Claudio F. Feo

Combined Biliary and Duodenal Stenting for Palliation of Pancreatic Cancer

The aim of this case report was to evaluate the usefulness of combined biliary and duodenal stenting in the palliation of pancreatic cancer. We report a series of 4 consecutive patients (2 men and 2 women, mean age 58.5 years, range 38–77 years) who underwent combined biliary and duodenal stenting in our department between March 2000 and April 2001. All patients had cancer of the head of the pancreas causing stricture of the common bile duct and second portion of the duodenum. Biliary and duodenal stents were successfully positioned, with relief of symptoms in all cases. No early complications were observed, except for a transient increase in serum lipase and amylase in one case. Mean follow‐up was 7.5 months (range 5–14 months). One patient presenting recurrence of vomiting after 4 months because of tumour overgrowth at the distal edge of the prosthesis was successfully treated by insertion of a partially overlapping second coaxial stent. Combined biliary and duodenal stenting for the palliation of pancreatic cancer was performed safely and successfully. Stents allowed effective re‐canalization of the biliary tract and duodenum, relieving both jaundice and vomiting. This procedure should be considered as an alternative to palliative surgery, especially in critically ill patients.

Asymptomatic Gastric Perforation by a Toothpick

Background: Many cases of gastric perforation with peritonitis, pylephlebitis, hepatic abscesses, or lethal bleeding, caused by ingested long and sharp objects, are reported in the literature. Methods: During a right hepatectomy for a giant hemangioma, a wooden toothpick was found between the two layers of the hepatogastric ligament. It was not possible to find the passage of the foreign body through the gastric wall. The patient did not report any correlated symptoms. Results: There was no sign of inflammation around the toothpick, which was enveloped in thin scar tissue. The removal of the foreign body was performed without complications. Conclusions: The peculiarity of our case is the total absence of symptoms during and after the perforation. Despite the benign evolution of our case, toothpicks must be considered as potentially dangerous, like other pointed objects, and, therefore, removed immediately.

Palliative Airway Stenting Performed Under Radiological Guidance and Local Anesthesia

PurposeTo assess the effectiveness of airway stenting performed exclusively under radiological guidance for the palliation of malignant tracheobronchial strictures.MethodsWe report our experience in 16 patients with malignant tracheobronchial stricture treated by insertion of 20 Ultraflex self-expandable metal stents performed under fluoroscopic guidance only. Three patients presented dysphagia grade IV due to esophageal malignant infiltration; they therefore underwent combined airway and esophageal stenting. All the procedures were performed under conscious sedation in the radiological room; average procedure time was around 10 min, but the airway impediment never lasted more than 40 sec.ResultsWe obtained an overall technical success in 16 cases (100%) and clinical success in 14 patients (88%). All prostheses were successfully placed without procedural complications. Rapid clinical improvement with symptom relief and normalization of respiratory function was obtained in 14 cases. Two patients died within 48 hr from causes unrelated to stent placement. Two cases (13%) of migration were observed; they were successfully treated with another stent. Tumor overgrowth developed in other 2 patients (13%); however, no further treatment was possible because of extensive laryngeal infiltration.ConclusionsTracheobronchial recanalization with self-expandable metal stents is a safe and effective palliative treatment for malignant strictures. Airway stenting performed exclusively under fluoroscopic view was rapid and well tolerated.

Spontaneous regression of hepatocellular carcinoma: report of a case.

The widespread use of ultrasound in screening programmes for chronic liver disease has led to early diagnosis of hepatocellular carcinoma (HCC), and to the observation of some cases of tumour spontaneous regression. This is a rare event whose underlying mechanism is still unclear. We present here a case of spontaneous regression of HCC in a 71-year-old woman with chronic hepatitis and discuss possible aetiologies. None of the causative mechanisms proposed for spontaneous regression of HCC is completely satisfactory, so further studies are necessary to improve understanding of this unusual biological event. Therefore, we stress the importance of accumulating all such cases in the literature, because the clarification of aetio-pathogenic mechanisms may lead to the development of new treatment strategies for HCC.

Visceral Aneurysm and Vascular Anomaly Involving the Splenic Artery

Visceral artery aneurysms are rare but potentially fatal.At present, they are detected with increasing frequency inasymptomatic patients because of the widespread use ofdifferent imaging modalities (1, 2). Standard treatment issurgical ligation or resection (3, 4), however, newer en-dovascular techniques have been applied with good re-sults in selected patients (5–8). We describe a case ofvisceral aneurysm and vascular anomaly involving thesplenic artery.

Sentinel node biopsy in early breast cancer: lessons learned from more than 1000 cases at a single institution

AIMS The aims of this paper are to report the development of sentinel node biopsy (SNB) in breast cancer at a single institution and to discuss the relevant issues on SNB still to be elucidated. PATIENTS AND METHODS From 1998 to 2010, 1021 SNBs with frozen section examination were carried out in patients with breast cancer. In the early period (1998-2002) SNB was always combined with axillary lymph node dissection (ALND). From 2002 onwards, only patients with a positive SNB result underwent ALND (late period). The characteristics of patients with infiltrating carcinoma (IC) and ductal carcinoma in situ (DCIS) and the histological status of the sentinel nodes were examined. The survival outcomes of node-negative patients were compared between patients submitted to SNB and ALND (ALND group) during the early period and patients who underwent only SNB during the late period (SNB group). RESULTS The sentinel node was identified intraoperatively in 98.3% of cases. During the early period the overall accuracy of SNB was 97.0%. During the late period, 700 patients with IC and 140 with DCIS underwent SNB. In the IC group, 149 patients (21.3%) had sentinel node macrometastases and 36 (5.1%) micrometastases; of that subgroup, 21 underwent ALND and no other metastatic lymph nodes were found, and 15 underwent SNB only. Axillary recurrences were observed in 4 patients (0.77%) with negative SNB; none of these were among the patients with micrometastatic SNB. Two patients (1.4%) with DCIS had a positive SNB. In node-negative patients the 5-year overall survival was 96.7% in the ALND group and 96.5% in the SNB group (P = 0.63). The 5-year disease-free survival was 93.8% and 93.2% in the ALND and SNB groups, respectively (P = 0.77). CONCLUSIONS Overall and disease-free survival in patients with a negative SNB result and no further axillary surgery were equal to those in patients with negative ALND. Intraoperative assessment of the sentinel node in expert hands has a low false-negative rate and allows immediate ALND in patients with sentinel node metastases, avoiding the need for a second operation. ALND for sentinel node micrometastases may be safely omitted in most patients with early stage breast cancer.

An expression signature of phenotypic resistance to hepatocellular carcinoma identified by cross-species gene expression analysis

Background and aimsHepatocarcinogenesis is under polygenic control. We analyzed gene expression patterns of dysplastic liver nodules (DNs) and hepatocellular carcinomas (HCCs) chemically-induced in F344 and BN rats, respectively susceptible and resistant to hepatocarcinogenesis.MethodsExpression profiles were performed by microarray and validated by quantitative RT-PCR and Western blot.ResultsCluster analysis revealed two distinctive gene expression patterns, the first of which included normal liver of both strains and BN nodules, and the second one F344 nodules and HCC of both strains. We identified a signature predicting DN and HCC progression, characterized by highest expression of oncosuppressors Csmd1, Dmbt1, Dusp1, and Gnmt, in DNs, and Bhmt, Dmbt1, Dusp1, Gadd45g, Gnmt, Napsa, Pp2ca, and Ptpn13 in HCCs of resistant rats. Integrated gene expression data revealed highest expression of proliferation-related CTGF, c-MYC, and PCNA, and lowest expression of BHMT, DMBT1, DUSP1, GADD45g, and GNMT, in more aggressive rat and human HCC. BHMT, DUSP1, and GADD45g expression predicted patients’ survival.ConclusionsOur results disclose, for the first time, a major role of oncosuppressor genes as effectors of genetic resistance to hepatocarcinogenesis. Comparative functional genomic analysis allowed discovering an evolutionarily conserved gene expression signature discriminating HCC with different propensity to progression in rat and human.

A Rare Variant of Gallstone Ileus: Bouveret’s Syndrome

IntroductionBouveret’s syndrome (gastric outlet obstruction due to impaction of a stone) is a rare variant of gallstone ileus. A recently observed case led us to review the literature, with the aim to discuss the recent advances in the management of this rare syndrome.DiscussionA 69-year-old woman was admitted with symptoms of high intestinal obstruction. Computed tomography scan of the abdomen showed a large gallstone impacted in the duodenum. One-stage surgery, consisting in enterolithotomy, cholecystectomy, and fistula repair, was carried out. Although several surgical and nonoperative procedures have been used, the optimal treatment of Bouveret’s syndrome remains controversial. Surgery still maintains a prominent position, even though nonoperative procedures have an increasing role especially in high risk patients with important comorbidities. The decision should be taken on an individual basis, after evaluating patient’s general condition and age, stone size, comorbidities influencing the operative risk, and expertise of surgical and endoscopic teams. One-stage surgery may offer definitive management in selected patients.

Retroperitoneal abscess and omphalitis in young infants.

Aim: To evaluate the aetiopathogenetic factors in cases of retroperitoneal abscess in young infants, particularly the correlation with omphalitis. Methods: We describe the cases of two infants, aged 8 and 3 wk, respectively, with a history of omphalitis during the first weeks of life and subsequent development of a retroperitoneal abscess. Both infants underwent surgical drainage of the abscess. Results: In case 1, Staphylococcus aureus was found in cultures from abscess pus, and in case 2 from umbilical pus, abscess purulent material and blood. Both infants are in good health after a follow‐up of 6 mo and 8 y, respectively.

Conservative approach to Hepatic Portal Venous Gas: A case report

Highlights • Hepatic Portal Venous Gas (HPVG) is a rare condition often associated with a significant underlying pathologies.• The mechanism underlying the passage of the gas from the intestine into the mesenteric, then portal, venous system is not fully understood.• The high mortality rate made HPVG a cause of mandatory explorative laparotomy throughout the last fifty years of the twentieth century.• The frequent presence of benign conditions underlying this condition has diverted the common therapeutic approach to more cautious options.