Minimally Invasive Approach Provides Oncological Benefit in Patients with High Risk of Very Early Recurrence (VER) After Surgery for Intrahepatic Cholangiocarcinoma (iCCA)

BACKGROUND

Surgery for intrahepatic cholangiocarcinoma (iCCA) is jeopardized by significant risk of early recurrence (≤ 6 months). The aim of the present study is to analyze the oncological benefit provided by laparoscopic over open approach for iCCA in patients with high risk of very early recurrence (VER).

MATERIALS AND METHODS

A total of 532 liver resections (LR) were performed for iCCA [265 by minimally invasive surgery (MIS) and 267 with open approach, matched through a 1:1 propensity score] and stratified using the postoperative prediction model of VER. Outcomes were compared between open and laparoscopic approaches, specifically evaluating oncological benefit.

RESULTS

The percentage of patients with high risk of VER was similar (32.7% in the laparoscopic group and 35.3% in the open group, pNS). The number of retrieved nodes as well as the rate and depth of negative resection margins were comparable between laparoscopic and open. The surgery-adjuvant treatment interval was shorter in laparoscopic patients in the overall series, as well in the subgroup of high risk of VER. The rate of patients starting adjuvant treatments within 2 months from surgery was higher in laparoscopic group compared with open group. In VER high-risk group both disease-free survival (DFS) and overall survival (OS) were significantly improved in MIS compared with open group (p = 0.032 and p = 0.026, respectively).

CONCLUSIONS

In patients with high risk of VER, laparoscopy translates into an advantage in terms of recurrence-free survival, likely related to lower biological impact of surgery, together with a shorter interval between surgery and start of adjuvant treatments, even allowing for a higher number of patients to start adjuvant therapies within 2 months from resection.

Defining and predicting textbook outcomes for perihilar cholangiocarcinoma: analysis of factors improving achievement of desired postoperative outcomes

BACKGROUND

Definition of textbook outcome (TO), defined as a single indicator combining the most advantageous short-term outcomes, is still lacking for perihilar cholangiocarcinoma (PHC). The primary endpoint of the present study is to analyze the rate of achievement of a disease-specific TO for PHC within a high volume tertiary referral centre. Secondary endpoints are to identify predictive factors of TO-achievement and to analyze the impact of achieving TO on long-term results.

METHODS

Between 2010 and 2022, a total of 237 patients undergoing combined liver and biliary resection for PHC at tertiary referral centre were included. Disease-specific TO were defined as: no 90-day mortality, no postoperative complications, no readmission, no intraoperative transfusions and resection margins. A logistic regression model was developed to identify predictors associated with TO-achievement. Kaplan-Meier curves were designed to determine TO's impact on survival.

RESULTS

TO was achieved in 60 (25.3%) patients. At multivariate logistic regression, preoperative biliary drainage [odds ratio (OR) 2.90 (1.13-3.40), P =0.026], high prognostic nutritional index [OR 7.11 (6.71-9.43), P =0.007[ and minimally invasive approach [OR 3.57 (2.31-3.62), P =0.013] were identified as independent predictors of TO. High ASA score [OR 0.38 (0.17-0.82), P =0.013] decreased the odds of TO. A significant improvement in both overall survival and disease-free survival was associated to TO fulfilment.

CONCLUSION

Since the achievement of TO correlates with better disease-free and overall survival, every effort should be made to ameliorate modifiable aspects prior to surery: management within referral centres with dedicated experience in biliary tract cancer and preoperative optimization protocol may positively contribute to improve postoperative outcomes, increasing the chance to obtain TO. Moreover, the implementation of advanced minimally invasive programs plays as well.

A "cui prodest" evaluation on the development of a minimally invasive liver surgery program: a differential benefit analysis of open and laparoscopic approach for left and right hemihepatectomies

BACKGROUND

The correlation between technical feasibility and short-term clinical advantage provided by laparoscopic over open technique for major hepatectomies is unclear. This monocentric retrospective study investigates the possible differences in the benefit provided by minimally invasive approach between left and right hepatectomy, deepening the concept of differential benefit in the setting of anatomical major resections.

METHODS

All hemihepatectomies performed from January 2004 to December 2021 were identified in the institutional database. A propensity score method was used to match minimal invasive (MILS) and open pairs in the left hemihepatectomies (LH) and right hemihepatectomies (RH) groups with a 1:1 ratio to adjust any potential selection bias. The differential benefit for left and right hepatectomy provided by laparoscopic over open technique was evaluated in a pure analysis (i.e., including cases converted to open) and a risk-adjusted analysis (i.e., after excluding open conversion from the laparoscopic series).

RESULTS

The analysis of the risk-adjusted differential benefit demonstrated better result of the MILS in the RH group than in the LH group, in terms of blood loss (∆ blood loss - 150 and - 350, respectively; differential benefit: 200 mL, p < 0.05), morbidity (∆ rate of morbidity - 11.3% and - 18.1%, respectively; differential benefit: 6.8%, p < 0.05) and length of stay, LOS (∆ LOS - 1 day and - 3 days, respectively; differential benefit: 2 days, p < 0.05).

CONCLUSION

While MILS is associated with improved clinical outcomes both in left and right hepatectomy procedures, the greater advantage provided by laparoscopy was documented in patients undergoing right hepatectomy, i.e. for more technically demanding procedures. A MILS program should include the broadest range of liver resections to ensure the full benefits of the laparoscopic technique.

Comparing Liver Venous Deprivation and Portal Vein Embolization for Perihilar Cholangiocarcinoma: Is It Time to Shift the Focus to Hepatic Functional Reserve Rather than Hypertrophy?

Purpose: Among liver hypertrophy technics, liver venous deprivation (LVD) has been recently introduced as an effective procedure to combine simultaneous portal inflow and hepatic outflow abrogation, raising growing clinical interest. The aim of this study is to investigate the role of LVD for preoperative optimization of future liver remnant (FLR) in perihilar cholangiocarcinoma (PHC), especially when compared with portal vein embolization (PVE). Methods: Between January 2013 and July 2022, all patients diagnosed with PHC and scheduled for preoperative optimization of FTR, through radiological hypertrophy techniques, prior to liver resection, were included. FTR volumetric assessment was evaluated at two distinct timepoints to track the progression of both early (T1, 10 days post-procedural) and late (T2, 21 days post-procedural) efficacy indicators. Post-procedural outcomes, including functional and volumetric analyses, were compared between the LVD and the PVE cohorts. Results: A total of 12 patients underwent LVD while 19 underwent PVE. No significant differences in either post-procedural or post-operative complications were found. Post-procedural FLR function, calculated with (99m) Tc-Mebrofenin hepatobiliary scintigraphy, and kinetic growth rate, at both timepoints, were greater in the LVD cohort (3.12 ± 0.55%/min/m2 vs. 2.46 ± 0.64%/min/m2, p = 0.041; 27.32 ± 16.86%/week (T1) vs. 15.71 ± 9.82%/week (T1) p < 0.001; 17.19 ± 9.88%/week (T2) vs. 9.89 ± 14.62%/week (T2) p = 0.034) when compared with the PVE cohort. Post-procedural FTR volumes were similar for both hypertrophy techniques. Conclusions: LVD is an effective procedure to effectively optimize FLR before liver resection for PHC. The faster growth rate combined with the improved FLR function, when compared to PVE alone, could maximize surgical outcomes by lowering post-hepatectomy liver failure rates.

Robo-Lap Approach Optimizes Intraoperative Outcomes in Robotic Left and Right Hepatectomy

Background

The aim of the present study is to evaluate the possible advantages of the Robo-Lap (parenchymal transection by laparoscopic ultrasonic dissector and robotic bipolar forceps and scissors) compared with pure robotic technique (parenchymal transection by use of robotic bipolar forceps and scissors) in major anatomical liver resections with specific focus on intraoperative outcomes.

Methods

Major liver resections performed by robotic approach between February 1, 2021 and March 31, 2023 were stratified into two groups according to the approach used to address the phase of liver transection; Pure Robotic Group (n = 21) versus Robo-Lap Group (n = 48). The two groups were compared in terms of intra- and postoperative outcomes and in terms of rate of achievement of intraoperative textbook outcomes.

Results

Conversion rate was similar between the two groups while incidence of adverse intraoperative events (according to Satava classification) was higher in the Pure Robotic compared with the Robo-Lap group (85.7% vs 39.6%, p < 0.001). Time to perform parenchymal transection was significantly shorter in the Robo-Lap group (180 min) compared with the Pure Robotic Group (240 min), p = 0.003. Intraoperative textbook outcomes were achieved in a lower proportion of patients in the Pure Robotic compared with the Robo-Lap group.

Conclusion

Outcomes of the present study suggest a favorable role of the Robo-Lap approach in robotic major resections as it allows an improvement of the intraoperative results, a greater probability of an uneventful conduction of the procedure, and therefore, better management of the operating room time.

Internal hernia after an open gastrectomy: an unusual treatment approach and a systematic review of the literature

Internal hernia (IH) is a serious complication that can occur after both laparoscopic and open surgery for the treatment of gastric cancer; the transverse colon and mesocolon, act as a natural partition between stomach and the small intestine and, once any type of gastrojejunal anastomosis is constructed, a potential space for internal hernia is created. We present the case of a 68-year-old patient diagnosed with intestinal ischemia due to an IH in the site of the jejunojejunostomy after an open gastrectomy for gastric cancer, treated with negative wound pressure therapy (NWPT) on open abdomen (ABTHERATM dressing).

Association between indocyanine green clearance test and ischemic type biliary lesions within one year after orthotopic liver transplantation

BACKGROUND

Ischemic type biliary lesions (ITBLs), a particular subset of non-anastomotic biliary strictures (NAS), are characterized by intra and extrahepatic strictures that occur in the absence of either hepatic artery thrombosis or stenosis. When they occur within the first year after liver transplantation their development is mostly related to ischemia-reperfusion injury (IRI). The indocyanine green plasma disappearance rate (ICG-PDR) might be able to predict the probability of IRI-induced graft damage after liver transplantation.

OBJECTIVE

Our aim was to evaluate the association between ICG-PDR and the occurrence of ITBLs. Secondly, we searched for evidence of IRI in patients presenting ITBLs.

METHODS

This retrospective single-center observational study assessed a cohort of 60 liver transplant patients. Each patient underwent ICG-PDR on the 1st postoperative day. ITBLs were identified by means of either cholangiography or magnetic resonance imaging evidence of a deformity and narrowing of the biliary tree in the absence of hepatic artery thrombosis/stenosis.

RESULTS

ITBLs were discovered in 10 patients out of 60 liver recipients (16.67%) within one year after transplantation. A low ICG-PDR value was found to be a significant predictive factor for ITBL development, with an OR of 0.87 and a 95% CI of 0.77-0.97. Liver biopsies were performed in 56 patients presenting unexplained abnormal liver function test results. A statistically significant association was found between the development of ITBLs and anatomopathological evidence of IRI.

LIMITATIONS

Retrospective, single-center study.

CONCLUSIONS

The findings from this study show a relationship between low ICG-PDR values on first post-operative-day and the occurrence of ITBLs within 1 year after transplantation.

Can Preoperative Multidetector Computed Tomography Identify Predictive Features of Difficult Native Hepatectomy at Liver Transplantation?

BACKGROUND

Native hepatectomy represents the most demanding surgical step during orthotopic whole liver transplantation (LT). The surgical risk assessment of LT candidates is currently mainly based on clinical and laboratory data, but even preoperative imaging data may be predictive of a complex native hepatectomy.

METHODS

A retrospective study on a cohort of 110 LT recipients was conducted. The radiologic variables investigated on pre-LT multidetector computed tomography scan were the length of the retrohepatic inferior vena cava (IVC-L), volume of the dorsal liver sector (DLS-V), complete encirclement of the IVC by the DLS (IVC-CE), max diameter of the native liver (L-D), max diameter of the spleen (S-D), and presence of large spontaneous portosystemic shunts (SPSS). The parameters defining complex native hepatectomy were the operative time, number of red blood cell (RBC) units transfused, IVC replacement technique switch, and post-LT relaparotomy for major bleeding.

RESULTS

In a multivariate analysis, the operative time was predicted by hepatocellular carcinoma (HCC) diagnosis (regression coefficient [RC]: 18.237, P = .009), S-D (RC: 3.733, P = .007), and IVC-CE (RC: 20.174, P = .01); the RBC units transfused by an history of gastroesophageal variceal bleeding (RC: 2.503, P = .039), Model for End-Stage Liver Disease (MELD) score (RC: .259, P = .039), and L-D (RC: -0.519, P = .027); the switch to a IVC replacement technique by L-D (odds ratio [OR]: 0.641, P = .028) and IVC-L (OR: 1.065, P = .023); and the relaparotomy for bleeding by L-D (OR: 0.632, confidence interval [CI]: 0.437 to 0.916, P = .015).

CONCLUSIONS

Pre-LT multidetector computed tomography (MDCT) seems to be a very useful tool in the surgical risk assessment of LT candidates.

Effectiveness and Toxicity of «Beld» Polychemotherapy in Advanced Malignant Melanoma

From January 1985 to December 1987, 17 patients with advanced malignant melanoma were treated with the poly-chemotherapy regimen BELD (bleomycin, 15 mg subcutaneously on day 1 and 4, vindesine 3 mg/m2 intravenously on day 1 and 5, CCNU 80 mg/m2 orally on day 1 and DTIC 200 mg/m2 intravenously on day 1 through 5) proposed as effective (CR + PR 45%) and tolerable. All patients were evaluable for toxicity and 14/17 also for response after 2 BELD cycles (total n. of cycles was 54). Criteria for response were just the same as those used by Young et al. A complete remission and a partial remission (2/14) have been observed at lymph nodal level, the unique sites of the disease in these two patients. Remission lasted 6 and 4 months, respectively. Two other patients showed a minimal response of 2 and 3 months duration (lymphonodal and cutis, respectively); 9 patients had stabilized disease of 5 months median duration. One case of progression of disease was observed. However, toxicity was relevant because of 2 early deaths after the first cycle, most probably therapy related; nausea and vomiting (82%), leukopenia (17%) and muscle rigors (11%).

A Phase II Study of Mitoxantrone

Thirty pretreated patients with progressive and measurable solid tumors (24/30 patients) or myeloproliferative diseases (6/30 patients) were given mitoxantrone at the dose of 5 mg/m2/day in 250 ml normal saline over 30 minutes infusion for 3 consecutive days every 3 weeks. A total of 104 cycles were administered, median 3 for each patient. 39/104 cycles were delayed for a median of 9 days (from 2 to 59 days) because of myelodepression grade I to III (median I); no infection or bleeding was observed. Grade I to II alopecia was recorded in 16 patients. Chronic cardiac toxicity was observed in one patient previously treated with adriamycin. Mitoxantrone at the studied dose schedule in heavily pretreated subjects was well tolerated every 3 to 4 weeks. In 25/30 patients evaluable for response, one patient had a PR, another had 25% reduction (both patients previously treated) and eleven patients obtained disease stability. This effectiveness, 1 PR, 1 MR, 11 disease stability, is not negligible when it is considered that mitoxantrone was the seventh median line of therapy and the fifth median antiblastic drug.

Dose finding of ifosfamide administered with a chronic two-week continuous infusion

PURPOSE

Ifosfamide (IFO) is an active drug in several malignancies. A short-term 3- to 7-day (A) continuous infusion (c.i.) has been used in different tumor types. The 14-day c.i. (B) has been investigated in advanced breast cancer and in soft tissue sarcoma patients at a fixed daily dose. The tolerance and response rate (RR) of therapies A and B has been considered encouraging.

AIM

To study the 14-day c.i. IFO schedule, every 28 days, with a dose-finding approach.

METHODS

From January 1998 to December 2001, 34 pretreated patients with advanced malignancy and disease progression were treated with c.i. IFO (and the same dose of mesna) from 400 to 1,000 mg/m(2)/24 h for 2 consecutive weeks every 28 days. An elastomeric pumping device via an Infuse-a-Port((R)) or a Groshong((R)) catheter was used.

RESULTS

A total of 159 cycles were evaluable for toxicity and results. No toxic deaths occurred. Three patients (8.8%) had a severe acute allergic cutaneous reaction with various grade 3-4 toxicities requiring hospitalization and therapy was stopped at day 6 of the first cycle, 7 and 12 of the second cycle respectively. In the other 31 patients, grade 4 neutropenia occurred in 6 (19.3%) and it represented the main toxicity. There was a positive relationship between the IFO dose step and neutropenia (p = 0.001). A positive relationship was observed between the RR and the received total IFO dose (g) (p < 0.004). Twelve patients out of 31 had progressive disease (PD) (38.7%), 8 had partial remission (PR) (25.8%), and 11 maintained a steady state (35.5%). Six of the 12 patients (50%) with PD and 2 of the 8 PRs (25%) had bone metastases.

CONCLUSIONS

IFO c.i. is generally well tolerated, but acute untoward allergic reactions can occur. In chemotherapy-pretreated patients the recommended daily dose of continuously infused IFO for 14 days every 4 weeks is 900 mg/m(2)/day, together with mesna at the same dose schedule.

Mitomycin C, cisplatin, and 5-fluorouracil for advanced and/or recurrent head and neck squamous cell carcinomas

The combination of cisplatin (CDDP 100 mg/m2 on day 1) and 5-fluorouracil (5-FU 1,000 mg/m2 continuous intravenous (i.v.) infusion days 1-5) is the most widely used chemotherapy regimen for the treatment of advanced head and neck carcinomas, with a response rate of 70-90% but with a survival and a duration of response which are not impressive. Most patients relapse in < or = 2 years and die of cancer. We evaluated the activity of a CDDP (90 mg/m2 on day 1), 5-FU (900 mg/m2/120 h continuous i.v. infusion from day 1), and mitomycin C (MMC 6 mg/m2 on day 1) regimen in advanced or recurrent head and neck squamous cell carcinoma (HNSCC). Fifty-six patients were treated and evaluated for response and toxicity: 5 (9%) complete responses (CR) and 36 (64%) partial responses, (PR) were observed (response rate 73%). The median duration of response was 12 months, and median survival was 15 months. At a median follow-up of 14 months, the estimated overall survival at 1 year was 65%; at 2 years, it was 35%. Grade 3-4 toxicity was noted in 14 patients, mostly hematologic; overall toxicity required a dose-intensity decrease in 20.2% of all cycles. No treatment-related deaths occurred. The regimen showed a good response rate and an encouraging median duration of response with a good tolerability profile.

Synthetic thymic fraction 5: effects of high dose administration on circulating lymphocytes in patients

The synthetic pentapeptide (Arg-Lys-Asp-Val-Tyr; TP-5) corresponding to the active site of the hormone thymopoietin, was given at the dose of 300 mg/m2/day (1 day), higher than the usually administered, to a group of 27 immunodepressed patients in order to determine the tolerability and the immunomodulatory activity. The examination of a series of hematological parameters including counts of differential clustering of lymphocytes by cytofluorimetric analysis was performed 24 hr and 48 hr after treatment, and repeated at different intervals up to 14 days after treatment. TP-5 caused a significant increase of circulating lymphocytes and particularly of CD3+CD4+ and CD3+CD8+ subtypes, peaking at 48 hr and maintaining the increased values up to the last examination on day 14 from treatment. A faster increase (zenith at 24 hr) was observed for CD4+ cells, in comparison with CD8+ cells (zenith at 48 hr). The number of patients that increased total lymphocytes or lymphocyte subset after treatment ranged between 52.6 (CD4+ cells) and 69.2% (NK cells), whereas about 7.7% (NK cells) to 36.9% (CD4+ cells) remained unchanged and a smaller amount of 10.5% (CD4+ and CD8+ cells) or 23.1% (NK cells) showed a decrease greater than 10% of their respective basal value. No significant relationship between responders and non-responders can be found on the basis of previous treatments, cancer type, sex or age.

Reduced lymphocyte subpopulations in patients with advanced or disseminated melanoma

BACKGROUND

Studies have revealed many features of lymphocyte behavior in patients with malignant melanoma, but there are conflicting results.

OBJECTIVE

The aim of this study was to measure with easily reproducible assays the circulating lymphocytes and other immunologic aspects in 33 patients with advanced or disseminated malignant melanoma (MM).

METHODS

The following variables were measured: circulating monocytes; total lymphocytes; B (CD19) and T-cell subpopulations; CD3, CD4, and CD8, natural killer cells (anti-Leu-7+ or CD57 and anti-Leu-11+ or CD16) (cytofluorimetry); plasma levels of IgG, IgA, IgM, and IgE; complement fractions 3, 4, and 1Q; antibodies against foreign microorganisms (AaM) (adeno, herpes simplex, herpes zoster, measles, parotitis, cytomegalo, Epstein-Barr, and rubella viruses) and Toxoplasma; and cutaneous delayed hypersensitivity (CDH) to recall antigens (tetanus, diphtheria, Streptococcus, tuberculin, Proteus, Trichophyton, and Candida). We also studied 96 healthy persons, matched for age and geographic location, who were tested on the same days as the patients.

RESULTS

In MM the number of total lymphocytes and subsets CD19, CD3, CD4, and CD8 was decreased from 25% to 40% (p < 0.001). The CD4/CD8 ratio increased (22%, p < 0.005) because of the relatively greater decrease of CD8. The CD57 and CD16 cells (expression of natural killer lymphocytes) were consistently reduced (30%; p < 0.002 to p < 0.003). C3 serum level was increased (30%; p < 0.001). Immunoglobulins, CDH, AaM, and all other tests were the same in the two groups.

CONCLUSION

The single most important result seems to be a reduction of CD57 and CD16 cells in patients with advanced MM.

Evaluation of the circulating glycoprotein CA549 in mammary cancer and other malignancies

A prospective study was carried out on a recent marker for breast cancer, CA549, a mucine-like acid glycoprotein present in the fat membranes of human milk. Fifty healthy control subjects and 91 with benign conditions, 103 mammary cancer patients and 256 patients with other types of malignancy were studied. For comparison, CEA and CA15-3 were also investigated. The CA549 cutoff was 11 U/ml. In breast cancer the marker was below the cutoff in 9 cases (92.8%); in malignancies other than breast cancer it was above the cutoff in 5 to 50% of patients. In breast cancer it was raised in 83.3% of cases (CA15-3 showed 82.9% and CEA 50%). In breast cancer after radical surgery, CA549 was normal in patients who were in TNM stage I but above the cutoff in 57.1% of those at more advanced stages. The follow-up study is ongoing among these patients. In all the study conditions, CA549 favorably compared to CA15-3 values, with sensitivity and specificity greater than CEA.