Laparoscopic versus open hemihepatectomy: comprehensive comparison of complications and costs at 90 days using a propensity method

Laparoscopic hemihepatectomy (LHH) may ofer advantages over open hemihepatectomy (OHH) in blood loss, recovery, and hospital stay. The aim of this study is to evaluate our recent experience performing hemihepatectomy and compare complications and costs up to 90 days following laparoscopic versus open procedures. Retrospective evaluation of patients undergoing hemihepatectomy at our center 01/2010-12/2018 was performed. Patient, tumor, and surgical characteristics; 90-day complications; and costs were analyzed. Inverse probability of treatment weighting (IPTW) was used to balance covariates. A total of 141 hemihepatectomies were included: 96 OHH and 45 LHH. While operative times were longer for LHH, blood loss and transfusions were less. At 90 days, there were similar rates of liver-specifc and surgical complications but fewer medical complications following LHH. Medical complications that arose with greater frequency following OHH were primarily pulmonary complications and urinary and central venous catheter infections. Complications at 90 days were lower following LHH (Clavien-Dindo grade≥III OHH 23%, LHH 11%, p=0.130; Comprehensive Complication Index OHH 20.0±16.1, LHH 10.9±14.2, p=0.001). While operating costs were higher, costs for hospital stay and readmissions were lower with LHH. Patients undergoing LHH experience a signifcant reduction in postoperative medical complications and costs, resulting in 90-day cost equity compared with OHH

Gefitinib in Non Small Cell Lung Cancer

Gefitinib is an oral, reversible, tyrosine kinase inhibitor of epidermal growth factor receptor (EGFR) that plays a key role in the biology of non small cell lung cancer (NSCLC). Phase I studies indicated that the recommended dose of gefitinib was 250 mg/day. Rash, diarrhea, and nausea were the most common adverse events. The positive results obtained in early phase 2 clinical trials with gefitinib were not confirmed in large phase 3 trials in unselected patients with advanced NSCLC. The subsequent discovery that the presence of somatic mutations in the kinase domain of EGFR strongly correlates with increased responsiveness to EGFR tyrosine kinase inhibitors prompted phase 2 and 3 trials with gefitinib in the first line-treatment of EGFR-mutated NSCLC. The results of these trials have demonstrated the efficacy of gefitinib that can be now considered as the standard first-line treatment of patients with advanced NSCLC harbouring activating EGFR mutations

Rationale and design of MILES-3 and MILES-4 studies: two randomized phase III trials comparing single-agent chemotherapy versus cisplatin-based doublets in elderly patients with advanced non-small cell lung cancer

BACKGROUND: Platinum-based chemotherapy is the cornerstone of treatment of advanced non-small-cell lung cancer (NSCLC) patients, but the efficacy of adding cisplatin to single-agent chemotherapy remains to be demonstrated in prospective phase III trials dedicated to elderly patients. Furthermore, the superiority of cisplatin/pemetrexed over cisplatin/gemcitabine in non-squamous NSCLC has not been confirmed prospectively. We present the rationale and design of two open-label, multicenter, randomized phase III trials for elderly patients with advanced NSCLC∶ Multicenter Italian Lung cancer in the Elderly Study (MILES)-3 and MILES-4. The aim is to evaluate the efficacy of adding cisplatin to single-agent chemotherapy (both trials) and the efficacy of pemetrexed versus gemcitabine in non-squamous tumors (MILES-4). PATIENTS AND METHODS: Both trials are dedicated to first-line therapy of patients older than 70 years with advanced NSCLC, ECOG performance status 0-1. In the MILES-3 trial, patients are randomized in a 1∶1 ratio to gemcitabine or cisplatin/gemcitabine. In the MILES-4 study patients with non-squamous histology are randomized, in a factorial design with 1∶1∶1∶1 ratio, to four arms: gemcitabine (A), cisplatin/gemcitabine (B), pemetrexed (C), cisplatin/pemetrexed (D). Two comparisons are planned∶ A+C vs B+D to test the role of cisplatin; A+B vs C+D to test the role of pemetrexed. Primary endpoint of both trials is overall survival. Secondary and exploratory endpoints include progression-free survival, response rate, toxicity, and quality of life. CONCLUSIONS: MILES-3 and MILES-4 results will add important evidence about the role of cisplatin-based doublets and pemetrexed in the first-line therapy of elderly patients with advanced NSCLC

Utilizzo di donatori a cuore non battente nel trapianto epatico. Esperienza dei Centri Trapianto di Pisa e Barcellona.

Il trapianto ortotopico di fegato rappresenta il trattamento di scelta per la malattia epatica terminale e per l’epatocarcinoma o, in casi selezionati, per altre neoplasie, comunque confinate al fegato. Negli ultimi anni il numero di trapianti eseguiti è aumentato considerevolmente, ma sempre in misura inferiore rispetto al numero di pazienti inseriti in lista d’attesa. Questa situazione ha stimolato lo sviluppo di nuove tecniche chirurgiche quali il trapianto di fegato split (split liver transplantation, SLT) ed il trapianto di fegato da donatore vivente (living donor liver transplantation, LDLT), che hanno prodotto un incremento relativo del numero di organi disponibili, tuttavia, ancora insufficiente a risolvere il problema della carenza dei grafts. Un’ulteriore modalità per incrementare il numero di trapianti è rappresentata dall’utilizzo dei cosiddetti donatori con criteri estesi (expanded criteria donor, ECD), possibilità percorsa attualmente dalla totalità dei centri trapianto, per il mutare delle caratteristiche epidemiologiche della popolazione di donatori cadavere (deceased donors, DD). Infine, una popolazione di DD largamente utilizzata presso altre nazioni, quali l’Olanda, la Spagna, l’Inghilterra e gli USA, e di recente introduzione anche in Italia, è rappresentata dai donatori a cuore fermo (donation after cardiac death, DCD). Attualmente, grazie alla maggiore esperienza dei gruppi trapianto e ai migliori criteri di selezione, i tassi di complicanze dopo l’utilizzo di donatori con criteri estesi e a cuore non battente si sono significativamente ridotti. Rispetto all'uso di tecniche di prelievo rapido, l’uso della perfusione addominale normotermica (N-ECMO) nei DCD, è stata una prima soluzione per ridurre al minimo i danni da ischemia-riperfusione mediante il ripristino del flusso sanguigno ossigenato a fegato, pancreas e reni dopo che la morte è stata dichiarata sulla base di criteri cardiocircolatori. Oltretutto permette anche una valutazione degli organi prima del prelievo. In Italia la diagnosi e accertamento di morte in asistolia esige una registrazione continua dell’ECG per 20 minuti. Questo è un tempo notevolmente superiore ai 5 o 10 minuti di registrazione previsti negli altri paesi che utilizzano routinariamente questo tipo di donazione (tra cui Regno Unito, Olanda e Spagna, USA). L’obiettivo di questa tesi è la valutazione dell’uso della perfusione normotermica ex-situ del graft nei donatori a cuore non battente nell’esperienza del Centro Trapianti di Pisa e un confronto con il modello spagnolo dell’Ospedale Clinic di Barcellona

Metastatic melanoma of the transverse colon heralded by vitiligo-like depigmentation: two rare conditions occurring in the same patient

We commend Wang et al. on their interesting work about the association between metastatic melanoma and vitiligo-like depigmentation. In that case, metastatic melanoma involved left inguinal and iliac nodes and the hypopigmentation manifested 4 months prior to lymph nodes enlargement. Herein, we present another atypical example of this clinically important correlation

An unusual case of repeated splenectomy: traumatic rupture of an accessory spleen in a previously splenectomized patient

The traumatic rupture of an accessory spleen is a very rare condition and only few cases have been reported in the literature. We describe the case of a 51-year-old man undergone splenectomy for trauma several years before, who developed hemoperitoneum due to a laceration of a voluminous accessory spleen, following an accidental two-meter fall. As a conservative management of the injury was not possible, an accessory splenectomy was then required. Thus, a briefly review of the literature about this uncommon topic was perfomed

Focus on Nintedanib in NSCLC and Other Tumors

Nintedanib is a new triple angiokinase inhibitor that potently blocks the proangiogenic pathways mediated by vascular endothelial growth factor (VEGF) receptors, platelet-derived growth factor (PDGF) receptors and fibroblast growth factor (FGF) receptors. Evidence about its efficacy in addition to second-line chemotherapy in non-small-cell-lung-cancer (NSCLC) has been produced by two large randomized phase III clinical trials (LUME-Lung-1 and LUME-Lung-2), conducted in patients with pretreated NSCLC, without major risk factors for bleeding. In the LUME-Lung-1, the addition of nintedanib to docetaxel significantly improved progression-free survival (PFS), that was the primary endpoint of the trial (3.4 vs 2.7 months, HR 0.79; p=0.0019). Furthermore, a significant improvement in median overall survival (OS) (from 10.3 to 12.6 months) was observed in patients with adenocarcinoma histology, with a greater advantage in patients with adenocarcinoma who progressed within 9 months after start of first line treatment (from 7.9 to 10.9 months), and in patients with adenocarcinoma most refractory to first line chemotherapy (from 6.3 to 9.8 months). Adverse events were more common in the docetaxel plus nintedanib group and they included diarrhea and increased liver enzymes, while no statistically significant increase in the incidence of bleeding and hypertension events by the addition of nintedanib was observed. On these bases, the combination of docetaxel and nintedanib can be considered a new option for the second-line treatment for patients with advanced NSCLC with adenocarcinoma histology. Future challenges are the identification of predictive factors to help the decision of using nintedanib in eligible patients

Hollow viscus injury due to blunt trauma. Epidemiology and outcome in a large urban area

INTRODUCTION: Hollows viscus injury (HVI) is a rare occurrence and represents a clinical challenge because of its subtle and nonspecific clinical findings. The specific aims of this study were to determine the overall frequency of HVI in blunt trauma patients occurring in large urban area, the relative frequency of various hollow organ injuries, and the outcomes of such injuries. MATERIALS AND METHODS: A retrospective trauma registry review was performed by analysing data from the University Hospital Sant' Andrea in Rome and data from the Emergency Surgery and Trauma Care Unit of S. Filippo Neri Hospital in Rome The clinical records of all blunt abdominal trauma observed between January 2006 and December 2014 were blind analysed. Variables considered for analysis were: sex, age, time/type of trauma, associated injuries, timing/characteristics of operative treatment, ISS, AIS, length of hospital stay, morbidity and mortality. RESULTS: Seventy-one, 7.5% of all abdominal trauma recorded, were coded having 89 HVI. The overall morbidity and mortality rates were 29.6% (n=21/71) and 19.7% (n=14/71) respectively. Multivariate analysis indicated that only WBC (p=0.007) was significant independent predictor of morbidity whereas preoperative transfusion (p=0.010) and ISS (p<0.001) were significant risk factors for mortality. DISCUSSION: HVI is rarely found in patients with blunt abdominal trauma and it can be fatal and life-threatening, particularly in patients for whom a pertinent diagnosis is delayed. CONCLUSION: It appears clearly that during an ER evaluation of a blunt abdominal trauma an HIV has nowadays always to be considered to reach a quick diagnosis and prompt surgical intervention