Laparoscopic vs. Open Liver Resection for Hepatocellular Carcinoma of Cirrhotic Liver: A Case–Control Study

Background

Laparoscopic liver resection is considered a safe and feasible alternative to open surgery for malignant liver lesions. However, laparoscopic surgery in cirrhotic patients remains challenging. The aim of this retrospective case–control study was to compare morbidity, mortality, and long-term patient survival between laparoscopic liver resections (LLR) and open liver resections (OLR) for hepatocellular carcinoma (HCC) in patients with histologically proven cirrhosis.

Methods

A total of 45 patients treated with LLR were matched by cause of cirrhosis, Child-Pugh score, type of surgical resection (subsegmentectomy, segmentectomy, and bisegmentectomy), tumor number, tumor size, and alpha-fetoprotein value with 45 patients treated with OLR. Pre-, intra-, and post-operative variables were compared between groups.

Results

Compared with OLR, the LLR group displayed a significantly shorter operative time (140 vs. 180 min; p = 0.02), shorter hospital stay (7 vs. 12 days; p < 0.0001), and lower morbidity rate (20 vs. 45 % of patients; p = 0.01). A higher rate of R0 resection was observed in the LLR group than in the OLR group (95 vs. 85 %; p = 0.03). Postoperative ascites was more frequently observed in the OLR group (18 vs. 2 %; p = 0.01). Mortality, patient, and disease-free survival rates were similar between groups. The 1-, 5-, and 10-year survival rates were 88, 59, and 12 %, respectively, in the LLR group and 63, 44, and 22 % in the OLR group (p = 0.27).

Conclusions

Significantly shorter operative times, better resection margins, lower postoperative complications, and shorter hospital stay were observed in the LLR group compared with the OLR group. LLR and OLR have similar overall and disease-free survival rates in cirrhotic HCC patients.     

Lung ultrasound during hemodialysis: the role in the assessment of volume status

Objective

Fluid balance is important in patients undergoing hemodialysis. “Dry” weight is usually estimated clinically, and also, bioimpedance is considered reliable. Ultrasonography of inferior vena cava (IVC) estimates central venous pressure, and lung ultrasound evaluates extravascular (counting B-lines artifact) lung water. Our study was aimed to clarify their usefulness in the assessment of volume status during hemodialysis.

Methods

A total of 71 consecutive patients undergoing hemodialysis underwent lung and IVC ultrasound and bioimpedance spectroscopy immediately before and after dialysis.

Results

There was a significant reduction in the number of B-lines (3.13 vs 1.41) and in IVC diameters (end-expiratory diameter 1.71 vs 1.37; end-inspiratory diameter 1.19 vs 0.95) during dialysis. The reduction in B-lines correlated with weight reduction during dialysis (p 0.007); none of the parameters concerning the IVC correlated with fluid removal. At the end of the dialysis session, the total number of B-lines correlated with bioimpedance residual weight (p 0.002).

Discussion

The reduction in B-lines correlated with fluid loss due to hemodialysis, despite the small pre-dialysis number, confirming that lung ultrasound can identify even modest variations in extravascular lung water. IVC ultrasound, which reflects the intravascular filling grade, might not be sensitive enough to detect rapid volume decrease. Clinically estimated dry weight had a poor correlation with both bioimpedance and ultrasound techniques. Post-dialysis B-lines number correlates with residual weight assessed with bioimpedance, suggesting a role for ultrasound in managing hemodialysis patients.     

Robot-assisted Laparoscopic Adrenalectomy: Step-by-Step Technique and Comparative Outcomes

Background

Recent evidence supports the use of robotic surgery for the minimally invasive surgical management of adrenal masses.

Objective

To describe a contemporary step-by-step technique of robotic adrenalectomy (RA), to provide tips and tricks to help ensure a safe and effective implementation of the procedure, and to compare its outcomes with those of laparoscopic adrenalectomy (LA).

Design, setting, and participants

We retrospectively reviewed the medical charts of consecutive patients who underwent RA performed by a single surgeon between April 2010 and October 2013. LA cases performed by the same surgeon between January 2004 and May 2010 were considered the control group.

Surgical procedure

The main steps of our current surgical technique for RA are described in this video tutorial: patient positioning, port placement, and robot docking; exposure of the adrenal gland; identification and control of the adrenal vein; circumferential dissection of the adrenal gland; and specimen retrieval and closure.

Outcome measurements and statistical analysis

Demographic parameters and main surgical outcomes were assessed.

Results and limitations

A total of 76 cases (RA: 30; LA: 46) were included in the analysis. Median tumor size on computed tomography (CT) was significantly larger in the LA group (3 cm [interquartile range (IQR): 3] vs 4 cm [IQR: 3]; p = 0.002). A significantly lower median estimated blood loss was recorded for the robotic group (50 ml [IQR: 50] vs 100 ml [IQR: 288]; p = 0.02). The RA group presented five minor complications (16.7%) and one major (Clavien 3b) complication (3.3%), whereas four minor complications (8.7%) and one major (Clavien 3b) complication (2.3%) were observed in the LA group. No significant difference was noted between groups in terms of malignant histology (p = 0.66) and positive margin rate (p = 0.60). Distribution of pheochromocytomas in the LA group was significantly higher than in the RA group (43.5% vs 16.7%; p = 0.02).

Conclusions

The standardization of each surgical step optimizes the RA procedure. The robotic approach can be applied for a wide range of adrenal indications, recapitulating the safety and effectiveness of open surgery and potentially improving the outcomes of standard laparoscopy.

Patient summary

In this report we detail our surgical technique for robotic removal of adrenal masses. This procedure has been standardized and can be offered to patients, with excellent outcomes.     

Serum levels of 17-β-estradiol are not predictive of prostate cancer diagnosis and aggressiveness: Results from an Italian biopsy cohort

ObjectivesTo explore the association between serum levels of 17-β-estradiol (17BE) and prostate cancer (PCa) risk in men undergoing prostate biopsy.Methods and materialsBetween 2006 and 2012, we prospectively enrolled 894 patients, with no history of PCa, undergoing prostate biopsy. Before biopsy was performed, general data, digital rectal examination (DRE), body mass index, 17BE, and prostate-specific antigen (PSA) were recorded. The risk of detecting cancer and high-grade cancer was assessed as a function of 17BE using crude and adjusted logistic regressions.ResultsSerum levels of 17BE were not associated with an increased risk of PCa or high-grade disease. Age (odds ratio [OR] 1.05; 95% confidence interval [CI]: 1.03–1.07; P = 0.000), DRE(OR 2.81; 95% CI: 1.98–4.00; P = 0.000), and PSA(OR 1.07; 95% CI: 1.04–1.10; P = 0.000) were found to be independent predictors of PCa risk. Age (OR 1.05; 95% CI: 1.01–1.09; P = 0.007), DRE (OR 3.04; 95% CI: 1.79–5.17; P = 0.000), body mass index (OR 1.07; 95% CI: 1.01–1.150; P = 0.040), and PSA (OR 1.08; 95% CI: 1.03–1.12; P = 0.000) were found to be independent predictors of high-grade disease.ConclusionIn our cohort of patients, serum levels of 17BE are not predictive of PCa or high-grade disease. In patients at risk of PCa, 17BE should not be considered a reliable marker to predict poorly differentiated PCa in the setting of initial prostate biopsy.     

Can we improve the definition of high‐risk,hormone naïve,non‐metastatic prostate cancer?

• To identify criteria beyond Tumour‐Node‐Metastasis (TMN)‐, prostate‐specific antigen (PSA)‐ and Gleason score‐based standard classifications to enhance the stratification of non‐metastatic high‐risk prostate cancer.
• A detailed search of the literature was performed using PubMed.
• The authors reviewed the literature and used a modified Delphi approach to identify relevant approaches to enhance standard classifications.
• Specific criteria for high‐risk prostate cancer vary across guidelines and clinical trials, reflecting the differing perspectives concerning the definition of ‘risk’ between different specialities within the urology/radiation oncology community.
• In addition to the present classifications, evidence exists that the measure of cancer volume can provide additional prognostic value.
• More accurate imaging, especially multiparametric magnetic resonance imaging can also provide information concerning staging and cancer volume, and thus may assist in the identification of patients with high‐risk prostate cancer.
• A refined definition of non‐metastatic high‐risk prostate cancer is proposed.
• Within this high‐risk cohort, patients with multiple high‐risk criteria are especially at risk of prostate cancer‐specific mortality.