Emanuele Lo Menzo

Incidental gallbladder cancer during laparoscopic cholecystectomy: Managing an unexpected finding

AIM To evaluate the impact of incidental gallbladder cancer on surgical experience. METHODS Between 1998 and 2008 all cases of cholecystectomy at two divisions of general surgery, one university based and one at a public hospital, were retrospectively reviewed. Gallbladder pathology was diagnosed by history, physical examination, and laboratory and imaging studies [ultrasonography and computed tomography (CT)]. Patients with gallbladder cancer (GBC) were further analyzed for demographic data, and type of operation, surgical morbidity and mortality, histopathological classification, and survival. Incidental GBC was compared with suspected or preoperatively diagnosed GBC. The primary endpoint was disease-free survival (DFS). The secondary endpoint was the difference in DFS between patients previously treated with laparoscopic cholecystectomy and those who had oncological resection as first intervention. RESULTS Nineteen patients (11 women and eight men) were found to have GBC. The male to female ratio was 1:1.4 and the mean age was 68 years (range: 45-82 years). Preoperative diagnosis was made in 10 cases, and eight were diagnosed postoperatively. One was suspected intraoperatively and confirmed by frozen sections. The ratio between incidental and nonincidental cases was 9/19. The tumor node metastasis stage was: pTis (1), pT1a (2), pT1b (4), pT2 (6), pT3 (4), pT4 (2); five cases with stage Ia (T1 a-b); two with stage Ib (T2 N0); one with stage IIa (T3 N0); six with stage IIb (T1-T3 N1); two with stage III (T4 Nx Nx); and one with stage IV (Tx Nx Mx). Eighty-eight percent of the incidental cases were discovered at an early stage (≤ II). Preoperative diagnosis of the 19 patients with GBC was: GBC with liver invasion diagnosed by preoperative CT (nine cases), gallbladder abscess perforated into hepatic parenchyma and involving the transversal mesocolon and hepatic hilum (one case), porcelain gallbladder (one case), gallbladder adenoma (one case), and chronic cholelithiasis (eight cases). Every case, except one, with a T1b or more advanced invasion underwent IVb + V wedge liver resection and pericholedochic/hepatoduodenal lymphadenectomy. One patient with stage T1b GBC refused further surgery. Cases with Tis and T1a involvement were treated with cholecystectomy alone. One incidental case was diagnosed by intraoperative frozen section and treated with cholecystectomy alone. Six of the nine patients with incidental diagnosis reached 5-year DFS. One patient reached 38 mo survival despite a port-site recurrence 2 years after original surgery. Cases with non incidental diagnosis were more locally advanced and only two patients experienced 5-year DFS. CONCLUSION Laparoscopic cholecystectomy does not affect survival if implemented properly. Reoperation should have two objectives: R0 resection and clearance of the lymph nodes.

The role of diet in gastric cancer: still an open question

The risk of gastric cancer is often related to lifestyle and diet. There have been several studies on correlation between Nutrition and the risk of gastric cancer with different and sometimes contradictory results. Here we reviewed the role of nutrition as risk/protective factor in the development of gastric cancer.

Colorectal cancer in elderly patients: From best supportive care to cure

Colorectal cancer is one of the major causes of cancer mortality in the elderly population (median age at diagnosis of 71 years) in Western Countries. Moreover patients with metastatic disease are often elderly with significant co- morbidities. Unfortunately, elderly patients are often untreated and under-represented in clinical trials, even if most clinical trials that have included this setting of population have shown similar survival rates and toxicities to younger patients. Age itself should not be considered for candidacy to chemotherapy but it should be taken in consideration the great heterogeneity of co-morbidities present in the elderly population. Therefore, the best treatment strategy for elderly colorectal cancer patients has not yet been defined. Comprehensive Geriatric Assessment is recommended to evaluate the best strategy treatment and to reduce the adverse events. In fact, while fit elderly patients could receive the same therapeutic treatment as the younger counterpart, a palliative approach should be taken in consideration for frail elderly patients and for those with a short life expectancy.

Laparoscopic revision of gastrojejunostomy and vagotomy for intractable marginal ulcer after revised gastric bypass.

The incidence of marginal ulceration after gastric bypass has been reported with significant variability (1–16%) [1]. lthough its pathogenesis is unclear, several factors are assoiated with ulcer formation, including acid exposure, ischemia, oreign body, medications, and tobacco. In general, pharmaologic therapy is highly effective for ulcer healing, and urgical intervention is usually reserved for complications— ypically bleeding or perforation. Rarely, surgical intervention s indicated for cases refractory to medical therapy. We present a laparoscopic revision of the gastrojejunosomy with pouch volume reduction and truncal vagotomy for ecurrent intractable marginal ulcer in the setting of a previusly revised open gastric bypass.

Hernioscopy: A Simple Application of Single-port Endoscopic Surgery in Acute Inguinal Hernias

Strangulated hernia remains one of the most common emergencies encountered in general surgery. During induction of general or spinal anesthesia, the potential self-reduction of a gangrenous bowel can occur in approximately 1% of cases. In these cases, bowel viability can no longer be directly assessed unless a more extensive operation (laparoscopy or laparotomy) is performed. A simple alternative to unnecessary laparotomy or to a standard laparoscopy is a hernia sac laparoscopy (hernioscopy). Here, we presented 4 patients with a diagnosis of small-bowel obstruction secondary to incarcerated inguinal hernias, in which the incarcerated hernia content was evaluated by hernioscopy. Only 1 case presented persistent signs of bowel ischemia after hernia reduction and required a small-bowel segmental resection. All hernias were repaired using prosthetic tension-free technique. Hernia sac laparoscopy (hernioscopy), the introduction of the laparoscope through an open inguinal hernia sac, can be useful to evaluate the viability of the incarcerated hernia content, to avoid unnecessary laparotomy.

Laparoscopic Sleeve Gastrectomy versus Roux-en-Y Gastric Bypass in Cardiovascular Risk Reduction: A Match Control Study

BACKGROUND There is a paucity of studies comparing risk reduction of the atherosclerotic cardiovascular disease (ASCVD) and Framingham-body mass index (BMI) Coronary Heart risk score after a laparoscopic Roux-en-Y gastric bypass (RYGB), and few studies have assessed the efficacy of laparoscopic sleeve gastrectomy (SG) in reducing cardiovascular risk. OBJECTIVE Our goal in this study was to compare the impact of SG and RYGB on cardiovascular risk reduction. SETTING U.S. university hospital. METHODS We retrospectively reviewed the records of all SG or RYGB cases at our institution between 2010 and 2015. Patients who met the criteria for calculating the ASCVD 10-year and Framingham-BMI score were included in the study. Propensity score matching was used to match SG and RYGB on demographic characteristics and co-morbidities. RESULTS Of the 1330 bariatric patients reviewed in the study period, 219 (19.3%) patients met the criteria for risk score calculation. SG was the most prevalent surgery in 72.6% (N = 159) of cases compared with RYGB in 27.4% (N = 60) of cases. At 12-month follow-up, ASCVD 10-year score had an absolute risk reduction of 3.9 ± 6.5% in SG patients and 2.9 ± 5.8% in RYGB patients (P = .3). Framingham-BMI score absolute risk reduction was 11.0 ± 12.0% in SG and 9.0 ± 11.0% in RYGB patients (P = .4), and the decrease in estimated heart age was 12.1 ± 15.6 years in SG versus 9.2 ± 9.6 years in RYGB (P = .1). The percentage of estimated BMI loss at 1 year was 68.1 ± 23.3% in SG versus 74.2 ± 24.8% in RYGB (P = .1). CONCLUSION Our results suggest that SG and RYGB are equally effective in improving cardiovascular risk and decreasing the estimated vascular/heart age at 12-month follow-up.

The Importance of the Biliopancreatic Limb Length in Gastric Bypass: A Systematic Review

BACKGROUND Bariatric surgery has proven to be the most durable treatment for obesity, and it also provides improvement of obesitys associated co-morbidities. Although several mechanisms for its metabolic effects have been studied, the implications of the surgically constructed anatomy on its functioning physiology have not been elucidated. This leaves some uncertainty regarding the recommended limb lengths in Roux-en-Y gastric bypass. The alimentary limb length and function has been studied extensively, but few have studied the influences of the biliopancreatic limb length. OBJECTIVE To present a systematic review of the literature comparing variations in length of BP limb and results in order to determine BP limb length influence. SETTING Academic Hospital, United States. METHODS We present a systematic review of all the articles comparing variations of the biliopancreatic limb length and their results. RESULTS Thirteen articles were identified and analyzed. Most of the articles are prospective studies. Weight loss was superior in longer limbs. CONCLUSION Based on our review of the subject, we can conclude that the release of enterohormones in response to a food load in the distal small bowel seems to play an important role in the remission of co-morbidities. Hence, the length of the biliopancreatic limb might affect this process.

Midgut volvulus as initial presentation of pneumatosis cystoides intestinalis.

Pneumatosis cystoides intestinalis (PCI) is a rare disease with unknown aetiology. It is characterized by the presence of gas-filled cysts within the submucosa or subserosa of the intestine; however, it can be located in any part of the intestinal tract. The pathogenesis, although unknown, seems to be related to the mucosal breakdown and bacterial fermentation. PCI is associated with a variety of diseases in which there is loss of bowel mucosal integrity and/or increased intraluminal pressure. PCI is usually incidentally discovered during diagnostic modalities being carried out for other reasons. In approximately 16% of cases, PCI presents as intestinal obstruction or perforation. Patients commonly present with non-specific gastrointestinal symptoms such as intermittent abdominal pain, nausea, and in cases with colonic involvement, diarrhoea, mucus discharge, rectal bleeding and constipation. Although previously PCI was thought to occur more frequently in the small intestine, more recent studies have shown that PCI appears more frequently in the colon (61.8%), followed by the small intestine (15.4%). A 72-year-old woman presented to the emergency department with a 3-week history of severe back pain with radiation to the abdomen and now recent onset of vomiting. On examination, the vital signs were normal and the abdomen was soft with only minimal tenderness without any peritoneal signs. Laboratory values were also within normal limits. An initial computed tomography (CT) scan without contrast was read as free intra-abdominal air under the right hemidiaphragm (Fig. 1). Because of the overall paucity of clinical signs, a CT with contrast was obtained. The CT scan with oral contrast revealed a large duodenum diverticulum in the right upper quadrant and suggested a possible internal hernia; small pockets of free air were again visualized (Fig. 2). At this point, the patient was taken to the operating room for diagnostic laparoscopy. During laparoscopic exploration, at a distance of about 40 cm from the ligament of Treitz, the small bowel was twisting on itself going under the superior mesenteric artery. The internal hernia was reduced by gentle traction. Once this was accomplished, it became evident that a segment of bowel that was folding on itself contained multiple diverticula. There was no evidence of inflammatory changes, but there appeared to be air under the layer of visceral peritoneum. Since those diverticula had functioned as a lead point for the torsion, the segment of bowel was resected (35 cm) (Fig. 3) with a linear stapler. A standard side-to-side functional end-to-end anastomosis was performed. She was discharged home on postoperative day 4 tolerating regular diet. The pathology report revealed the following: small bowel segment with diverticular disease and serosal adhesions. Histological changes were consistent with arteriovascular malformation and severe atherosclerosis. Seven reactive lymph nodes were negative for neoplasm. In this unusual case report, the clinical presentation was of a volvulus around the superior mesenteric artery, likely secondary to the bulky PCI in the jejunum. To our knowledge, this is the first description of such a presentation of PCI. This underlies the importance of a complete clinical evaluation that does not only take into account the radiological findings. The initial CT scan in our case