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Background/aims: This study was intended to evaluate the incidence and the long-term outcome of fluid collecting between the hepatic resection surface and a collagen patch. To our knowledge, this is the first study to analyze these aspects., Methodology: All patients undergoing hepatic resection with patch application from February 2006 to September 2008 were included. At followup, all patients found to have a collection between the liver surface and the patch underwent a CT scan every three months., Results: Ten patients underwent hepatic resection with the patch application. No mortality occurred and the morbidity rate was 10%. No biliary leaks or free abdominal fluid collection occurred. At follow-up, fluid collections were detected in 60% of cases. The collected fluid did not increase in volume and in 66.6% of the cases the fluid spontaneously reabsorbed after a mean of 5.5 +/- 1.9 months from the operation., Conclusion: The high incidence, lack of symptoms, favorable evolution and constant stability should be considered a display of patch tightness rather than a complication.

Background/aims: This reports on the modification of a technique of parenchymal compression ideated to reduce blood loss during liver transection, favorably affecting patient's outcome by reducing the need of Pringle maneuver and operative time through the active role of the second surgeon., Methodology: After echographic examination a water-cooled, high-density, monopolar dissecting sealer is introduced into the hepatic parenchyma allowing pre-coagulation of liver tissue. After coagulation of the traced line, a small Kelly forceps is used to fracture the liver parenchyma. As the transection proceeds, the hemostatic efficacy of the dissecting sealer reduces. At this step, where the Pringle maneuver is usually requested to stop bleeding, bimanual compression determines the occlusion of all the afferent vessels, bleeding is effectively stopped with a limited amount of residual backflow arising from the opposite plane., Results: During a three-year period this approach was used in 9 patients affected by HCC. The Pringle maneuver was not necessary in any patient. The median blood loss was 200mL. The median transection time was 120 min, with a median operative time of 180 min. No mortality occurred., Conclusion: Compression during the transection represents a valid support not only for the dissecting sealer, but also in all cases in which similar devices are used, and by avoiding the need of further devices there is an unquestionable reduction of costs.

Background/aims: To present the initial experience with laparoscopic technique of restoration after Hartmann procedure compared to open surgery., Methodology: All patients submitted to Hartmann procedure from 2003 to 2008 were considered. The following parameters were evaluated: age, gender, comorbidities, American Society of Anesthesiologists score, indication for the procedure, Hinchey scale, interval between Hartmann and reversal procedure, total operative time of Hartmann reversal, pain management, delay in renewal of peristalsis, start of alimentation, length of hospital stay, morbidity, and mortality., Results: Six patients were divided into groups A and B. Patients in group A underwent open Hartmann reversal and patients in group B underwent laparoscopic Hartmann reversal. Mean operative time was 136,6 min for group A and 95,6 min for group B. Mean postoperative duration of nasogastric tube placement was 2 days for group A and 1 day for group B. Group B showed a earlier return of bowel function and earlier restart of alimentation. Group B had shorter length of stay. There was no mortality or morbidity., Conclusions: Laparoscopic approach showed a shorter mean postoperative nasogastric tube time of placement and a shorter mean hospital stay, with faster resumption of bowel movements and early solid diet alimentation.

Background/aims: Aim of this work was to analyze retrospectively two groups of patients who underwent hepatic resection using two different techniques, to determine whether exists a difference in hepatic tolerance and in the early outcome., Methodology: We retrospectively analyzed seventy-one patients divided into group 1, treated with kellyclasia and Pringle maneuver, and group 2 treated with a radiofrequency device. The following parameters were analyzed: age; sex; type of disease, number of major/minor resections; total operative time and transection time; number and time of clampings; blood loss; pre- and postoperative transaminases and total bilirubin; length of hospitalization; morbidity and mortality., Results: Median total operative time and median hospital stay were similar in both groups but median median blood loss was higher in group 1. ALT levels in group 1 were higher than in group 2. Morbidity and mortality were observed only in group 1., Conclusions: Kelly-crush is related to a lower parenchymal tolerance as shown by the higher increase in postoperative alanine aminotransferase levels.

Hepatic portal vein embolization and transcatheter arterial chemoembolization are well-defined procedures respectively introduced to increase the future remnant liver and to avoid tumor progression before a scheduled hepatectomy. If used alone, both this approaches do not always improve surgical outcome, sometimes resulting in drop out from definitive surgery because of progression of disease. Since the late 1980s, sequential approach with TACE and PVE has been introduced as a preoperative treatment in order to: prevent tumor progression during the weeks intervening before operation; strengthen the effects of PVE by embolizing possible arterio-portal shunts; improve the FRL volumetric increase through the acceleration of hepatocytes proliferation. The risk of liver parenchymal necrosis, related to the double occlusion of blood supply, is usually avoided by maintaining an interval of weeks between the two procedures (PVE performed 2-3 weeks after TACE and surgery performed 4-6 weeks after PVE), but during this period the tumor may grow, nullifying the results obtained. We herein report a literary review and our initial experience with one patient affected by hepatocellular carcinoma involving the whole right liver, treated with TACE and right PVE, both performed in the same session. Although this technique still needs validation after the treatment of a wider number of patients, it seems to be feasible and effective.

Background/aims: To present our experience with 2 patients treated with a fibrinogen- and thrombin-coated collagen patch to repair a perforated peptic ulcer., Methodology: Age, sex, gastric disease, time between symptom appearance and operation, duration of operation, duration of nasogastric tube placement, renewal of peristalsis and feeding, and overall hospital stay were considered. Each patient underwent the laparotomic suture of the gastric wall, followed by patch application covered by the omental patch., Results: 2 male patients underwent ulcer repair using the patch. The duration of the operation was 45 min. The nasogastric tube was kept in place for 3d and for 2d. The renewal of peristalsis occurred 12h after the operation in both patients. The patients started to eat 5d and 3d after the operation and were discharged after 6d and 4d, respectively., Conclusions: The patch may improve the seal of the traditional repair, has no complications, and makes the overall operation faster.

Background/aims: [corrected] The aims of this study were to evaluate the incidence of overwhelming postsplenectomy infection (OPSI), the usefulness of vaccination in preventing OPSI, and whether affected patients had received the current best practice preventive measures., Methodology: The patients, observed from June 1991 to May 2005, were reviewed retrospectively. Gender, age, causes of splenectomy, vaccinations and complications were studied., Results: 225 patients (178 males, 47 females) underwent splenectomy, and of these, 79 patients (35.1%) were considered for the present study. Seven patients (8.8%) were informed about the risks of infection and received pneumococcal polysaccharide vaccine after splenectomy. Sixty-eight patients (86.7%) receive influenza vaccine every year. One of the patients that did not receive immunoprophylaxis had OPSI (incidence 1.26%) 1 year after splenectomy., Conclusion: Vaccination seems to prevent OPSI. Because of low incidence of OPSI, however, prospective randomised studies in patients without risk factors are needed to evaluate the usefulness of immunoprophylaxis.

Background/aims: The incidental finding of hemangiomas has increased, but the problem of the correct surgical indications of this tumor has yet to be solved. The aim of this work is to establish whether the psychological request of surgery from patients known to have a benign tumor of the liver must be avoided or not., Methodology: Age, sex, symptoms, estroprogestinic oral therapy, methods of diagnosis, surgical procedures, morbidity, mortality, postoperative hospital stay and follow-up of the patients affected by hepatic hemangioma, observed from 1992 to 2002 in our institution, have been considered., Results: Seventeen patients, with a mean age of 44 years (range 26-72), were hospitalized for hepatic hemangioma, 8 (47%) of them were operated on and 9 (53%) were managed by observation. The operated patients presented various symptoms. One patient was operated on for traumatic rupture of the hemangioma. Non-operated patients were asymptomatic or with slight dyspeptic symptoms not related with the tumor. The first diagnostic radiological examination was ultrasonography (US) in all cases. All lesions were larger than 4cm. The types of surgical procedures were 5 enucleations, and 3 hepatic resections. All operated patients resolved their clinical symptomatology, except two patients that had requested surgery for psychological implications. These patients presented their symptoms again after 2and 3 years of follow-up respectively., Conclusions: Our results suggest that liver hemangiomas should be operated for symptoms well related to the tumor or for bleeding. Psychological requests from the patients should be avoided every time.

Adrenocortical carcinoma is a very rare tumor which can develop at any age in either sex, with an estimated incidence of 0.5-2 new cases per million per year. Only few cases of adrenocortical carcinoma are reported in the literature, probably because the differential diagnosis between malignant and benign mass is not easy. Surgery represents the treatment of choice for adrenocortical carcinoma and for its possible recidivisms. We report the case of a 36-year-old female patient affected by adrenocortical carcinoma, operated on in 1999 and re-operated on in 2002 for a liver metastasis of the same tumor, without any other treatment. This case may be interesting for its rarity as well as for the several difficulties of the diagnosis and the choice of treatment. In conclusion, the follow-up of these patients is mandatory due to the difficulties of diagnosis and curative surgery represents the best choice of treatment.

The authors report a complication of a totally implantable arterial device in a patient in which the device was inserted to prevent recurrence of hepatic metastasis. After intrahepatic chemotherapy, during the nursing of the totally implantable arterial device, the patient developed a mass close to the duodenal loop that disappeared seven months later. The spontaneous decrease of this mass suggests the hypothesis of a hematoma due to a rupture of a pseudoaneurysm of a small collateral artery.

Background/aims: In recent years, surgical and non-surgical options have been developed in the treatment of hepatocellular carcinoma in cirrhotic patients. We review our personal series from 1995-1999, in order to assess the choice of treatment., Methodology: Of 90 cases of hepatocellular carcinoma observed in the years 1995-1999, 15 underwent curative resective surgery; in 42 cases TAE, PEI or RITA were utilized (9 of them as multimodal therapy). In the remaining 33 patients any kind of therapy was scheduled., Results: The mean survival of the 15 resected patients was 18 months, non-statistically better than RITA survival, compared by Log-Rank test. Perioperative mortality calculated in all procedures was 5.2% (2 pts surgery, 1 pt TAE)., Conclusions: The high percentage of not treated hepatocellular carcinomas in our series is generally due to large tumor size diagnosed in advanced Child's stage. PEI, TAE and RITA have to be considered effective and safe for palliation for HCCs. However, surgical resection represents the curative therapy in selected cirrhotic patients affected by HCC.

Totally implantable venous access devices are usually implanted by surgical cut-down technique or by percutaneous approach, after a first surgical procedure. The authors describe a new surgical approach utilizing the right gonadal vein or the vena cava for totally implantable venous access device placement in patients submitted to major digestive surgical procedures for tumors. This new surgical approach allows one to avoid a second operative procedure.

A new alternative technique for regional perfusion chemotherapy in the presence of a right hepatic artery arising from the superior mesenteric artery is described. The cystic artery branch of the right hepatic artery and the gastroduodenal artery can be used to place two catheters and thus apply two implantable systems. This risk-free, straightforward technique preserves native flow and achieves homogeneous distribution of the chemotherapeutic agent.