Search

Background: Transarterial radioembolization (TARE) is an effective treatment to control tumor growth and improve survival in hepatocellular carcinoma (HCC). The role of TARE in downstaging patients to liver transplantation (LT) is unclear. The aim of this study was to investigate the downstaging efficacy of TARE for intermediate and advanced HCC., Methods: Intention-to-treat analysis with multistate modeling was performed. Patients moved through 5 health states: (1) from TARE to listing, (2) from TARE to death without listing, (3) from listing to LT, (4) from listing to death without LT, and (5) from transplant to death. Factors affecting the chance of death after TARE were considered to stratify outcomes., Results: Two hundred fourteen patients underwent TARE. Of those, 43.9% had radiological response, 29.9% were listed, and 22.8% were transplanted. The probability of being alive without LT was 40.5% 1 y after TARE and 11.5% at 5 y. The chance of being listed was 9.4% at 1 y and 0.9% at 5 y. The probability of dying after TARE without LT was 38% at 1 y and 73% at 5 y. The overall survival of patients receiving LT was 61% at 5 y after transplant. Tumor beyond up-to-seven criteria, alfafetoprotein >400 ng/mL, and albumin-bilirubin ≥2 were associated with death. Three risk groups were associated with different response, chances of being listed, and receiving LT. Median survival was 3 y for low-risk, 1.9 y for intermediate-risk, and 9 mo for high-risk patients (P < 0.001)., Conclusions: In intermediate and advanced HCC, TARE allows for a 44% chance of response, 30% downstaging, and 23% probability of permitting LT. Patient's and tumor's characteristics allow for risk stratification and predict survival from TARE., Competing Interests: The authors declare no funding or conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Surgical-related injuries are frequent, in fact the reported percentage of musculoskeletal disorders in surgeons is between 47% and 87%. These conditions are caused by long periods of standing, incorrect postures, repeated movements, little rest between operations, the lack of integrated operator rooms, the correct number and arrangement of monitors and the use of non-ergonomic instruments. This survey aims to assess the Italian overview both highlighting how prevalent surgical-related injury is in our surgeons and whether there is an operating room ergonomics education program in Italian surgical specialty schools., Methods: An anonymous questionnaire was designed through SurveyMonkey© web application. This survey was composed of 3 different sections concerning the general characteristics of the participants, their surgical background and any training performed, and any injuries or ailments related to the surgical activity. The survey was carried out in the period 1th of December 2022 and the 6th of February 2023., Results: At the close of our survey, 300 responses were collected. Among the participants, the two most represented specialties were Gynecology and Obstetrics (42.3%) and General Surgery (39.7%) and surgeons were mainly employed in the Northern regions of Italy (54.8%). Analyzing the participants' background, 61.7% of the respondents had laparoscopic training during their training and only 53.1% had a pelvic trainer during their residency. In accordance with 98.7% of the respondents, during surgery we have the feeling of being in an uncomfortable position that causes discomfort or muscle pain, and regarding the frequency of these discomforts, the majority of our study population experiences these problems monthly (46.2%), while in 29.6% it is experienced weekly, 12.1% annually and finally 12.1% daily. The surgical approach that is most correlated with these disorders is laparoscopy (62.7%) while the one that causes the least discomfort is robotic surgery (1.4%). These discomforts cause 43.9% of our population to take a break or do short exercises to reduce pain during surgery, and the body areas most affected are the back (61.6%), neck (40.6%) and shoulders (37.8%)., Conclusion: Despite this, our survey allows us to highlight some now-known gaps present in the surgical training program of our schools and the lack of protection toward our surgeons during their long career., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Restaino, D’Indinosante, Perelli, Arcieri, Cherchi, Petrillo, Cavaliere, Cianci, Pellecchia, Meniconi, Coppola, Chiantera, Scambia, Driul, Vizzielli and SPIGC Working Group.)

Background: Clinically relevant postoperative pancreatic fistula (CR-POPF) is the most frequent complication of pancreatic surgery and can be fatal. Selection and stratification of patients according to the risk of POPF are important for the perioperative management. Predictive metrics have been developed and validated in pancreatojejunostomy. Aim of this study is to assess whether the most used prognostic scores can be predictive of fistula following Wirsung-pancreaticogastrostomy (WPG) for pancreatoduodenectomy (PD)reconstruction., Method: This single-center prospective observational study included 212 PDs between January 2008 and October 2022 with a standardized WPG. All component variables of the six scores were separately validated in our cohort. The overall predictive ability of the six fistula scores was measured and compared with the receiver operating characteristics curves (ROC) method and expressed by the area under the ROC-curve (AUC). Univariate and multivariate logistic regression analyses were performed considering all risk factors in the scores in order to identify variables independently correlated with POPF in the WPG., Results: CR-POPF occurred in 36 of 212 (17 %) patients. All scores showed poor prognostic stratification for the development of CR-POPF. The occurrence of CR-POPF was associated with nine factors: male gender (p = 0.003); BMI (kg/m 2 ) (p = 0.005); ASA (%) (p = 0.003); Soft pancreatic texture (%) (p = 0.003), Pathology (p = 0.008); MPD (p = 0.011); EBL (mL) (p = 0.021); Preop. Bilirubin (mg/dl) (p = 0.038); Preop. Glucose (mg/dl) (p = 0.0369). Male gender (OR: 5.54, CI 1.41-21.3) and soft consistency of the remnant pancreas (OR: 3.83, CI 1.14-12.8) were the only independent prognostic factors on multivariate analysis., Conclusions: Our study including exclusively pancreatogastrostomies failed to validate the most used predictive scores for POPF. We found that only male gender and soft pancreatic texture are associated with POPF. Specific predictive scores following pancreatogasgtrostomy are needed., (Copyright © 2023 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Surgery and postoperative systemic chemotherapy represent the standard treatment for patients with perihilar cholangiocarcinoma (PHC). Minimally Invasive Surgery (MIS) for hepatobiliary procedures has spread worldwide in the last two decades. Since resections for PHC are technically demanding, the role of MIS in this field is yet to be established. This study aimed to systematically review the existing literature on MIS for PHC, to evaluate its safety and its surgical and oncological outcomes. A systematic literature review on PubMed and SCOPUS was performed according to the PRISMA guidelines. Overall, a total of 18 studies reporting 372 MIS procedures for PHC were included in our analysis. A progressive increase in the available literature was observed over the years. A total of 310 laparoscopic and 62 robotic resections were performed. A pooled analysis showed an operative time ranging from 205.3 ± 23.9 and 840 (770-890) minutes, and intraoperative bleeding between 101.1 ± 13.6 and 1360 ± 809 mL. Minor and major morbidity rates were 43.9% and 12.7%, respectively, with a 5.6% mortality rate. R0 resections were achieved in 80.6% of patients and the number of retrieved lymph nodes ranged between 4 (3-12) and 12 (8-16). This systematic review shows that MIS for PHC is feasible, with safe postoperative and oncological outcomes. Recent data has shown encouraging results and more reports are being published. Future studies should address differences between robotic and laparoscopic approaches. Given the management and technical challenges, MIS for PHC should be performed by experienced surgeons, in high-volume centers, on selected patients.

Laparoscopic liver resections (LLRs) have been increasingly adopted for the treatment of hepatocellular carcinoma (HCC), with safe short- and long-term outcomes reported worldwide. Despite this, lesions in the posterosuperior segments, large and recurrent tumors, portal hypertension, and advanced cirrhosis currently represent challenging scenarios in which the safety and efficacy of the laparoscopic approach are still controversial. In this systematic review, we pooled the available evidence on the short-term outcomes of LLRs for HCC in challenging clinical scenarios. All randomized and non-randomized studies reporting LLRs for HCC in the above-mentioned settings were included. The literature search was run in the Scopus, WoS, and Pubmed databases. Case reports, reviews, meta-analyses, studies including fewer than 10 patients, non-English language studies, and studies analyzing histology other than HCC were excluded. From 566 articles, 36 studies dated between 2006 and 2022 fulfilled the selection criteria and were included in the analysis. A total of 1859 patients were included, of whom 156 had advanced cirrhosis, 194 had portal hypertension, 436 had large HCCs, 477 had lesions located in the posterosuperior segments, and 596 had recurrent HCCs. Overall, the conversion rate ranged between 4.6% and 15.5%. Mortality and morbidity ranged between 0.0% and 5.1%, and 18.6% and 34.6%, respectively. Full results according to subgroups are described in the study. Advanced cirrhosis and portal hypertension, large and recurrent tumors, and lesions located in the posterosuperior segments are challenging clinical scenarios that should be carefully approached by laparoscopy. Safe short-term outcomes can be achieved provided experienced surgeons and high-volume centers.

Introduction: The COVID-19 pandemic has led to the disruption of surgical training. Lack of communication, guidelines for managing clinical activity as well as concerns for safety in the workplace appeared to be relevant issues. This study aims to investigate how surgical training has been reorganized in Italy, almost 2 years after the outbreak of COVID-19 pandemic., Materials and Methods: A 16-item-electronic anonymous questionnaire was designed through SurveyMonkey © web application. This survey was composed of different sections concerning demographic characteristics and impacts of the second COVID-19 pandemic wave on surgical and research/didactic activities. Changes applied in the training programme and activities carried out were also investigated. The survey was carried out in the period between June and October 2021., Results: Four hundred and thirty responses were collected, and 399 were considered eligible to be included in the study analysis. Three hundred and thirty-five respondents continued working in Surgical Units, with a significant reduction (less than one surgical session per week) of surgical sessions in 49.6% of them. With concern to didactic and research activities, 140 residents maintained their usual activity, while 116 reported a reduction. A sub-group analysis on resident moved to COVID-19 departments showed a reduction of research activities in 35% of them. During the period considered in this survey, the surgical training program was not substantially modified for most of participants (74.6%)., Conclusion: Our survey demonstrated that surgical residency programs haven't improved 2 years after the beginning of the pandemic. Further improvements are needed to guarantee completeness of surgical training, even in emergency conditions., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Gallo, Guaitoli, Barra, Picciariello, Pasculli, Coppola, Pertile, Meniconi and SPIGC Surgical Training Working Group.)

Introduction: A significant reorganization of working activities including those of teaching hospitals occurred after COVID-19 outbreak, leading to the need to re-assess the current status of training after the pandemic. This study aimed to investigate the state of general surgery (GS) residency in Italy. The impact of COVID-19 on GS residents was also assessed., Methods: Between October and November 2020, an anonymous online survey was distributed to GS residents across Italy. Email addresses were provided by the Regional Committees of the Italian Polyspecialistic Society of Young Surgeons. The residents completed a set of questions regarding their training schedule and three standardized questionnaires to measure burnout and psychological distress., Results: Overall, 1709 residents were contacted and 648 completed the survey. Almost two-thirds of the residents (68.4%, n = 443) reported to not reach the minimum annual operative case volume. According to ordinal logistic regression analysis, two of the most perceived effects of COVID-19 by trainees on training were reduction of surgical activities (OR = 2.21, p < 0.001) and increased concerns about future employment (OR = 1.14, p = 0.025). Loss of training opportunities was also associated with a significant increase of distress (OR = 1.26, p = 0.003) but not with burnout., Conclusions: This study provided a snapshot of the situation of GS residents in Italy after COVID-19 outbreak. Reduction of activities due to pandemic highlighted the need to improve the level of surgical education in our country by implementing all the new available tools for training and ensuring at the same time the well-being of the residents., (© 2022. Italian Society of Surgery (SIC).)

Patients with advanced hepatocellular carcinoma (HCC) and macrovascular invasion (MVI) have dismal prognosis and are referred to systemic treatment or palliation. To investigate the outcomes of patients with HCC and MVI undergoing the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure. Demographics and operative data were retrospectively reviewed. All types of hepatectomies and all types of ALPPS modifications were included. MVI was categorized according to the Japanese Liver Cancer Study Group classification. 28 patients were included. Viral aetiology was the most common cause of chronic liver disease (89.3%). 85.7% of patients were cirrhotic, with a median MELD score of 9 (7-10). MVI of the hepatic veins or inferior vena cava was diagnosed in 46.4% of patients while portal vein involvement was present in 64.2% of cases. Four patients (14.2%) were diagnosed with bile duct involvement. No patients died after Step 1 while complications occurred in 21.4% of cases. Following step 2, 3 patients (11.5%) died and 20 (69.2%) developed complications. Grade B and C post-hepatectomy liver failure occurred in 57.6% and 11.5% of patients, respectively. After a median follow-up of 18 months (7-35), median survival was 22 months (3-40). Eleven patients (39.3%) recurred. Median disease-free survival was 15 months (5-26). The ALPPS procedure is an extreme rescue approach in otherwise inoperable advanced HCC with MVI. The procedure is associated with high morbidity and mortality and patients' selection is pivotal. Oncological outcomes are safe and should be further investigated., (© 2022. Italian Society of Surgery (SIC).)

Background: Despite the successful oncological results of liver transplantation, patients with hepatocellular carcinoma (HCC) can develop tumor recurrence. When technically feasible, liver resection represents the preferred treatment for recurrent HCC, even in the setting of transplanted patients. Recent progresses in minimally invasive liver resections have pushed the surgical community to attempt more challenging cases. We report a full laparoscopic left hepatectomy for HCC recurrence on transplanted liver., Methods: A routine follow-up computed tomography (CT) scan of a 53-year-old male who previously underwent an orthotopic liver transplantation for alcoholic-related liver disease showed a 3 cm HCC in segment 4 in close relationship with the peripheral portion of the left portal pedicle. A full laparoscopic left hepatectomy was performed using an extrahepatic intraglissonean approach., Results: Operative time was 332 min and blood loss was 100 mL. The patient had an uneventful postoperative recovery and was discharged home after 3 days., Conclusions: Laparoscopic liver resection on transplanted patients is feasible. Challenging clinical scenarios should only be attempted in referral centers and after an appropriate learning curve. 1-8 ., (© 2021. Society of Surgical Oncology.)

Laparoscopic liver resections have gained widespread popularity among hepatobiliary surgeons and is nowadays performed for both standard and more complex hepatectomies. Given the increased technical challenges, preoperative planning and intraoperative guidance is pivotal in laparoscopic surgery to safely carry out complex and oncologically safe hepatectomies. Modern tools can help both preoperatively and intraoperatively and allow surgeons to perform more precise hepatectomies. Preoperative 3D reconstructions and printing as well as augmented reality can increase the knowledge of the specific anatomy of the case and therefore plan the surgery accordingly and tailor the procedure on the patient. Furthermore, the indocyanine green retention dye is an increasingly used tool that can nowadays improve the precision during laparoscopic hepatectomies, especially when considering anatomical resection. The use of preoperative modern imaging and intraoperative indocyanine green dye are key to successfully perform complex hepatectomies such as laparoscopic parenchymal sparing liver resections. In this narrative review, we discuss the aspects of preoperative and intraoperative tools that are nowadays increasingly used in experienced hepatobiliary centers.

Liver is the main target organ for colorectal cancer (CRC) metastases. It is estimated that ~25% of CRC patients have synchronous metastases at diagnosis, and about 60% of CRC patients will develop metastases during the follow up. Although several teams have performed simultaneous laparoscopic resections (SLR) of liver and colorectal lesions, the feasibility and safety of this approach is still widely debated and few studies on this topic are present in the literature. The purpose of this literature review is to understand the state of the art of SLR and to clarify the potential benefits and limitations of this approach. Several studies have shown that SLR can be performed safely and with short-term outcomes similarly to the separated procedures. Simultaneous laparoscopic colorectal and hepatic resections combine the advantages of one stage surgery with those of laparoscopic surgery. Several reports compared the short-term outcomes of one stage laparoscopic resection with open resections and showed a similar or inferior amount of blood loss, a similar or lower complication rate, and a significant reduction of hospital stay for laparoscopic surgery respect to open surgery but much longer operating times for the laparoscopic technique. Few retrospective studies compared long term outcomes of laparoscopic one stage surgery with the outcomes of open one stage surgery and did not identify any differences about disease free survival and the overall survival. In conclusion, hepatic and colorectal SLR are a safe and effective approach characterized by less intraoperative blood loss, faster recovery of intestinal function, and shorter length of postoperative hospital stay. Moreover, laparoscopic approach is associated to lower rates of surgical complications without significant differences in the long-term outcomes compared to the open surgery., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Sena, Picciariello, Marino, Goglia, Rocca, Meniconi and Gallo.)

COVID-19 is rapidly spreading worldwide. Healthcare systems are struggling to properly allocate resources while ensuring cure for diseases outside of the infection. The aim of this study was to demonstrate how surgical activity was affected by the virus outbreak and show the changes in practice in a tertiary referral COVID-19 center. The official bulletins of the Italian National Institute for the Infectious Diseases "L. Spallanzani" were reviewed to retrieve the number of daily COVID-19 patients. Records of consecutive oncological and transplant procedures performed during the outbreak were reviewed. Patients with a high probability of postoperative intensive care unit (ICU) admission were considered as high risk and defined by an ASA score ≥ III and/or a Charlson Comorbidity Index (CCI) ≥ 6 and/or a Revised Cardiac Risk Index for Preoperative Risk (RCRI) ≥ 3. 72 patients were operated, including 12 (16.6%) liver and kidney transplantations. Patients had few comorbidities (26.3%), low ASA score (1.9 ± 0.5), CCI (3.7 ± 1.3), and RCRI (1.2 ± 0.6) and had overall a low risk of postoperative ICU admission. Few patients had liver cirrhosis (12.5%) or received preoperative systemic therapy (16.6%). 36 (50%) high-risk surgical procedures were performed, including major hepatectomies, pancreaticoduodenectomies, total gastrectomies, multivisceral resections, and transplantations. Despite this, only 15 patients (20.8%) were admitted to the ICU. Only oncologic cases and transplantations were performed during the COVID-19 outbreak. Careful selection of patients allowed to perform major cancer surgeries and transplantations without further stressing hospital resources, meanwhile minimizing collateral damage to patients.

Introduction: Recently, Italy has been heavily hit by COVID-19 pandemic and today it is still one of the most affected countries in the world. The subsequent necessary lockdown decreed by the Italian Government had an outstanding impact on the daily life of the entire population, including that of Italian surgical residents' activity. Our survey aims to evaluate the impact of COVID-19 on the training programme of Italian surgical residents., Materials and Methods: We designed a 12-item-electronic anonymous questionnaire on SurveyMonkey© web application. The survey was composed of different sections concerning demographic characteristics and impacts of COVID-19 on the concrete participation in clinical, surgical and research activities. Future perspectives of responders after the pandemic were also investigated., Results: Eighty hundred responses were collected, and 756 questionnaires were considered eligible to be included in the study analysis. Almost 35 and 27% of respondents experienced, respectively, complete interruption of surgical and clinical activities. A subgroup analysis, comparing the COVID-19 impact on clinical activities with demographics data, showed a statistically significant difference related to specialties (p = 0.0062) and Italian regions (p < 0.0001). Moreover, 112 residents have been moved to non-surgical units dealing with COVID-19 or, in some case, they voluntarily decided to interrupt their residency programme to support the ongoing emergency., Conclusion: Our survey demonstrated that COVID-19 pandemic has severely impacted the educational programme of Italian surgical residents. Despite many regional differences, this survey highlighted the overall shortage of planning in the re-allocation of resources facing this unexpected health emergency.

Introduction: Risk factors of postoperative pancreatic fistula (POPF) after laparoscopic distal pancreatectomy (LDP) are not well known and were studied, including the stapler cartridge size and drainage modality., Methods: Between January 2008 and December 2016, 181 LDP were performed and the pancreas was sectioned by stapler in 130 patients (72%). Patients received white (2.5 mm), blue (3.5 mm), or green (4.1 mm) staplers and the size was not based on any pre or peroperative randomization. As primary analysis of the first 84 patients (28 in each group) showed no effect of stapler size on POPF, we decided to use the white (total = 47) or blue and finally the blue (total = 55) of medium size for standardization. Drainage was obtained by multi-tubular drain (first, 79) and a small suction drain (last, 102). Risk factors of POPF were studied and grades B and C were compared to grade A or no POPF., Results: POPF (n = 66; 36%) was of grade A (n = 25, 14%), grade B (n = 32, 18%), and grade C (n = 9, 5%). The comparison of the three groups of staplers showed that the blue stapler was used more with a small suction drain (85 vs 23%, p < 0.0001), had lower rate of grade B POPF (p = 0.028), and a shorter hospital stay (p = 0.004). On multivariate analysis, only the use of a small suction drain was associated with significant decrease in grades B and C POPF (6 vs 44%, odds ratio 7.385 (1.919-28.418); p = 0.004)., Conclusion: The occurrence of POPF following LDP is influenced by the type of drainage alone and is significantly decreased with a small suction drain.

Background: Cystic echinococcosis (CE) is a worldwide zoonosis and the liver is the most commonly affected organ. Clinical manifestations range from completely asymptomatic cysts to a potential lethal cyst rupture and anaphylaxis., Case Presentation: Severe chest allodynia was an unusual clinical presentation of hepatic cyst rupture in the retroperitoneal space, without any other specific symptoms. CE diagnosis was confirmed by computed tomography scan and magnetic resonance. The patient underwent hepatectomy with complete resolution of the neuropathic pain., Conclusions: Retroperitoneal hydatid cyst rupture is a rare event and its clinical manifestation may mimic other chest neuropathies.

Pancreaticoduodenectomy (PD) is associated with high postoperative morbidity. The management of postoperative complications is paramount for reducing the mortality rate. The aim of this study was to evaluate the importance of surgical and hospital experience on outcomes by comparing postoperative results in three different hospitals with increasing resources for supporting the same surgical team. Patients data and surgical outcome of 300 consecutive patients undergoing PD were collected prospectively in the department database and divided into three periods (A = 1990-2000, B = 2001-March 2007, C = April 2007-2015). Pancreatico-jejunostomy was the procedure of choice between 1995 and 2004, and pancreatico-gastrostomy was performed afterwards. In the periods A, B and C, a total of 78, 85 and 137 PD were performed, respectively, and the number of PDs per year increased from 5 to 25. Between the three periods, the death rate (10.4 vs. 6 vs. 1.6%, p = 0.01) and intraoperative RBC transfusion rate (84.9 vs. 42.4 vs. 6.5%, p = 0.01) decreased significantly, whereas the vascular resection rate increased significantly (1.2 vs. 7 vs. 14.5, p < 0.002). Morbidity and reoperation rates did not change significantly between the three periods as well as operative time and median length of stay. Infectious complications and sepsis represented the most frequent major complication. Massive bleeding associated with uncontrolled pancreatic leak represented the major cause of morbidity and reoperation in the three periods, however, the relative mortality rate decreased significantly with no deaths in the last period. PD remains a challenging procedure with high morbidity and mortality rate. A multidisciplinary pancreatic team represents the "safety net" of pancreatic surgeon because it improves the results beyond the surgeon skills and experience.

Background: Uterine leiomyomas represent the gynecological neoplasm with the highest prevalence worldwide. This apparently benign pathological entity may permeate into the venous system causing the so-called intravenous leiomyomatosis of the uterus (IVL). IVL may seldom extend to large caliber veins and reach the right cardiac chambers or pulmonary arteries and cause signs of right sided congestive heart failure and sudden death. Due to its low incidence, however, IVL with intracardiac extension is often misdiagnosed resulting in deferred treatment. No consensus has been obtained regarding the standard surgical approach to be used for this rare condition. We describe the case of a massive pelvic recurrence of uterine leiomyomatosis with intracardiac extension and provide a review of the literature, analyzing management and surgical outcomes., Case Presentation: We present the case of a 46-year-old premenopausal woman presenting with lower-extremity edema, recurrent syncopes and a history of subtotal hysterectomy for multiple uterine fibroids. She was diagnosed with pelvic recurrence of uterine leiomyomatosis and IVL with cardiac involvement. A two-stage surgical excision of the intracardiac-intracaval mass and pelvic leiomyomatosis was performed. The patient had an uneventful recovery and no evidence of recurrence was observed on follow-up., Conclusions: By virtue of the rarity of the present pathology, awareness is widely scarce and diagnosis is often delayed. Early recognition is difficult due to initial aspecific and subtle clinical manifestations. Nevertheless, suspicion should be held high in premenopausal women with known history of uterine leiomyomata, presenting with cardiovascular symptoms and evidence of a free-floating mass within the right cardiac chambers. In-depth imaging is crucial for defining its anatomical origin and relations. Prompt surgical treatment with radical excision of pelvic and intravenous leiomyomatosis guarantees favorable outcomes and excellent prognosis with low rates of recurrence, whereas delayed diagnosis and treatment exposes to increased risk of congestive heart failure and sudden death.

Background: Liver transplantation (LT) is a well-established procedure for hepatocellular carcinoma (HCC) within the Milan criteria. Yttrium-90 microspheres radioembolization (Y90-RE) has shown to be an effective and safe treatment of primary liver tumors. We retrospectively evaluate the efficacy of the Y90-RE in patients with HCC prior to LT., Methods: From January 2002 to December 2015, 365 patients were transplanted at the San Camillo Hospital Center. One hundred forty-three patients were transplanted for HCC, and in 22 cases the patients were treated with Y90-RE before LT., Results: Three patients were treated with Y90-RE within the Milan criteria, and 19 patients were out of criteria before Y90-RE. Four patients had an increasing MELD score between Y90-RE and LT. On the other hand, alpha-fetoprotein decreases after Y90-RE treatment in all cases. No patient death was observed in Y90-RE procedure or at LT. In 78.9 % of cases, a successful downstaging was observed, and in 100 % of cases bridging was achieved. From Y90-RE treatment overall survival was 43.9 months. From LT, overall mean survival was 30.2 months with a free survival of 29.6 months. The overall survival after LT analysis between the patients treated with Y90-RE and patients without was not significant (p = 0.113). Free survival analysis was not significant (p = 0.897) between the two populations., Conclusions: We successfully performed LT in patients after Y90-RE treatment both as bridging and downstaging for HCC and obtained a similar overall and free survival of LT for HCC within Milan criteria. Y90-RE becomes a real option to provide curative therapy for patients who traditionally are not considered eligible for surgery.

Background: In case of liver tumor, surgical resection is the therapeutic gold standard to increase patient survival. Among liver resections, right hepatectomy (RH) is defined as a major hepatectomy. The first aim of this study was to analyze the overall morbidity and mortality of patients undergoing RH, the second aim was to assess changes in both patients characteristic and surgical parameters and mortality rates in a single center institution., Materials: From 2001 to December 2015, 225 RH were performed in our center. We analyzed two time period: 2001-2007 and 2008-2015., Results: Ninety days post operative mortality was observed in 9 cases (4%) for the overall cohort. We observed a difference between the two groups in the use of Pringle Maneuver (p<0,001). This result is consistent in each major surgical indication: HCC (p=0,001), CLM (p=0,015) and BT (p=0,015). The estimated blood losses improved (p=0,028), particularly for the HCC cases (p=0,024). No difference was observed in terms of number of transfusions received between the two groups. Reduced length of stay was observed in the second group (p<0,001), more markedly for CLM cases (p=0,001)., Conclusion: To further improve the outcomes of RH, it is important to performed this major hepatectomy in hepatobiliary centers with an overall liver resection experience of at least few hundred cases., (Copyright © 2016 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: A potential mechanism of the infection would be an infected donor, contamination at the time of the infusion and/or packaging, back-table procedure, and finally during the transplantation, all are potential sources of infection. The aim of our study is to analyze the incidence and significance of infection in the preservation solution according with the graft temperature. The second aim was to analyze the impact graft temperature on the clinical infections and the ischemia reperfusion injury., Methods: Sixteen donors were prospectively included in this study, including 9 males and 7 females. The liver graft temperature monitoring shows variation in four different phases: at the harvesting beginning, before the graft packaging, at the beginning of the backtable, at the end of the backtable., Results: There was no correlation between the functionality of the graft and the temperature of the perfusion fluid., Conclusions: In conclusion, we did not found a correlation between graft temperature, culture of the preservation solution and early post-transplant follow up., Competing Interests: The authors have no conflicts of interest to declare.

Background: The use of cadaveric vein allografts was first described by our group as a feasible option for venous reconstruction. The aim of this study was to report long-term results of this innovative technique., Methods: Cold-stored veins harvested from donor cadavers were used as homologous grafts for venous reconstruction after vascular resection during pancreaticoduodenectomy. Surgical technique included patch closure or segmental interposition. Graft patency was assessed by computed tomography postoperatively and during follow-up. Postoperative morbidity and mortality were also analyzed., Results: Eleven patients underwent venous resection and reconstruction by using fresh vein allografts for patch closure in four cases, conduit interposition in six cases and a Y-shaped graft interposition in one case. Median clamping time, operative time and estimated blood loss were 30 min, 6.6 h, and 337 ml, respectively. One patient, who had preoperative SMV thrombus, developed early portal vein thrombosis and died. Among the remaining 10 patients, there were no cases of graft thrombosis or stenosis during active follow-up (median 9, range 1-23, months)., Conclusions: Our experience with cold-stored vein allografts suggests that this technique is a useful option for treating major vascular resections during pancreaticoduodenectomy with good results on follow-up., (© 2015 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Portal vein aneurysm is an unusual vascular dilatation of the portal vein, which was first described by Barzilai and Kleckner in 1956 and since then less than 200 cases have been reported. The aim of this article is to provide an overview of the international literature to better clarify various aspects of this rare nosological entity and provide clear evidence-based summary, when available, of the clinical and surgical management. A systematic literature search of the Pubmed database was performed for all articles related to portal vein aneurysm. All articles published from 1956 to 2014 were examined for a total of 96 reports, including 190 patients. Portal vein aneurysm is defined as a portal vein diameter exceeding 1.9 cm in cirrhotic patients and 1.5 cm in normal livers. It can be congenital or acquired and portal hypertension represents the main cause of the acquired version. Surgical indication is considered in case of rupture, thrombosis or symptomatic aneurysms. Aneurysmectomy and aneurysmorrhaphy are considered in patients with normal liver, while shunt procedures or liver transplantation are the treatment of choice in case of portal hypertension. Being such a rare vascular entity its management should be reserved to high-volume tertiary hepato-biliary centres., (Copyright © 2015 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Hepatocellular carcinoma (HCC) often recurs after curative resection, and thus the optimal treatment strategy to treat recurrences remains uncertain. We analyzed the results of different options to treat recurrent HCC and emphasized the impact of pathologic patterns of the tumor at initial resection., Methods: Between 2000 and 2014, 293 patients underwent potentially curative hepatic resection for HCC. Among them, 150 experienced a recurrence and have been treated by repeat resection (RR), radiofrequency ablation (RFA), salvage liver transplantation (SLT), transarterial chemoembolization (TACE), or conservative treatment, including systemic or targeted chemotherapy. Clinical outcomes were analyzed and compared between the treatment groups, focusing on clinical and pathologic characteristics of the tumor at initial resection., Results: After a median follow-up of 26 months, the overall survival (OS) at 1, 3, and 5 years after recurrence was 62%, 48%, and 40%, respectively. Survival rates were greater in patients treated by a curative approach (RR, RFA, SLT) than those treated by TACE, with 5-year OS of >70% and 37%, respectively. Univariate analysis showed satellitosis and microvascular invasion (MVI) at initial resection as negative prognostic factors of survival after recurrence (P < .05). On multivariate analysis, type of treatment was the only independent factor associated with survival. A subgroup analysis showed that RR/RFA led to better survival outcomes than TACE for early stage intrahepatic recurrences in the absence of satellitosis or MVI on the primary resected tumor., Conclusion: Curative treatments of recurrent HCC improve patient survival. Satellitosis and MVI on the primary resected specimen may be used as selection criteria for the best treatment strategy for intrahepatic recurrences., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Inferior vena cava (IVC) preservation during orthotopic liver transplantation (OLT) is known as the "piggyback" technique. The end-to-side anastomosis is constructed between the graft's IVC and recipient's hepatic veins using a Satinsky side clamp applied in a transverse position. To stabilize the large Satinsky clamp and preserve a sufficient vascular stump after hepatectomy and before graft implantation, we propose a technical innovation consisting of hanging the septa between the left and middle hepatic vein and between the middle and right hepatic vein using 2 tapes. This technique showed some advantages when performing the caval outflow anastomosis, representing a further technical refinement of the piggyback end-to-side technique for the implantation on the 3 hepatic veins. From November 2001 to September 2012, we performed 272 consecutive OLT at our institution with the piggyback technique using the hanging of the hepatic veins septa in all cases. In conclusion, the hanging of the 3 hepatic veins septa presented in this study represents a simple, safe and reproducible technique for the outflow anastomosis using the piggyback technique., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Patients with extensive peritoneal spread from advanced ovarian cancer often undergo several upper abdominal surgical procedures including subphrenic peritonectomy to obtain optimal cytoreduction. The most common complications are pleural effusions, pancreatic leakage and endoabdominal collections. This case report describes an unusual complication, a diaphragmatic hernia with an intrathoracic gastric volvulus developing four months after the patient underwent left subphrenic peritonectomy during interval debulking surgery and hyperthermic intraperitoneal chemotherapy for advanced ovarian cancer.

Aim: Gastrointestinal spontaneous hematomas (GSHs) represent 5-10% of patients with acute abdomen. Conservative treatment is the most common approach but the bowel perforation can be a fatal complication. In patients with spontaneous rectal wall hematoma, high comorbidity and abdominal signs of acute abdomen but without radiological signs of intestinal perforation, an early exploratory laparotomy should be considered., Case Presentation: A 70-year-old man with severe dilatative cardiomyopathy and chronic obstructive pulmonary disease (COPD) on anticoagulant therapy was admitted with acute abdominal pain and anemia. An abdominal CT scan showed a perihepatic, perisplenic and parietocolic effusion associated with a retro-rectal hematoma measuring 6 × 6 × 14 cm without signs of active bleeding. Because of sudden onset of signs of peritonitis, a laparotomy was performed which showed an ischemic perforation of the sigmoid-rectal junction. We performed a recto-sigmoid resection (Hartmann operation) but the patient died twelve days later for septic shock., Discussion: In patients with GSH the main problem is represented by the choice between conservative and surgical treatment. In case of complications, such as active and persistent intra-abdominal bleeding, wall ischemia with or without bowel perforation and peritonitis, surgical treatment is mandatory. The absence of radiological signs of perforation can cause a delay of surgical treatment with unfavourable outcome especially in patient with rectal hematoma and severe comorbidity., Conclusions: GSHs of rectum are uncommon but a strict clinical monitoring is crucial because the extraperitoneal position make it possible a late clinical or radiological identification of perforation and a late laparotomy.

Introduction: An inguinal hernia is a common surgical disease in elderly patients, but an association with intra-abdominal malignancies is rare., Case Presentation: We report a case of a 78-year-old Caucasian woman presenting with a right inguinal mass suspected to be an irreducible hernia. A computed tomography scan showed the presence of the cecum in her inguinal canal, with an irregular thickening of the cecal wall suggesting a neoplasm within the inguinal hernia. A colonoscopy was not completed owing to the huge involvement of the cecum into the hernia sac. A laparotomy was performed, at which time the cecum was herniated through her right inguinal canal and the cecal tumor had infiltrated her abdominal wall and femoral artery. A right inguinal incision was necessary for good vascular control and to carry out an en bloc resection of the tumor with the inguinal wall. A right colectomy was performed and the inguinal wall repaired. The postoperative course was uneventful and our patient received adjuvant radiochemotherapy., Conclusion: We describe a rare case of a locally advanced cecal tumor presenting as a right inguinal hernia. Both diagnosis and surgical treatment in elderly patients represent a challenge for the surgeon in cases of aggressive tumors as reported in this paper.

Background: Different methods of pancreatic stump closure after distal pancreatectomy (DP) have been described to decrease the incidence of pancreatic fistula (PF) which still represents one of the most common complications in pancreatic surgery. We retrospectively compared the pancreato-jejunostomy technique with the hand-sewn closure of the pancreatic stump after DP, and analyzed clinical outcomes between the two groups, focusing on PF rate., Methods: Thirty-six patients undergoing open DP at our institution between May 2005 and December 2011 were included. They were divided in two groups depending on pancreatic remnant management: in 24 cases the stump was closed by hand-sewn suture (Group A), while in 12 earlier cases a pancreato-jejunostomy was performed (Group B). We analyzed postoperative data in terms of mortality, morbidity and length of hospital stay between the two groups., Results: PF occurred in 7 of 24 (29.1%) cases of group A (control group) compared to zero fistula rate in group B (anastomosis group) (p=0.005). Operative time was significantly higher in the anastomosis group (p=0.024). Mortality rate was 0% in both groups. Other postoperative outcomes such as hemorrhages, infections, medical complications and length of hospital stay were not significant between the two groups., Conclusion: Despite a higher operative time, the pancreato-jejunostomy after DP seems to be related to a lower incidence of PF compared to the hand-sewn closure of the pancreatic remnant.

Introduction: Venous resections and reconstructions of portal vein and/or superior mesenteric vein in course of pancreaticoduodenectomy are becoming a common practice and many surgical options have been described, from simple tangential resection and venorrhaphy to large segmental resections followed by interposition grafting. The aim of this study was to report the first experience of using fresh cadaveric vein allografts for venous reconstruction during pancreaticoduodenectomy focusing on technical feasibility and postoperative outcomes., Methods: From January 2001 to October 2012, out of 151 patients undergoing pancreaticoduodenectomy for pancreatic head tumor, 22 (14.5 %) received a vascular resection of the mesentericoportal axis. In five of these patients, vascular reconstruction was accomplished by using cold-stored venous allografts of iliac and femoral veins from donor cadaver. Patients' data, surgical techniques, and clinical outcomes were analyzed., Results: Five patients undergoing pancreaticoduodenectomy were selected to receive a vascular reconstruction using a fresh venous allograft for patch closure in three cases, conduit interposition in one case and a Y-shaped graft in the last case. No graft thrombosis or stenosis occurred postoperatively and at long-term follow-up. Mortality rate was zero., Conclusion: The use of fresh vein allografts is a feasible and effective technique for venous reconstruction during pancreaticoduodenectomy. However, prospective surveys including large cohorts of patients are necessary to confirm these results.

Introduction: Acute pancreatitis occurs less frequently in children than in adults, although it seems to be more common than has been considered in the past. There are several causes of pancreatitis in childhood: trauma, infections or structural gland anomalies as pancreas divisum., Case Presentation: We report a case of non-traumatic severe acute pancreatitis in a 8-year-old girl with pancreas divisum, complicated by a rapid formation of a large infected pseudocyst which required a surgical internal drainage by a Roux-en-Y cystojejunostomy., Discussion: Pancreas divisum is the most common congenital anomaly of the pancreas with an incidence of 3-10% of population, and its role in causing acute or recurrent pancreatitis is still controversial. There are only sporadic observations of acute pancreatitis complicated by pseudocyst in children with pancreatic anomalies and its treatment is not standardized. Three different approaches have been described to treat a pancreatic pseudocyst: percutaneous, endoscopic or surgical drainage. We decided to perform a pseudocyst-jejunostomy because of the disease severity., Conclusion: Even in the non-invasive era, the surgical approach to treat a large complicated pseudocysts in children still represents a safe and feasible approach in emergencies as acute abdomen, bleeding or sepsis. Complications of percutaneous and endoscopic drainages are avoided and long term results are excellent., Key Words: Acute pancreatitis, Pancreas divisum, Pancreatic pseudocyst.

Duplication of the inferior vena cava (IVC) involves large veins on both sides of the aorta that join anteriorly at the level of the renal arteries to become the suprarenal IVC. We report CT scan and intraoperative images of a patient with duplication of the IVC who underwent pancreaticoduodenectomy with para-aortic lymphadenectomy for carcinoma of the pancreatic head: nodal dissection along the left caval vein was not carried out. The anatomical background of the lymphatic flow to the para-aortic lymph nodes and the theoretic basis for lymph node dissection of the para-aortic area in cases of double IVC are highlighted. Lymphadenectomy along the left caval vein is not necessary in patients with double IVC who undergo pancreaticoduodenectomy with extended lymphadenectomy for carcinoma of the pancreatic head in the absence of preoperative appearance of para-aortic disease.

Introduction: Adrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis and the association with tumor thrombus into the inferior vena cava (IVC) is not common. The best treatment is represented by radical surgery., Presentation of Case: We describe a case of a large ACC of the left adrenal gland extending into the IVC through the left renal vein in a young patient with agenesis of the right kidney and signs of acute renal failure. A midline laparotomy was performed, subsequently extended by a left thoracophrenotomy through the 7th intercostal space in order to control the proximal surface of the mass and the thoracic aorta. The tumor was completely excised preserving the kidney, and thrombectomy was performed by a cavotomy with a temporary caval clamping, without cardiopulmonary by-pass (CPB)., Discussion: We discuss surgical approaches reported in literature in case of ACC with intracaval extension. The tumor must be completely resected and the thrombectomy can be performed by different approaches: cavotomy with direct suture, partial resection of caval wall without reconstruction, resection of vena cava with graft reconstruction. These procedures could require a CPB, with an increased mortality. In our case we preserved the kidney and a thrombectomy without CPB was performed., Conclusion: Intracaval extension of ACC does not represent a contraindication to surgery. The best treatment of intracaval thrombus should be the cavotomy with direct suture. The CPB is not always required. In presence of renal agenesis, the preservation of the kidney is mandatory., (Copyright © 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Inflammatory myoglandular polyp (IMGP) is a rare non-neoplastic polyp of the large bowel, commonly with a distal localization (rectosigmoid), obscure in its pathogenesis. Up till now, 60 cases of IMGP have been described in the literature, but none located in the cecum., Case Presentation: We report a case of a 53-year-old man who was admitted to our hospital for further evaluation of positive fecal occult blood test associated to anemia. A colonoscopy identified a red, sessile, lobulated polyp of the cecum, 4.2 cm in diameter, partially ulcerated. The histological examination of the biopsy revealed the presence of inflammatory granulation tissue with lymphocytic and eosinophil infiltration associated to a fibrous stroma: it was diagnosed as inflammatory fibroid polyp. Considering the polyp's features (absence of a peduncle and size) that could increase the risk of a polypectomy, a surgical resection was performed. Histological examination of the specimen revealed inflammatory granulation tissue in the lamina propria, hyperplastic glands with cystic dilatations, proliferation of smooth muscle and multiple erosions on the polyp surface: this polyp was finally diagnosed as IMGP. There was also another little polyp next to the ileocecal valve, not revealed at the colonoscopy, 0.8 cm in diameter, diagnosed as tubulovillous adenoma with low grade dysplasia., Conclusions: This is the first case of IMGP of the cecum. It is a benign lesion of unknown pathogenesis and must be considered different from other non-neoplastic polyps of the large bowel such as inflammatory cap polyps (ICP), inflammatory cloacogenic polyps, juvenile polyps (JP), inflammatory fibroid polyps (IFP), polyps secondary to mucosal prolapse syndrome (MPS), polypoid prolapsing mucosal folds of diverticular disease. When symptomatic, IMGP should be removed endoscopically, whereas surgical resection is reserved only in selected patients as in our case.

Purposes: Central pancreatectomy is indicated for treatment of traumatic lesions and benign or low-grade tumors of the pancreatic neck and proximal body. After central pancreatectomy, the proximal pancreatic stump is usually closed, and pancreaticojejunostomy or pancreaticogastrostomy carried out with the distal pancreas. Adopting these reconstructive techniques in most series revealed a prevalence of postoperative fistula that was higher than after pancreaticoduodenectomy or left pancreatectomy. We present a case treated by novel application of the reconstructive method of the Beger procedure., Methods: Reconstruction by Roux-en-Y double pancreaticojejunostomy after central pancreatectomy was done in a 71-year-old female suffering from insulinoma of the proximal pancreatic body., Results: Postoperative complications were not observed. No alteration of pancreatic endocrine and exocrine function occurred at 22-month follow-up., Conclusions: Double pancreaticojejunostomy is a promising method for treating the proximal pancreatic stump after central pancreatectomy.

Background: The elevated serum and peritoneal cytokine concentrations responsible for the systemic response syndrome (SIRS) and multiorgan failure in patients with severe acute pancreatitis lead to high morbidity and mortality rates. Prompted by reports underlining the importance of reducing circulating inflammatory mediators in severe acute pancreatitis, we designed this study to evaluate the efficiency of laparotomy followed by continuous perioperative peritoneal lavage combined with postoperative continuous venovenous diahemofiltration (CVVDH) in managing critically ill patients refractory to intensive care therapy. As the major clinical outcome variables we measured morbidity, mortality and changes in the Acute Physiology and Chronic Health Evaluation (APACHE II) score and cytokine concentrations in serum and peritoneal lavage fluid over time., Methods: From a consecutive group of 23 patients hospitalized for acute pancreatitis, we studied 6 patients all with Apache II scores >/=19, who underwent emergency surgery for acute complications (5 for an abdominal compartment syndrome and 1 for septic shock) followed by continuous perioperative peritoneal lavage and postoperative CVVDH. CVVDH was started within 12 hours after surgery and maintained for at least 72 hours, until the multiorgan dysfunction syndrome improved. Samples were collected from serum, peritoneal lavage fluid and CVVDH dialysate for cytokine assay. Apache II scores were measured daily and their association with cytokine levels was assessed., Results: All six patients tolerated CVVDH well, and the procedure lasted a mean 6 days (range, 3-12). Five patients survived and one died of Acinetobacter infection after surgery (mortality rate 16.6%). The mean APACHE II score was >/= 19 (range 19-22) before laparotomy and decreased significantly during peritoneal lavage and postoperative CVVDH (P = 0.013 by matched-pairs Students t-test). The decrease in cytokine concentrations in serum and lavage fluid was associated with the decrease in APACHE II scores and high interleukin 6 (IL-6) and tumor necrosis factor (TNF) concentrations in the hemofiltrate., Conclusion: In critically ill patients with abdominal compartment syndrome, septic shock or high APACHE II scores related to severe acute pancreatitis, combining emergency laparotomy with continuous perioperative peritoneal lavage followed by postoperative CVVHD effectively reduces the local and systemic cytokines responsible for multiorgan dysfunction syndrome thus improving patients' outcome.