Przesuwanie granicy wieku i zmniejszanie liczby przeciwwskazań do resekcji wątroby u obciążonych onkologicznych chorych — opis przypadku

Liver resections are performed in increasing numbers due to oncological indications. Thus, the indications for surgical treatment of liver tumors are constantly expanding. Advanced age and other comorbidities often exclude this group of patients from treatment by liver resection. Patient C.S. (80 y.a., height 166 cm, weight 97 kg, ASA = 4) with risk factors was admitted for resection of metastatic lesions (adenocarcinoma) of the cecum to the liver. The patient was diagnosed with hypertension, atherosclerosis, stable coronary heart disease, type 2 diabetes, chronic renal failure (eGFR = 37), obesity, degenerative spinal lesions, sigmoid colon diverticulitis, dystonic tremor of the head. Previously operated upon and had amputation of the uterus with appendages (2005), cholecystectomy, right hemicolectomy (2012) complicated by respiratory failure with the need for ventilation seven days post-surgery. Prior to surgery, the patient had imaging tests such as ultrasound, CT and MRI scans of the abdomen, which confirmed a 55mm metastatic tumor in the seventh segment of the liver. The results were analyzed during a radiological and surgical consultation in order to prepare the safest available surgical access and the scope of the planned resection. A cardiac echocardiography was performed and the patient had a cardio-, neuro- and anesthetic consultation. The patient was fully informed about the high risk of complications and possible operational failure. During surgery a right hemihepatectomy was performed. The resected lobe weighed 712 g. Blood loss was < 500 ml, 2 units RBC and 2 units FFP were transfused. The surgery and the postoperative period proceeded without serious complications. The only problem was a short-lived biliary fistula, which healed spontaneously. Age and comorbid conditions are often a contraindication for surgery, but with proper medical support, the opportunity to interact with other professionals and thorough preparation of the patient and the team of surgeons, the risk of failure can be significantly minimized. A modern, personalized, multidisciplinary approach towards each patient can expand indications and reduce contraindications for hepatic resection.Resekcje wątroby ze wskazań onkologicznych są coraz częściej wykonywaną operacją. Wskazania do leczenia operacyjnego nowotworów wątroby stale są rozszerzane, wciąż jednak zaawansowany wiek pacjenta oraz inne towarzyszące choroby często wykluczają tę grupę chorych z leczenia resekcją wątroby. Chora C.S. (lat 80, wzrost 166 cm, masa ciała 97 kg, ASA = 4) obciążona internistycznie została zakwalifikowana do resekcji zmiany przerzutowej gruczolakoraka kątnicy do wątroby. W wywiadzie nadciśnienie tętnicze, uogólniona miażdżyca, stabilna choroba niedokrwienna serca, cukrzyca typu 2, przewlekła niewydolność nerek (eGFR = 37), otyłość, stany zwyrodnieniowe kręgosłupa, uchyłkowatość esicy, drżenie dystoniczne głowy. Stan po amputacji macicy z przydatkami (2005), po cholecystektomii, po hemikolektomii prawostronnej (2012) powikłanej niewydolnością oddechową z koniecznością wentylacji 7 dni od operacji. Wykonano USG, TK i MR jamy brzusznej, które potwierdzały guz przerzutowy o średnicy 55 mm w VII segmencie wątroby. Wyniki tych badań były dokładnie omówione na konsylium radiologiczno-chirurgicznym w celu zaplanowania najbezpieczniejszego dostępu i zakresu planowanej resekcji. Wykonano echokardiografię serca i konsultowano chorą kardiologicznie, neurologicznie oraz anestezjologicznie. Pacjentka była w pełni poinformowana o wysokim ryzyku powikłań i ewentualnego niepowodzenia operacji. Podczas operacji wykonano hemihepatektomię prawostronną. Resekowana część wątroby ważyła 712 g. Utrata krwi w czasie operacji < 500 ml, przetoczono 2 j. KKCz oraz 2 j. FFP. Chora zniosła zabieg operacyjny i okres pooperacyjny bez powikłań. Jedynym problemem była krótkotrwała przetoka żółciowa, która zagoiła się samoistnie. Wiek i choroby towarzyszące często stanowią przeciwwskazanie do leczenia operacyjnego, jednak przy odpowiednim zapleczu medycznym, możliwości współpracy z innymi specjalistami oraz dokładnym przygotowaniem chorego i zespołu przeprowadzającego operację ryzyko niepowodzenia znacznie spada. Zatem nowoczesne, indywidualne, wielospecjalistyczne podejście do chorego pozwala rozszerzać wskazania i zmniejszać przeciwwskazania do resekcji wątroby

Management of Giant Hepatic Hemangioma in Atypical Localization; Report of a Case and Literature Review

Hemangiomas are the most common benign primary hepatic neoplasms, often being incidentally discovered. In most of the cases they are small and asymptomatic. It is widely accepted that clinical intervention is indicated only for symptomatic hemangiomas. We present a case of an asymptomatic giant hemangioma managed by enucleation due to its atypical localization. The hemangioma, originally located in segment 5, was now described in Computer Tomography (CT) Imaging as separating the gallbladder from the liver parenchyma. A careful evaluation of images revealed proximity to the portal vein (PV), right hepatic artery (RHA), right hepatic duct (RHD) and right branch of the portal vein (RBPV). Thus, in the case of an emergent operation, surgical maneuvers in the area of the altered hepatic anatomy and proximity to the hemangioma itself, would in fact increase the risk endangering the patient’s life. After patient’s consent, a surgical enucleation en block with the gall-bladder was performed. It is of great importance that specifically selected, asymptomatic patients diagnosed with a giant hemangioma, with the above mentioned or similar localization should be considered for surgical treatment

Is there a rationale for aggressive breast cancer liver metastases resections in Polish female patients? Analysis of overall survival following hepatic resection at a single centre in Poland

Introduction Breast cancer (BC) makes up nearly 26% of malignant tumours worldwide and is the leading cause of cancer-related deaths in European women. With approximately 18,000 new cases of BC diagnosed in Polish women annually, breast cancer liver metastasis (BCLM) is respectively an increasing issue. Recent data found in literature indicates improved survival following liver resection with systemic therapy. Objective The aim of study was to evaluate surgical treatment in patients with isolated BCLM. Material and Methods During 2009–2013, a retrospective study was undertaken and 30 cases analysed. From nearly 2,000 liver resections performed, 11 female patients at the mean age of 59.18 years with BCLM were qualified for surgery. Results The median time between primary and secondary treatment was 3.5 years (1–7). One patient (9.1%) presented an extrahepatic lesion – bone metastasis. The left lobe, right lobe and both lobes of the liver were affected, respectively, in 3 (27.3%), 4 (36.4%) and 4 (36.4%) patients. 5 patients (45.5%) presented single hepatic lesion, in contrast to the maximum number of lesions which equalled 6 in the right lobe. Average hospitalisation period was 13.27 days and discharge on the 11.3 postoperative day. One-year survival was 72.7% (8 patients); therefore, three-year survival was 36.4% (4 patients). Conclusions Oncological centres should assess BCLM patients more openly and qualify them for hepatic resection along with adjuvant systemic treatment in order to improve overall survival. This, however, needs to be studied in a multicentre randomized trial

Is there a rationale for aggressive breast cancer liver metastases resections in Polish female patients? Analysis of overall survival following hepatic resection at a single centre in Poland

Introduction Breast cancer (BC) makes up nearly 26% of malignant tumours worldwide and is the leading cause of cancer-related deaths in European women. With approximately 18,000 new cases of BC diagnosed in Polish women annually, breast cancer liver metastasis (BCLM) is respectively an increasing issue. Recent data found in literature indicates improved survival following liver resection with systemic therapy. Objective The aim of study was to evaluate surgical treatment in patients with isolated BCLM. Material and Methods During 2009–2013, a retrospective study was undertaken and 30 cases analysed. From nearly 2,000 liver resections performed, 11 female patients at the mean age of 59.18 years with BCLM were qualified for surgery. Results The median time between primary and secondary treatment was 3.5 years (1–7). One patient (9.1%) presented an extrahepatic lesion – bone metastasis. The left lobe, right lobe and both lobes of the liver were affected, respectively, in 3 (27.3%), 4 (36.4%) and 4 (36.4%) patients. 5 patients (45.5%) presented single hepatic lesion, in contrast to the maximum number of lesions which equalled 6 in the right lobe. Average hospitalisation period was 13.27 days and discharge on the 11.3 postoperative day. One-year survival was 72.7% (8 patients); therefore, three-year survival was 36.4% (4 patients). Conclusions Oncological centres should assess BCLM patients more openly and qualify them for hepatic resection along with adjuvant systemic treatment in order to improve overall survival. This, however, needs to be studied in a multicentre randomized trial

Expression of resistin in the liver of patients with non-alcoholic fatty liver disease

Adipokines are cytokines that presumably connect the pathologies of metabolic syndrome. One of the adipokines is resistin, the role of which in insulin resistance, obesity, and non-alcoholic fatty liver disease (NAFLD) needs to be determined. Liver biopsy specimens were obtained intraoperatively from 214 obese patients. Histological assessment was based on NAFLD activity score according to Kleiner. Statistical analysis involved semi-quantitive immunohistochemistry assessment of resistin staining and: NAFLD status in obese patients compared with a non-obese control group, selected clinical data (age, sex, body mass index – BMI), selected biochemical data, comorbidities (hypertension, type 2 diabetes mellitus, dyslipidaemia), and metformin treatment in patients with type 2 diabetes mellitus. Resistin expression was observed in the histiocytes of inflammatory infiltrate, Kupffer cells, and histiocytes surrounding the hepatocytes with steatosis. There was a positive correlation between the total expression of resistin and: (1) NAFLD advancement (NAFLD Activity Score- NAS), (2) AST, ALT, BMI, glucose, insulin, Homeostasis Model Assessment (HOMA), LDH, GGT, triglycerides (TG), and glycated haemoglobin (HbA1c). Resistin expression was more intense in patients with type 2 diabetes mellitus and dyslipidaemia and less intense in the control group. Resistin probably plays a role in the pathogenesis of hepatic insulin resistance and aggravates pathologic changes in the liver of patients with NAFLD

Acetaminophen (Paracetamol) induced acute liver failure – A social problem in an era of increasing tendency to self-treatment

Introduction The widespread availability of medication without prescription, so-called over the counter (OTC), and the rapid development of health consciousness of Poles is associated with broad access to medical information in the mass media. This causes patients to recognize their own disease, cancel doctor’s appointments, and begin self-treatment. This time and money-saving behavior, often signaled by pain, usually leads to the treatment of symptoms alone, without seeking the cause of the disease.The aim of the study was to present life-threatening paracetamol poisoning, and the treatment of acute liver failure. Material and Methods In 2002–2014, 35 patients were hospitalized due to acute paracetamol poisoning: 17 female and 18 male patients aged between 17–59 (mean 32.3 years). Patients were treated in the surgical intensive care unit, where their parameters of liver and renal function were continuously monitored. If there was no improvement in the liver function, patients underwent albumin dialysis with the Prometheus system and were qualified for liver transplantation (LTx). Results 26 patients were treated pharmacologically and 7 out of 9 patients who underwent LTx were dialyzed. Overall, 11 patients had 26 albumin dialysis in total; 4 patients died – 1 post-transplant and 3 pre-transplant. Conclusions Paracetamol is the cause of many poisonings resulting from the lack of public awareness about toxic interactions with alcohol, and suicide attempts. Acetaminophen-induced acute liver failure concerns a small percentage of patients but can be successfully treated with albumin dialysis, and in extreme cases by liver transplantation

Acetaminophen (Paracetamol) induced acute liver failure – A social problem in an era of increasing tendency to self-treatment

Introduction The widespread availability of medication without prescription, so-called over the counter (OTC), and the rapid development of health consciousness of Poles is associated with broad access to medical information in the mass media. This causes patients to recognize their own disease, cancel doctor’s appointments, and begin self-treatment. This time and money-saving behavior, often signaled by pain, usually leads to the treatment of symptoms alone, without seeking the cause of the disease.The aim of the study was to present life-threatening paracetamol poisoning, and the treatment of acute liver failure. Material and Methods In 2002–2014, 35 patients were hospitalized due to acute paracetamol poisoning: 17 female and 18 male patients aged between 17–59 (mean 32.3 years). Patients were treated in the surgical intensive care unit, where their parameters of liver and renal function were continuously monitored. If there was no improvement in the liver function, patients underwent albumin dialysis with the Prometheus system and were qualified for liver transplantation (LTx). Results 26 patients were treated pharmacologically and 7 out of 9 patients who underwent LTx were dialyzed. Overall, 11 patients had 26 albumin dialysis in total; 4 patients died – 1 post-transplant and 3 pre-transplant. Conclusions Paracetamol is the cause of many poisonings resulting from the lack of public awareness about toxic interactions with alcohol, and suicide attempts. Acetaminophen-induced acute liver failure concerns a small percentage of patients but can be successfully treated with albumin dialysis, and in extreme cases by liver transplantation

Short and Long-Term Outcomes After Primary Liver Transplantation in Elderly Patients

The number of elderly patients undergoing liver transplantation (LT) is increasing worldwide. The aim of the study was to evaluate the impact of recipient age exceeding 60 years on early and long-term outcomes after LT. Material and methods. This study comprised data of 786 patients after primary LT performed at a single center between January 2005 and October 2012. Patients over and under 60 years of age were compared with respect to baseline characteristics and outcomes: postoperative mortality (90-day) and 5-year patient (PS) and graft (GS) survival. Associations between recipient age exceeding 60 years and LT results were assessed in multiple Cox regression models. Results. Recipients older than 60 years (n=107; 13.6%) were characterized by more frequent hepatitis C virus infections (p<0.001), malignancies (p<0.001), and cardiovascular comorbidities (p<0.001); less frequent primary sclerosing cholangitis (p=0.002) and Roux-en-Y hepaticojejunostomy (p<0.001); lower Model for End-stage Liver Disease (MELD; p=0.043); and increased donor age (p=0.012). Fiveyear PS of older and younger recipients was 72.7% and 80.6% (p=0.538), while the corresponding rates of GS were 70.3% and 77.5% (p=0.548), respectively. Recipient age exceeding 60 years was not significantly associated with postoperative mortality (p=0.215), PS (p=0.525) and GS (p=0.572) in multivariate analyses. The list of independent predictors comprised MELD (p<0.001) for postoperative mortality; malignancies (p=0.003) and MELD (p<0.001) for PS; and malignancies (p=0.003), MELD (p<0.001) and donor age (p=0.017) for GS. Conclusions. Despite major differences between elderly and young patients, chronological age exceeding 60 years alone should not be considered as a contraindication for LT