Cucinotta E

Asymptomatic Cholelithiasis in Children With Sickle Cell Disease Early or Delayed Cholecystectomy

Summary Background Data:Our study aimed to evaluate the role of elective laparoscopic cholecystectomy (LC) in children with sickle cell disease (SCD) and asymptomatic cholelithiasis and, furthermore, to determine whether the outcome is related to the operation timing. Methods:The records of 30 children with SCD diagnosed with cholelithiasis from June 1995 to September 2005 were retraspectively reviewed. All 30 children were asymptomatic at the time of the first visit, and an elective LC was proposed to all of them. The operation was accepted in the period of study by 16 children and refused by 14. During medical observation, 10 of the 14 children who refused surgery were admitted for severe biliary colics. Acute cholecystitis was diagnosed by abdominal ultrasound in 3 cases and in 1 case choledocholithiasis, ultrasonographically suspected, was confirmed by magnetic resonance cholangiopancreatography (MRCP) and treated during endoscopic retrograde cholangiopancreatography (ERCP). All children, emergency admitted, underwent LC after the onset of symptoms. The patients were divided up into 2 groups (A: asymptomatic; B: symptomatic) depending on clinical presentation and operation timing and the respective outcomes were compared. Results:Elective LC in asymptomatic children (group A) is safe with no major complications reported. During medical observation in children who refused elective surgery (group B), 6 biliary colics, 3 acute cholecystitis, and 1 choledocholithiasis were observed. Three sickle cell crises occurred in symptomatic children during biliary colics. The correlation between cholecystectomy performed in asymptomatic children (group A) and cholecystectomy performed in symptomatic children (group B) showed significant differences in the outcome. Morbidity rate and postoperative stay increased when children with SCD underwent emergency LC. Conclusions:Elective LC should be the gold standard in children with SCD and asymptomatic cholelithiasis to prevent the potential complications of biliary colics, acute cholecystitis, and choledocholithiasis, which lead to major risks, discomfort, and longer hospital stay.

Incidental gall bladder carcinoma: does the surgical approach influence the outcome?

Background:  The aim of the study was to evaluate the outcome in patients with unsuspected gall bladder carcinoma diagnosed after cholecystectomy, comparing the laparoscopic approach with open surgery.

Laparoscopic cholecystectomy in children with chronic hemolytic anemia. Is the outcome related to the timing of the procedure

BackgroundThe aim of this study was to evaluate whether the outcome in children with chronic hemolytic anemia (CHA) and cholelithiasis undergoing laparoscopic cholecystectomy (LC) is related to the operation timing.MethodsFrom June 1995 to December 2004, 46 children with CHA were referred to our division of surgery for cholelithiasis. All 46 children were asymptomatic at the time of the first visit, and an elective LC was proposed to all of them before the onset of symptoms. The operation was accepted in the period of study by 24 children and refused by 22. The patients were divided into three groups (group A, asymptomatic; group B, symptomatic; and group C, emergency admitted) depending on clinical presentation and operation timing, and the respective outcomes were compared.ResultsElective LC in asymptomatic children (group A) is safe with no major complications reported. In children who refused surgery (groups B and C), we observed four sickle cell crises, four acute cholecystitis, and two choledocholithiasis, and all these complications were related to waiting. Two sickle cell crises occurred in symptomatic children waiting for surgery during biliary colic. The risk of emergency admission in children with cholelithiasis and CHA awaiting surgery was found to be high: 28% of the children admitted in emergency after a mean of 32 months (range, 22–36). Morbidity rate and postoperative stay increased when children with hemoglobinopathies underwent emergency LC.ConclusionsElective LC should be the gold standard in children with CHA and asymptomatic cholelithiasis in order to prevent the potential complications of cholecystitis and choledocholithiasis, which lead to major risks, discomfort, and longer hospital stay.

Giant retroperitoneal liposarcoma: Case report and review of the literature

Highlights • The origin from perirenal fat is very uncommon.• The occurrence of hematogenous metastasis is a rare finding at the time of diagnosis.• The undifferentiated and pleomorphic type are neoplasm with high grade of malignancy.• In case of diagnostic doubt and in presence of recurrence, magnetic resonance imaging (MRI) may be useful because can identifying in a reliable manner the satellite localizations of the main lesion.• The complete surgical (R0) resection represents the only possibility of radical treatment.• Following surgical resection, the 50–100% of liposarcomas recur from residual tissue, which is the primary cause of death.• Percutaneous biopsy has low accuracy in the diagnosis of retroperitoneal dedifferentiated liposarcoma (DDLS).

Wernicke encephalopathy as rare complication of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Highlights • Peritoneal carcinomatosis (PC) of gastric origin is a frequent event even in the early phase of the disease.• This is the first case, to our knowledge, of Wernicke Encephalopathy (WE) complicating CRS plus HIPEC used as treatment of peritoneal carcinomatosis of gastric origin.• WE is an uncommon neurological disorder characterized by a classical triad of symptoms: ataxia, ocular motor cranial neuropathies and changes in consciousness.• A deficiency of thiamine is responsible for the WE syndrome.• The application of Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) gives encouraging results.• A deficiency of thiamine is responsible for the WE syndrome.

Reply to “The incidence of cisplatin nephrotoxicity post hyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive surgery”

We read an article by Hakeam, Breakiet, Azzam, Nadeem, and Amin, with interest and would like to congratulate the authors for the effort that they have put in a field so challenging. Cytoreductive Surgery plus Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is, in fact, a promising approach to treat peritoneal surface malignancies, but it is characterized by high morbidity and mortality. In literature it is reported that a major morbidity rate ranges from 12% to 57% in highvolume centres; the mortality incidence ranges from 0.9% to 11%. The short-term outcome is related to surgery, but also to chemoperfusion. We agree with the conclusions made by the authors, confirming, on the basis of our experience, that nephrotoxicity can complicate HIPEC, above all if it is performed using cisplatin. As this topic has not yet been fully elucidated, we measured the plasma level of cisplatin before, during and after HIPEC, in order to identify the period within which there is the higher risk of toxicity linked to the intraperitoneal chemotherapy. Our experience had demonstrated that the peak of serum level of cisplatin is reached during the perfusion; until the 4th post-operative (p.o.) day high levels remain and, in 7th p.o. day, the value returns to that before the intervention. At the light of these considerations, we retain that, for 4 days after the procedure, is necessary to ensure the hyperhydration, and the infusion of albumin and of fresh frozen plasma, in order to dilute the effective quantity of circulating cisplatin, to increase the proportion of albuminbound cisplatin, and to maintain a normal blood volume and perfusion.

Therapeutic strategies for jejunal diverticulitis: our experience and a review of the recent literature

The jejunoileal diverticulosis is an uncommon entity, which affects elderly people, and its complications can be fatal due to delayed diagnosis. The disease often presents with non-specific symptoms like intermittent abdominal pain, dyspepsia, bloating or abdominal fullness and constipation. Complications of jejunal diverticulosis include perforation, acute intestinal obstruction and diverticular bleeding. Nowadays the mortality was reduced because of the improvement of the diagnostic, pharmaceutical and surgical protocols, but preoperative diagnosis of jejunal diverticulitis is still rarely made. We report two cases of elderly patients presenting with acute abdominal pain and fever. Both underwent to an exploratory laparotomy, which revealed multiple jejunal diverticula. In both cases intestinal resections with primary anastomosis was performed. There are different therapeutic approaches depending on the severity of the disease and the general clinical condition of the patient. We also discussed about the various therapeutic strategies.

Cystic lymphangioma of the pancreas: a hard diagnostic challenge between pancreatic cystic lesions—review of recent literature

Lymphangiomas are rare congenital benign tumors arising from the lymphatic system. The incidence of this disease in the pancreas is extremely rare, accounting for less than 1% of these tumors. Before introducing the review we reported a case of a 67-year-old woman with cystic lymphangioma of the pancreas. We reported the radiological investigations carried out preoperatively and the treatment performed. The review tries to identify the features described in literature of the pancreatic lymphangioma. We have performed a PubMed research of the world literature between January 1st 2000, to November 31st 2017, using the keywords [Lymphangioma pancreas], [diagnosis], [CT lymphangioma] and [MRI lymphangioma]. We have found 158 articles, of which about 100 were case reports. Based on our search criteria, we have identified 31 pancreatic lymphangioma in literature reporting their imaging characteristics. According to our report and to several authors in literature the diagnosis of cystic pancreatic lymphangioma should be considered as a differential diagnosis of pancreatic cystic lesions (PCLs). The role of imaging exams (CT and MRI) can help to identify and suspect this possibility of diagnosis. The endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) can have a potential role to reach the correct diagnosis.

Evaluation of cisplatin plasma levels in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

ABSTRACT Introduction Peritoneal surface malignancies have long been regarded as incurable, however, they can be treated with cytoreductive surgery in addition to hyperthermic intraperitoneal chemotherapy. This approach is associated with an increase in morbidity and mortality, unless hyperhydration is provided in a timely manner. Methods Cisplatin (CDDP) is the most widely used chemotherapeutic agent. Plasma levels of cisplatin (CDDP), a widely used chemotherapeutic agent, were measured before, during, and after the procedure. This was done in order to identify the window of highest risk as a function of drug concentrations, assuming a dose-dependent effect. Results Plasma levels of CDDP peak during perfusion. The concentration remains high until the 4th post-operative day and returns to pre-operative levels by the 7th post-operative day. Conclusions Our findings suggest that ensuring hyperhydration as well as infusing albumin and fresh frozen plasma may be of particular value for at least the first 4 days after the procedure.

Morbidity and Mortality

Mortality and morbidity rates remain the most comprehensive measures used to assess short-term outcomes of a specific procedure. Surgical complications are frequently the main reason to modify patient treatment and ultimately attain wide acceptance for a particular procedure by the medical community. Nevertheless, these two outcome measures remain hard to asses and identify by the surgical literature due to lack of standardization and underreporting. For this reason, in the surgical field, there is an absence of a clear system to classify complications. These considerations are valid for cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC), which is not an exception to the rule. In fact, appreciable effort has been developed by surgeons performing CRS plus HIPEC to relate morbidity and mortality to the procedure. However, the issue is relatively complex because the appearance of postoperative complications related to intraoperative manipulation can be confounded with toxic side effects of the intraperitoneally administered chemotherapy (IP-CHT).