A. De Cesare

Unusual breakage of a plastic biliary endoprosthesis causing an enterocutaneous fistula.

OBJECTIVE The objective of our study was to illustrate a case of endoscopically placed biliary stent breakage. METHODS A72-year-old woman with a prolonged history of cholangitis following laparoscopic cholecistectomy was referred to our institution 8 years ago. Dilatation of the intra- and extrahepatic biliary tree and a benign stricture at the cystic confluence were observed at US and endoscopic retrograde cholangiopancreatography (ERCP). A 12-F gauge plastic endoprosthesis was placed. In the absence of any symptoms, breakage of the stent was revealed 18 months later at plain radiology. Eight years later an enterocutaneous fistula occurred originating from a jejunal loop containing the indwelled distal part of the stent. Surgery was undertaken and the distal part of the stent removed with the perforated jejunal loop. The proximal part was successively endoscopically removed. CONCLUSIONS Disruption of a biliary endoprosthesis is observed in patients in whom the stent is kept in situ for a long period or consequent to exchange. The removal and exchange is mandatory when the stent disruption is followed by cholangitis. In the current case, because of the absence of any symptoms the removal of the stent was not attempted. Immediate endoscopic removal of the prosthetic fragments seems to be the treatment of choice for replacement of a new stent.

Isolated intestinal neurofibromatosis of colon. Single case report and review of the literature

Isolated intestinal neurofibromatosis of the colon is a most unusual disease: from 1937 to 1999 only 12 cases have been reported. The differential diagnosis and treatment of this lesion are very difficult. A review of the literature is made and personal experience in the diagnosis and treatment of a case in a 68-year-old female is described.

Adenovirus 36 DNA in human adipose tissue

Recent studies have suggested a possible correlation between obesity and adenovirus 36 (Adv36) infection in humans. As information on adenoviral DNA presence in human adipose tissue are limited, we evaluated the presence of Adv36 DNA in adipose tissue of 21 adult overweight or obese patients. Total DNA was extracted from adipose tissue biopsies. Virus detection was performed using PCR protocols with primers against specific Adv36 fiber protein and the viral oncogenic E4orf1 protein nucleotide sequences. Sequences were aligned with the NCBI database and phylogenetic analyses were carried out with MEGA6 software. Adv36 DNA was found in four samples (19%). This study indicates that some individuals carry Adv36 in the visceral adipose tissue. Further studies are needed to determine the specific effect of Adv36 infection on adipocytes, the prevalence of Adv36 infection and its relationship with obesity in the perspective of developing a vaccine that could potentially prevent or mitigate infection.

Endoscopic stenting for colorectal obstruction from unresectable ovarian and colorectal cancer: a bridge to surgery.

Dear Sir, We read with interest the paper from Debove et al. [1] on the prognostic importance of microscopic involvement of the circumferential resection margin (CRM). They reported the oncological outcome of 333 patients undergoing curative laparoscopic total mesorectal excision (TME) for rectal cancer. They stated that all previous studies found that the overall and disease-free survival and locoregional recurrence rates were significantly lower in patients with a positive CRM. They found that the 2year disease-free survival was significantly lower in the CRM positive group, mainly related to a higher rate of metastatic recurrence, but there were no significant differences in overall survival and local recurrence between the CRM positive and negative groups. Despite this the authors state that ‘our study confirmed these results’ that survival rates are lower and local recurrence higher. In the modern era of rectal cancer management with good optimal TME and en bloc surgery if indicated, together with neoadjuvant and adjuvant oncological treatment, we suggest that a positive CRM is not the prognostic factor that it was when most studies on CRM were performed and when both surgical and oncological treatment were not optimal. In a large population-based single centre study [2] of 448 patients and a median follow-up of 5.7 years, we found that a positive CRM (7%) did not predict local recurrence or survival and provided no additional prognostic value. The rectal cancer patients were managed according to a modern multidisciplinary approach, where therapeutic decisions were based on MRI and CT and surgery was performed by few experienced TME surgeons capable of en bloc resection. Preoperative oncological treatment and meticulous surgery resulted in specimens with a completely excised mesorectum without any defect in the mesorectal fascia in 92% of the patients (after 2007) and an intraoperative perforation rate of only 1.7%, in no case through the tumour. Only one of the 32 patients with a CRM of ≤ 1 mm developed local recurrence, resulting in a positive predictive value of CRM positivity of 3%. Additionally in a recent Dutch study [3] the authors reported an ‘interesting and puzzling finding’ that none of the patients (10/230) with a positive CRM developed local recurrence, and in a recent Korean study [4] of 780 patients a positive CRM was not related to local recurrence but it was to survival. The data from the study of Debove et al. actually confirm these results that positive CRM is not a prognostic factor for local recurrence, also after laparoscopic surgery. CRM is of course an important measurement but it should not be used as a prognostic marker or surrogate end-point for local recurrence.