Minimally Invasive Surgery for Hepatocellular Carcinoma; Latest Advances

Surgical resection is the gold standard for hepatocellular carcinoma management for early stages of the disease. With advances in technology and techniques, minimally invasive surgery provides a great number of advantages for these patients during their surgery and for their post-operative care. The selection of patients following a multi-disciplinary approach is of paramount importance. Adding to this, the developments in laparoscopic instruments and training, as well as the promising advantages of robotic surgery along with other forms of technology, increase the pool of patients that can undergo operation safely and with good results worldwide. We review results from great centres worldwide and delineate the accurate multi-disciplinary approach for this

Outcomes of elective liver surgery worldwide: a global, prospective, multicenter, cross-sectional study

Background: The outcomes of liver surgery worldwide remain unknown. The true population-based outcomes are likely different to those vastly reported that reflect the activity of highly specialized academic centers. The aim of this study was to measure the true worldwide practice of liver surgery and associated outcomes by recruiting from centers across the globe. The geographic distribution of liver surgery activity and complexity was also evaluated to further understand variations in outcomes. Methods: LiverGroup.org was an international, prospective, multicenter, cross-sectional study following the Global Surgery Collaborative Snapshot Research approach with a 3-month prospective, consecutive patient enrollment within January–December 2019. Each patient was followed up for 90 days postoperatively. All patients undergoing liver surgery at their respective centers were eligible for study inclusion. Basic demographics, patient and operation characteristics were collected. Morbidity was recorded according to the Clavien–Dindo Classification of Surgical Complications. Country-based and hospital-based data were collected, including the Human Development Index (HDI). (NCT03768141). Results: A total of 2159 patients were included from six continents. Surgery was performed for cancer in 1785 (83%) patients. Of all patients, 912 (42%) experienced a postoperative complication of any severity, while the major complication rate was 16% (341/2159). The overall 90-day mortality rate after liver surgery was 3.8% (82/2,159). The overall failure to rescue rate was 11% (82/ 722) ranging from 5 to 35% among the higher and lower HDI groups, respectively. Conclusions: This is the first to our knowledge global surgery study specifically designed and conducted for specialized liver surgery. The authors identified failure to rescue as a significant potentially modifiable factor for mortality after liver surgery, mostly related to lower Human Development Index countries. Members of the LiverGroup.org network could now work together to develop quality improvement collaboratives

The effect of natural antioxidants on small intestine ischemia/reperfusion

Introduction: Intestinal ischemia and reperfusion triggers a severe oxidative stress with enhanced production of reactive oxygen species (ROS), mediates the expression of nuclear factors, inducing apoptosis and triggering lipid peroxidation. We evaluate the potential protective effect of-epigallocatechin-3-gallate (EGCG) administration in minimizing lipid peroxidation and attenuating apoptosis, inhibition of expression of NF-kB, c-Jun, caspase-3 in a model of intestinal ischemia-reperfusion. Methods: thirty (30) male wistar rats, weighting 250-300g, were used divided into three groups. EGCG administrated intra-peritonealy 15 min before the induction of ischemia. Intestinal ischemia was induced for 60 min by cross-clamping the superior mesenteric artery with a vascular microclip. Intestinal MDA and MPO, TUNNEL, immunocytochemistry for NF-kB, c-Jun, caspace-3, transmission electron microscopy and light histology examinations of intestine were performed after 160 min of reperfusion. Results: apoptosis as indicated by TUNNEL was increased in I/R group compared with the sham and EGCG pretreated group. Activated caspase-3 was widely expressed in positive for NF-Kb, c-Jun in I/R group but negative in EGCG treated group. Mean MDA (nmoles/g wet weight) and MPO values (U/g) were 0.524, 0.913, 0565 and 1.8, 2.92, 1.9 in groups A,B and C respectively. Transmission electron microscopy and light histology examination revealed significant protection of small intestine from ischemia/reperfusion injury by inhibition of apoptic signal transduction pathways and reduction of lipid peroxidation.Η ισχαιμία και επαναιμάτωση του λεπτού εντέρου προκαλεί οξειδωτικό stress με αυξημένη παραγωγή ΕΡΟ και έκφραση μεταγραφικών παραγόντων, προκαλώντας απόπτωση, και λιπιδική υπεροξείδωση. Εξετάστηκε η πιθανή προστατευτική δράση του EGCG στη μείωση της λιπιδικής υπεροξείδωσης, στη μείωση της απόπτωσης και στην αναστολή της έκφρασης των NF-kB, c-Jun και caspace-3 σε ένα μοντέλο ισχαιμίας/επαναιμάτωσης λεπτού εντέρου. Υλικά και Μέθοδος : τριάντα επίμυες τύπου Wistar, χωρισμένοι σε τρείς ομάδες. Α1: Εικονική επέμβαση (Ε/Ε), Β1: ισχαιμία/επαναιμάτωση (Ι/Ε), Γ1: I/E+ΕGCG 50mg/kg ΒΣ. H χορήγηση του EGCG έγινε 15' πριν από την εγκατάσταση της ισχαιμίας. Ισχαιμία εγκαταστάθηκε για 60 min με αποκλεισμό της ΑΜΑ και ακολούθησε επαναιμάτωση για 120 min. Έγινε προσδιορισμός της MDA, MPO, TUNEL, ανοσοϊστοχημεία για NF-kB, c-Jun, caspase-3, και έλεγχος με οπτικό μικροσκόπιο στο τέλος της επαναιμάτωσης. Αποτελέσματα: η απόπτωση όπως προσδιορίζεται από το TUNEL ήταν αυξημένη στην ομάδα Ι/Ε σε σύγκριση με την ομάδα ελέγχου και την ομάδα που χορηγήθηκε EGCG. H caspase-3 ήταν ευρέως ενεργοποιημένη στην ομάδα Ι/Ε ενώ στην ομάδα στην ομάδα του EGCG πολύ μικρή έκφραση εμφανίστηκε. Το λεπτό έντερο χρωματίστηκε θετικά για NF-kB, c-Jun στην ομάδα Ι/Ε αλλά αρνητικά στην ομάδα του EGCG. Οι μέσες τιμές για την MDA (nmole/g w.t.):1,8, 2,92, 1,9 στις ομάδες Α1, Β1, Γ1 αντίστοιχα. Οι εξετάσεις από οπτικό μικροσκόπιο έδειξαν σοβαρές βλάβες στην ομάδα Ι/Ε και σημαντική προστασία στην ομάδα του EGCG. Συμπεράσματα : η χορήγηση EGCG προστατεύει το λεπτό έντερο από τη βλάβη ισχαιμίας/επαναιμάτωσης αναστέλλοντας την οδό της απόπτωσης και της διάδοσης του σήματος και παράλληλα προστατεύει από τη λιπιδική υπεροξείδωση

Emergency Open Incarcerated Hernia Repair with a Biological Mesh in a Patient with Colorectal Liver Metastasis Receiving Chemotherapy and Bevacizumab Uncomplicated Wound Healing

Bevacizumab is a humanized monoclonal antibody targeting vascular endothelial growth factor (VEGF), often used in combinational chemotherapy regimens for the treatment of patients with colorectal liver metastases. However adverse events have been attributed to the use of bevacizumab including gastrointestinal perforations, thrombotic events, hypertension, bleeding, and wound healing complications. 53-year-old male, with a history of colorectal cancer with liver metastasis, receiving a combination of cytotoxic chemotherapy (FOLFIRI, irinotecan with fluorouracil and folinic acid) with bevacizumab presented as an emergency with an incarcerated incisional hernia. The last administration of chemotherapy and bevacizumab had taken place 2 weeks prior to this presentation. As the risk of strangulation of the bowel was increased, a decision was made to take the patient to theatre, although the hazard with respect to wound healing, haemorrhage, and infection risk was high due to the recent administration of chemotherapy with bevacizumab. The patient underwent an open repair of the incarcerated recurrent incisional hernia with placement of a biological mesh, and the postoperative recovery was uncomplicated with no wound healing or bleeding problems

Molecular Signalling in Hepatocellular Carcinoma: Role of and Crosstalk among Wnt/β-Catenin, Sonic Hedgehog, Notch and Dickkopf-1

Hepatocellular carcinoma is the sixth most common cancer worldwide. In the majority of cases, there is evidence of existing chronic liver disease from a variety of causes including viral hepatitis B and C, alcoholic liver disease and nonalcoholic steatohepatitis. Identification of the signalling pathways used by hepatocellular carcinoma cells to proliferate, invade or metastasize is of paramount importance in the discovery and implementation of successfully targeted therapies. Activation of Wnt/β-catenin, Notch and Hedgehog pathways play a critical role in regulating liver cell proliferation during development and in controlling crucial functions of the adult liver in the initiation and progression of human cancers. β-catenin was identified as a protein interacting with the cell adhesion molecule E-cadherin at the cell-cell junction, and has been shown to be one of the most important mediators of the Wnt signalling pathway in tumourigenesis. Investigations into the role of Dikkopf-1 in hepatocellular carcinoma have demonstrated controversial results, with a decreased expression of Dickkopf-1 and soluble frizzled-related protein in various cancers on one hand, and as a possible negative prognostic indicator of hepatocellular carcinoma on the other. In the present review, the authors focus on the Wnt/β-catenin, Notch and Sonic Hedgehog pathways, and their interaction with Dikkopf-1 in hepatocellular carcinoma

Emergency Pancreatoduodenectomy with Preservation of Gastroduodenal Artery for Massive Gastrointestinal Bleeding due to Duodenal Metastasis by Clear Cell Renal Cell Carcinoma in a Patient with Celiac Artery Stenosis

Duodenal metastasis from renal cell carcinoma is rare, and even rarer is a massive gastrointestinal bleeding from such tumours. Coeliac occlusive disease, although rarely symptomatic, can lead to ischaemic changes with anastomotic dehiscence and leaks when a patient undergoes pancreatoduodenectomy. A 41-year-old man with known metastasis to the adrenal glands and the second part of the duodenum close to the ampulla of Vater from clear cell renal cell carcinoma was admitted to our department due to massive gastrointestinal bleeding from the duodenal metastasis. Endoscopic control of the bleed was not possible, while the bleeding vessel embolization was able to control the haemorrhage only temporarily. An angiography during the embolization demonstrated the presence of stenosis of the coeliac artery and also hypertrophic inferior pancreaticoduodenal arteries supplying the proper hepatic artery via the gastroduodenal artery (GDA). The patient underwent emergency pancreatoduodenectomy with preservation of the gastroduodenal artery. The patient had an uneventful recovery and did not experience further bleeding. Also the blood flow to the liver was compromised as shown by the normal liver function tests (LFTs) postoperatively. To the best of our knowledge, this is the first report of a preservation of the GDA during an emergency pancreatoduodenectomy