F. D’Amico

Follow-Up of Exocrine Pancreatic Function in Type-1 Diabetes mellitus

In a previous study, mild to moderate exocrine pancreatic insufficiency, as measured by the secretin-pancreozymin test, was found in 23 (43%) of 53 patients with type-1 diabetes mellitus. Of these 53 patients, 20 (7 of whom initially had an abnormal secretin-pancreozymin test) were available for a follow-up examination 11 years later. Of the 7 patients with abnormal exocrine pancreatic function at the first test, 5 remained abnormal and 2 became normal, whereas of the 13 patients with initially normal pancreatic function the test result remained normal in 11 patients and became abnormal in 2. In these 2 groups the test result did not differ significantly between both tests. However, exocrine pancreatic function had returned to normal or had become abnormal in 2 patients, respectively, at the second test. In the 3 patients with exocrine pancreatic insufficiency at the first and second tests, the lipase level had not fallen below 10% or less than the normal level at which steatorrhea occurs and therapy is required. There was no significant correlation between the duration of the diabetes and the test results for both time points of investigation. The data suggest that mild to moderate exocrine pancreatic insufficiency found in type-1 diabetes is due to an early event in the course of the diabetes and does not progress. Therefore, this finding is of minor clinical importance and expensive pancreatic enzyme substitution will not be required.

The survival benefit of liver transplantation in hepatocellular carcinoma patients.

BACKGROUND There are no studies evaluating the survival benefit of liver transplantation over alternative therapies for patients with hepatocellular carcinoma. METHODS The short- to mid-term survival benefit (study group=135 aggressively treated patients with hepatocellular carcinoma, 52% beyond Milan criteria at pathology) was calculated by comparing the mortality rates of liver transplantation vs alternative therapies patients. A Markov prediction model was then created to estimate the long-term survival benefit of liver transplantation (gain in life expectancy) over alternative therapies. The long-term survival rates in the liver transplantation group were calculated using the Metroticket website calculator (http://89.96.76.14/metroticket/calculator/). RESULTS The short- to mid-term analysis indicated that liver transplantation afforded no significant survival benefit in the group of patients with hepatoma as a whole (hazard ratio=1.229, 95% confidence interval 0.544-2.773, p=.6200). The benefit was concentrated in patients with a poor initial response to alternative therapies (hazard ratio=3.137, 95% confidence interval 1.428-6.891, p=.0044). In the long-term analysis, the gain in life expectancy of liver transplantation vs alternative therapies was 6.115 years (base-case analysis) and the main determinants of gain in life expectancy were the 5-year survival prospects after alternative therapies and the patients age. CONCLUSIONS The survival benefit of liver transplantation for patients with hepatocellular carcinoma is strongly related to the patients age and the effectiveness of available alternative therapies.

Clear Cell Sarcoma of the Ileum Report of a Case and Review of the Literature

Introduction. Clear cell sarcoma of the gastrointestinal tract (CCS-GI) is an extremely rare and aggressive tumor, which often mimics other neoplastic processes. Because of this feature, its real incidence may have been underestimated, especially in the past when genetic tests were less available than nowadays. To date, less then 30 cases have been described in the literature on the GI tract. Case presentation. We report the case of a 69-year-old woman who presented with active rectal bleeding. After a negative colonoscopy, the patient underwent a video-capsule endoscopy. The latter detected an ileal mass that was surgically resected. The microscopic appearance was consistent with a malignant mesenchymal neoplasm; immunohistochemistry was positive for S100 protein, CD56, and INI1. Fluorescence in situ hybridization showed a translocation involving the EWSR1 (Ewing sarcoma 1) gene region. All these findings were consistent with a CCS-GI. Conclusion. Herein we present a case of CCS-GI, discuss its clinical and pathological features, and review the literature on the subject.

Early Surgery for the Treatment of Toxic Megacolon

Background: Toxic megacolon (TM) is a potentially lethal complication of idiopathic inflammatory bowel disease or infectious colitis, characterized by total or segmental non-obstructive colonic dilatation of at least 6 cm associated with systemic toxicity. Methods: Overall, 15 patients had surgery for TM at our institutions over a 10-year period (1993–2003). In contrast to other studies that used medical therapy as the first-line treatment for TM, in our experience all patients underwent surgery as soon as possible after diagnosis of TM (early surgery). Results: 14 patients underwent subtotal colectomy with terminal ileostomy, while for 1 patient the surgical procedure consisted only in a decompressive cecostomy. Two major complications occurred consisting of 2 cases of multiple organ failure leading to death. No other major complications or deaths were reported. The overall mortality rate was therefore 13% (0% in patients <65 years). Conclusion: This study shows that early surgery has the potential to represent a valid therapeutic strategy for patients with TM resulting in a small number of TM-related complications and deaths. Elderly patients seem to have a high risk of multiple organ dysfunction syndrome and post-surgical death.

Sclerosing Angiomatoid Nodular Transformation of the spleen, focal nodular hyperplasia and hemangioma of the liver: A tale of three lesions

Sclerosing Angiomatoid Nodular Transformation (SANT) of the spleen is a benign vascular lesion with peculiar histological features. The pathogenesis of SANT is still largely unknown and variable etiologies have been proposed, including autoimmune, inflammatory, and/or vascular disorders. The present report describes a unique case of splenic SANT, associated with focal nodular hyperplasia and a sclerosing hemangioma of the liver. The clinic-pathological features of such an unusual case are thoroughly illustrated. Its possible pathogenic mechanisms are also briefly addressed.

Left split grafts in pediatric liver transplantation: an unexploited resource open to a multiple scenario evolution

We read with particular interest the article by Angelico and colleagues entitled “Outcomes of left split graft transplantation in Europe: report from the European Liver Transplant Registry” (1), published recently in Transplant International . The manuscript, reporting the outcome of 1,500 pediatrics transplantation performed in different European transplant centers using left split grafts (LSG) from deceased donors, makes an updated continental point on one of the most complex activities in the liver transplant (LT) area. Importantly enough, the study represents the widest LSG transplantation series ever reported.

Colorectal cancer in the young: a possible role for immune surveillance?

Abstract Background: Younger patients with colorectal cancer (CRC) generally have better survival in spite of worse clinical and pathological features. Methods: Twenty-six patients under 50 years operated for primary CRC were enrolled and matched 1:2:2 according to stage, tumor site and gender with 52 patients from 50 to 70 years and 52 patients over 70 years old. Results: Patients under 50 years had a significantly longer overall, cancer specific and disease free survival (p = .001, p = .007 and p = .05, respectively). However, they had more frequently lymphovascular invasion (p = .006) and they more frequently developed metachronous CRC at follow-up (p = .03). Nevertheless, preoperative lymphocytes blood count/white blood count (LBC/WBC) ratio inversely correlated with age at operation (rho = −.21, p = .04) and it predicted CRC recurrence with an accuracy of 70%, p < .001 (threshold value LBC/WBC = 0.21%) and better overall, cancer specific and disease free survival (p < .0001 for all). At multivariate analysis, stage and LBC/WBC ratio resulted independent predictors of disease free survival (p = .0001 and p = .01, respectively). Conclusions: Patients under 50 years had a significantly longer survival with a higher LBC/WBC ratio. These results could suggest a possible role of immunosurveillance in neoplastic control.

Segment 6: Laparoscopic Approach

Totally laparoscopic liver resection (LLR), first described by Gagner et al. in 1992 [1], now appears to be safe and effective procedure to treat lesions located on left lateral (2 and 3), middle (4b), and anterior right (5, 6) segments. Tumors localized in the posterior and superior segments of the liver or masses requiring major liver resections (right hepatectomy, left hepatectomy, extended right or left hepatectomy) are still considered less frequent indications for the minimally invasive approach and should be reserved to centers with significant experience in laparoscopic liver surgery (LLS), open hepatic surgery, and intraoperative ultrasound (US) [2]. Indications for LLS, with particular reference to resection of segment 6 (S6), remain basically the same as in open surgery and, technical feasibility of S6 resection using a minimally invasive approach is increasing with surgeon skill [2]. On this basis, a liver lesion located on S6 should be routinely evaluated for LLR in high-volume centers.