).Adrenalectomy can be more beneficial than conservative management in SCS and may achieve remission of laboratory hormonal abnormalities and improve BP, glycemic control, body mass index, and quality of life.

We previously reported that subnormothermic machine perfusion (sMP; 20°C) is able to improve the preservation of livers obtained from non–heart-beating donors (NHBDs) in rats. We have compared sMP and standard cold storage (CS) to preserve pig livers after 60 minutes of cardiac arrest. In the sMP group livers were perfused for 6 hours with Celsior at 20°C. In the CS group they were stored in Celsior at 4°C for 6 hours as usual. To simulate liver transplantation, both sMP- and CS-preserved livers were reperfused using a mechanical continuous perfusion system with autologus blood for 2 hours at 37°C. At 120 min after reperfusion aspartate aminotransferase levels in sMP versus CS were 499 ± 198 versus 7648 ± 2806 U/L (P < .01); lactate dehydrogenase 1685 ± 418 versus 12998 ± 3039 U/L (P < .01); and lactic acid 4.78 ± 3.02 versus 10.46 ± 1.79 mmol/L (P < .01) respectively. The sMP group showed better histopathologic results with significantly less hepatic damage. This study confirmed that sMP was able to resuscitate liver grafts from large NHBD animals.

Background Primary hyperaldosteronism may be caused by an aldosterone-producing adenoma (APA), which is correctable by unilateral adrenalectomy or by idiopathic adrenal hyperplasia, a bilateral disease without any indication for surgery. This study sought to assess the prevalence and the results of surgery in unilateral adrenal hyperplasia (UAH). Methods The study included 35 patients who underwent unilateral adrenalectomy because of primary hyperaldosteronism after unequivocal successful lateralization by adrenal venous sampling. Demographics, biochemical evaluation, and blood pressure were assessed pre- and postoperatively. Pathology was categorized as APA (isolated adenoma), nodular (multiple micromacronodules), and diffuse UAH (gland thickening without nodules). Results Pathology revealed 9 APAs and 23 nodular and 3 diffuse UAHs. Patients with APAs and UAHs were statistically similar regarding demographics and preoperative blood pressure levels. Bilateral adrenal involvement was evident at imaging in 10 patients (11% in APA versus 35% in UAH, P = NS). After surgery, biochemical cure of the disease was achieved in all patients; blood pressure levels normalized in 66.6% of patients and ameliorated in 22.2% in APA versus 34.6% and 50% in patients with UAH ( P = NS). At a long-term follow-up, only 1 patient with nodular UAH experienced a biochemical recurrence of disease. Conclusion UAH is not rare, sharing the same features of APA. When disease lateralization is confirmed by adrenal venous sampling, unilateral adrenalectomy achieves excellent long-term results.

Background Polycystic liver disease (PLD) is due to a genetic disorder and frequently coexists with polycystic kidney disease (PKD). If the cysts produce symptomatology owing to their number and size, many palliative treatments are available. When none of the liver parenchyma is spared, or kidney insufficiency is marked, the only potentially curable treatment is liver transplantation (LT). Case Report A 49-year old woman, diagnosed with PLD and PKD, was listed in January 2008 for combined LT and kidney transplantation (KT). A compatible organ became available 8 months later. Despite preserved liver function, the patient's clinical condition was poor; she experienced dyspnea, advanced anorexia, abdominal pain, and severe ascites. At LT, which took 9 hours and was performed using the classic technique, the liver was hard, massive in size (15.5 kg), and not dissociable from the vena cava. The postoperative course was complicated by many septic episodes, the last one being fatal for the patient at 4 months after transplantation. Discussion LT for PLD in many series shows a high mortality rate. The Model for End-Stage Liver Disease (MELD) score does not stage patients properly, because liver function is usually preserved. The liver can achieve a massive size causing many symptoms, especially malnutrition and ascites; in this setting LT is the only possible treatment. Patients with a low MELD score undergo LT with severe malnutrition that predisposes them to greater susceptibility to sepsis. To identify predictor factors, beyond MELD criteria that relate to the increased liver volume before development of late symptoms is essential to expeditiously treat patients with the poorest prognosis to improve their outcomes.

To assess B1a cell expression in the rectal mucosa of ulcerative colitis (UC) patients in comparison with healthy controls.Rectal mucosa biopsies were collected from 15 UC patients and 17 healthy controls. CD5(+) B cells were analysed by three colour flow cytometry from rectal mucosal samples after mechanical disaggregation by Medimachine(®). Immunohistochemical analysis of B and T lymphocytes was also performed. Correlations between, on the one hand, rectal B1a cell concentrations and, on the other, erythrocyte sedimentation rate and C-reactive protein levels and clinical, endoscopic and histological disease activity indices were evaluated.Rectal B-lymphocyte (CD19(+)/CD45(+)) rate and concentration were higher in UC patients compared with those in healthy controls (47.85% ± 3.12% vs 26.10% ± 3.40%, P = 0.001 and 501 ± 91 cells/mm(2) vs 117 ± 18 cells/mm(2), P0.001); Rectal B1a cell density (CD5(+)CD19(+)) was higher in UC patients than in healthy controls (85 ± 15 cells/mm(2) vs 31 ± 6.7 cells/mm(2), P = 0.009). Rectal B1a cell (CD5/CD19(+)) rate correlated inversely with endoscopic classification (Rs = -0.637, P0.05).B1a lymphocytes seem to be involved in the pathogenesis of UC, however, the role they play in its early phases and in disease activity, have yet to be defined.

Laparoscopic microwave ablation and portal vein ligation for staged hepatectomy (LAPS) is a new technique with a first laparoscopic step available in cases of unresectable right liver masses and inadequate future liver remnant (FLR).In Step 1, laparoscopic right portal vein occlusion is performed with microwave ablation on the future transection plane and in the FLR. Step 2 consists of a totally laparoscopic right trisectionectomy.Duration of the Step 1 operation was 170 min, without the need for blood transfusions and intensive care unit admission. The postoperative liver volumetric computed tomography scan was performed on postoperative day 9 and revealed a satisfactory left hepatic hypertrophy (FLR 666 cm(3); FLR to body weight ratio 0.96; FLR increase 90.4 %; daily FLR hypertrophy 35 cm(3)/day). Duration of the Step 2 operation was 630 min (liver transection time 240 min). Blood loss was 700 cc, with no need for transfusion. The specimen was extracted through a 10-cm Pfannenstiel incision, and pathology revealed a tumor-free resection margin (R0). The patient was discharged on postoperative day 7 without complications (total hospital stay for Step 1 + Step 2: 10 days).Totally LAPS is a technically feasible and safe procedure. It could provide benefit in selected patients with primarily non-resectable liver cancer, making extreme liver surgery easy and safe in well-selected patients.

Cholangiocarcinoma has historically represented a major contraindication to liver transplantation at many centers because of its high recurrence rate and low disease-free survival rate, even after radical surgery. Novel neoadjuvant therapy protocols combined with demolitive surgery and liver transplantation seem to achieve successful results in terms of overall and disease-free survivals. Surgery frequently seems to be unsatisfactory only for patients also suffering from chronic cirrhosis or end-stage liver disease. We have reported a case of hilar cholangiocarcinoma occurring in a case of primary sclerosing cholangitis treated with neoadjuvant radiochemotherapy and endoscopic brachytherapy, followed by liver transplantation combined with pancreatoduodenectomy, who has survived free of disease for >8 years.

Surgical resection for malignant hepatic tumors, especially hepatocarcinoma (HCC), has been demonstrated to increase overall survival; however, the majority of patients are not suitable for resection. Radiofrequency ablation (RFA) is the most widely used modality for radical treatment of small HCC (

Late diagnosis of cancer in CD often occurs, and the prognosis is poor. The primary aim of this study was to assess the relationship between clinical presentation and diagnosis of intestinal adenocarcinoma in CD; the secondary aim was to evaluate the timing of cancer occurrence in CD patients.Medical records of 12 consecutive patients with intestinal adenocarcinoma in CD and of 79 consecutive CD patients undergoing bowel surgery were reviewed. Presentation symptoms were analyzed as possible predictors. Timing of intestinal adenocarcinoma occurrence in patients with CD was analyzed including all the 347 consecutive patients that had undergone surgery for CD in our institute from January 1984 to June 2008. Life table analysis and uni/multivariate analyses were performed.Ten men and two women underwent surgery for intestinal cancer in CD with a median age of 50 years (31-68). Carcinomas were localized in the terminal ileum in four cases, right colon in three, transverse colon in one, sigmoid colon in one, rectum in two, and an anorectal fistula in one. Only three patients were pre-operatively diagnosed with cancer. At multivariate analysis only age (OR 1.057 (95% CI 0.999-1.107), p = 0.05) and obstruction (OR 6.530 (95% CI 1.533-27.806), p = 0.01) significantly predicted cancer diagnosis. The risk rate (RR) for cancer occurrence started to rise at the end of the third decade of life (RR = 0.005). The analysis of risk rate for cancer occurrence during overt CD showed that it is initially high at onset (RR = 0.001) and after two other peaks at 150 months from onset, it began to rise again. The presence of Crohn's colitis was associated to a significant risk of cancer (HR = 4.790, p = 0.009) while the use of 5-ASA resulted to be a protective factor against cancer occurrence (HR = 0.122, p = 0.013).In CD, rectal bleeding, the most common alarm symptom for intestinal cancer, is not useful for an early diagnosis. CD patients presenting with an older age and obstruction should be thoroughly investigated to rule out neoplastic lesions. There is probably no safe interval of CD where surveillance for intestinal cancer can be omitted. In the meantime, even in absence of active disease, all CD patients should undergo therapy with 5-ASA.

s of the 4th Congress of ECCO the European Crohn’s and Colitis Organisation S55 agents, OR 1.4, 95%CI (1.01 1.9). The area under the ROC curve was 0.7 CI95% (0.5 0.9) for TPMT levels for predicting AZA withdrawal due gastrointestinal intolerance, with a sensitivity of 73% and a specificity of 67%. A new course of treatment with 6MP was offered in all patients with gastrointestinal intolerance to AZA. Fourteen patients accepted. Five, (38%) per protocol and 36% per intention to treat tolerated the treatment with MP. Tolerance to MP was not associated with any of the variables studied. Conclusions: Incidence of gastrointestinal intolerance is relevant during AZA treatment; slow dose escalation could be useful. A shift to MP should be considered in case of severe gastrointestinal intolerance. The association with TPMT levels could reflect the role of 6-methylmercaptopurine nucleotide metabolites in its pathogenesis. P112 Intestinal surgery for Crohn’s disease: predictors of recovery, complications and health related quality of life M. Scarpa1 *, C. Ruffolo2, D. Bassi2, R. Boetto3, R. D’Inca3, A. Buda3, G.C. Sturniolo3, I. Angriman3. 1Veneto Oncological Institute, Dept of Surgery, Padova, Italy, 2University of Padova, Dept of Surgical and Gastroenterological Sciences, Padova, Italy, 3University of Padova, Dept of Surgical and Gastroenterological Sciences, Padova, Italy, Padova, Italy Introduction: During their life, 80% of patients affected by Crohn’s disease (CD) require at least one surgical procedure. Surgery is among the most important concerns of these patients. Minimally invasive surgery and strictureplasty were introduced to ameliorate the burden of surgery in these patients. However, extensive bowel resection and/or stoma creation may be still necessary. The aim of this study was to evaluate the predictors of recovery, complications and quality of life on an unselected cohort of patients submitted to intestinal surgery for CD. Patients and Methods:All the 47 consecutive patients admitted for intestinal surgery for CD in our department from May 2006 to July 2008 were enrolled in this prospective study. Patients’ characteristics are shown in Table 1. Surgical predictors (video assisted intestinal surgery, strictureplasty, stoma creation, ileal resection and colonic resection) as well as clinical predictors (age, gender, CD duration, activity and localization, recurrent CD) were evaluated. Outcome measures were medical and surgical complication, reoperation, day of first bowel movement, postoperative hospital stay and Barthel’s score. After at least 3 months, an interview that included the Cleveland Global Quality of Life score, the Body Image Score and the Harvey BradshawActivity Index was made. Univariate and multivariate analysis were performed. Results: The median post operative stay duration was 7 (5 20) days and the first bowel movement occurred medially on the 3rd (1st 6th) post operative day. Two anastomotic leaks, 3 intestinal obstruction, 2 intestinal bleeding and a wound infection occurred and 2 re-laparotomy were necessary. Median sick leave was 30 (2 360) days. Stoma creation was the only independent predictor of the post operative hospital stay (p = 0.006) in a model that also included minimally invasive surgery, colonic resection, small bowel resection and CD duration (R2=0.38). Patients who had strictureplasty had their first bowel movement later than those who had bowel resection (p = 0.042). Barthel’s score on the 3rd postoperative day significantly correlated with number of intestinal localisation, stoma creation and perianal CD. Nevertheless, none of them was an independent predictor at multivariate analysis. After follow up, CGQL score correlated only with Harvey Bradshaw Activity Index (t = 0.42, p < 0.001). Body image score was independently predicted by the Harvey Bradshaw Activity Index (p = 0.006) and the use of video assisted surgery (p = 0.036). Conclusions: Stoma creation was associated to a long post operative hospital stay and strictureplasty was associated to a slower recovery of bowel function. However, none of them seemed related to postoperative complication. Body image score was independently predicted by disease activity and the use of video assisted surgery. Health related quality of life appeared to be significantly related only to current disease activity independently from the surgical procedure.

extracted from critical appraisal to literature because only a few cases are available for study preventing randomized controlled trials. This study assessed the long-term success of addressing simultaneously defects in the external sphincter and complex fistulas in patients with Crohn’s disease treated with Infliximab and whose complaint was gross incontinence not related to diarrhoea. Methods:A consecutive series of seven patients with a diagnosis of sphincter defect and complex fistula were prospectively scheduled for surgical repair between June 2004 and March 2007. Patients were evaluated by physical examination, Endoanal Ultrasound and Magnetic Resonance Imaging. Patients underwent surgery after induction therapy with Infliximab at 5mg/ kg at weeks 0, 2, and 6 using a standard protocol. Subsequently, maintenance dosing every four weeks was associated with azathioprine or 6-mercaptopurine. Surgery was performed in an elective setting. All patients had complex fistula, often with any additional secondary extensions, horseshoe tracks and abscess, which were situated in the same quadrant or far from the sphincter damage. Outcomes were assessed considering continence, complications and patient’s quality of life. Results: Follow-up was 33 months (20 48). Sphincter defect ranged from 75 to 160o. Patients had undergone previous surgery for perianal fistula mean 3 (range 1 5) or abscess mean 3 (range, 1 10). Continence evolution assessed by Wexner’s score demonstrated a mean of 17 (range, 14 20) on presentation; score of 9.5 (range, 6 12) 12 months after surgery, 9.6 (range, 6 12) and 10.4 (range, 9 12) after 24 and 36 months of follow-up respectively. None of them has gross incontinence now. There was not any suture dehiscence in sphincter repair. Two fistula recurrences were detected immediately and two years later. Both patients had a low transsphincteric fistula and they remain little symptomatic with intermittent discharge of pus. After follow-up of 12 months, all patients were comfortable and asymptomatic. All patients quoted quality of life as much better than before surgery. Longterm outcome remains satisfactory without change. Conclusion: Immunomodulators have changed the surgical approach to perianal disease. Sphincter repair and fistula treatment can be simultaneously performed with good functional results and could be an alternative to proctectomy.