Marcello Bartolotta

Palliative antecolic isoperistaltic gastrojejunostomy : a randomized controlled trial comparing open and laparoscopic approaches

Gastric outlet obstruction is a common, often preterminal, event for patients with inoperable neoplasms of the distal stomach, duodenum, and biliopancreatic area. It can be surgically managed by open or laparoscopic gastrojejunostomy. This study aimed to compare the results of open and laparoscopic palliative gastrojejunostomy for patients with gastric outlet obstruction resulting from inoperable neoplasms. A total of 24 patients were randomized prospectively to undergo laparoscopic (12 patients) or open (12 patients) palliative laterolateral antecolic isoperistaltic gastrojejunostomy. All the procedures were completed as planned. The mean duration of surgery was not significantly different between the two groups (p = 0.75). The mean intraoperative blood loss was significantly less after laparoscopic gastrojejunostomy (LGJ) (p = 0.0001). Time to oral solid food intake was longer after open gastrojejunostomy (OGJ) (p = 0.04). Two patients in the OGJ group experienced postoperative delayed gastric empting, whereas no patients in the LGJ group experienced such a complication (p = 0.04). The mean postoperative stay was shorter in the LGJ group, but the difference did not reach statistical significance (p = 0.65). No readmissions were registered after a minimum follow-up period of 2 months. The findings show that LGJ is a safe, feasible, and effective alternative to OGJ. However, because the current data involved only a small number of patients, large studies still are required for further evaluation of the this operation’s effectiveness.

Retromuscular sutured incisional hernia repair: a randomized controlled trial to compare open and laparoscopic approach.

To compare the early and intermediate results of the open and laparoscopic tension-free repair of incisional hernia, 24 patients were randomized prospectively to undergo laparoscopic or open repair of incisional hernia with retromuscular placement of the prosthesis using transabdominal sutures for mesh fixation. All the procedures were completed as planned. The mean duration of surgery was not significantly different between the 2 groups (P=0.15). Time to oral solid food intake was longer in the open group (P=0.002). The analgesic requirement was lower in the laparoscopic group (P=0.05). One patient after open surgery and 2 in the laparoscopic group suffered postoperative complications (P=0.71). Postoperative stay was shorter in the laparoscopic group (P=0.006). No readmission or recurrence was registered within 6 months from surgery in either group. Laparoscopic incisional hernia repair, based on the Rives-Stoppa technique, is a safe, feasible alternative to open techniques. However, larger studies and long-term follow-up are required to further evaluate the true effectiveness of this operation.

Simple versus double jejunal pouch for reconstruction after total gastrectomy

BACKGROUND Even though many types of reconstruction after total gastrectomy have been proposed to reduce postgastrectomy syndromes, choosing a method that would further improve the quality of life and nutrition of the gastrectomized patient is controversial. Hunt-Lawrence single pouch reconstruction seems to obtain better results compared with the more common Roux-en-Y technique, but both of these reconstructive approaches are associated with some reduction in food intake and some problems in achievement of ideal body weight. METHODS In this prospective, randomized trial, after total gastrectomy 18 patients had reconstruction according to the Hunt-Lawrence or single pouch technique (SP group), whereas for 23 patients, the technique was modified with construction of a second pouch in the distal portion of the jejunal loop (DP group). Patients in the two groups were compared at 12 months after surgery for problems in gastrointestinal function, quality of life, improvement in body weight and nutritional parameters, serum albumin, hemoglobin level, and serum protein. RESULTS The DP group demonstrated fewer symptom problems, better weight maintenance, and better laboratory values when compared with patients undergoing standard single jejunal pouch reconstruction. CONCLUSIONS Reconstruction with use of a double pouch as a gastric substitute leads to better outcome assessments than with a single pouch reconstruction. Our double pouch technique has demonstrated significant improvement in quality of life and nutritional recovery in terms of functional results as well as patient satisfaction.

Ultrasound-guided radiofrequency-assisted segmental liver resection. A new technique

Segmental hepatectomy is appealing for several reasons including preservation of liver parenchyma, reduction of intraoperative blood loss, and blood replacement by dividing tissues along the anatomic planes. A simple technique guided by intraoperative ultrasound is described here using radio-frequency energy to create coagulative desiccation of segmental or subsegmental arterial and portal vessels. Thirty patients underwent a segmental resection using this technique without mortality and with minor morbidity. This technique has a major advantage of being easy and safe to apply. We believe it has a potentially important role in both open and laparoscopic liver surgery.

Ultrasound-guided radiofrequency-assisted segmental arterioportal vascular occlusion in laparoscopic segmental liver resection

BackgroundStudies have shown laparoscopic liver resection to be feasible and safe. Segmental hepatectomy is appealing because it allows a reduction of intraoperative blood loss and blood replacement by dividing tissues along the anatomic planes. However, an effective technique that allows the closure of segmental vessels during systematic segmentectomies before resection still is lacking in laparoscopic surgery.MethodsA simple technique guided by intraoperative ultrasound to facilitate laparoscopic liver segmentectomies is described. Coagulative desiccation of the vessels feeding the segment to be resected was induced by introduction of a “cooled-tip” radiofrequency electrode percutaneously under intraoperative ultrasound guidance at the level of the vessels. The intrahepatic parenchymal change induced by the radiofrequency was monitored using intraoperative ultrasound. After the application of energy to destroy the vessels feeding that segment, an area of marked discoloration on the surface of the liver became obvious. Liver parenchymal transection followed without any form of hepatic inflow occlusion.ResultsFor this study, 10 patients underwent a segmental resection using the described technique. The resection time ranged from 40 to 60 min including the time required to destroy the feeding vessels with radiofrequency. The intraoperative blood loss was less than 50 ml and did not necessitate intra- or postoperative blood transfusion. The surgical margins of the specimen were free of disease. There was no morbidity or mortality.ConclusionsThe preliminary experience shows that the reported technique is safe and effective, with the potential to make even difficult laparoscopic liver segmentectomies for segments such as VII and VIII, easier to manage.

A case of Candida krusei peritonitis secondary to duodenal perforation due to Candida duodenitis

A case of a 62-year-old man with Candida krusei peritonitis secondary to duodenal perforation due to Candida duodenitis that was successfully treated with a 14-day course of caspofungin is reported. The potential role of Candida infection in the pathogenesis of peptic ulcers and duodenal perforation is considered. If this role is confirmed, antifungal treatment should be included in the therapeutic armamentarium of peptic disease.

miRNA expression profiling regulates necroptotic cell death in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most aggressive types of cancer and is among the leading causes of cancer-related mortality worldwide. Although the dysregulation of microRNAs (miRNAs or miRs) has often been reported in HCC, the precise molecular mechanisms by which miRNAs modulate the process of tumorigenesis and the behavior of cancer cells are not yet clearly understood. In this study, we identified a novel three‑miRNA signature, including miR‑371-5p, miR‑373 and miR‑543, that appears to orchestrate programmed cell necrosis in HCC by directly targeting the caspase‑8 gene (Casp‑8). Our results demonstrated that miR‑371-5p, miR‑373 and miR‑543 were overexpressed in HCC tissues compared with paired adjacent normal tissues. The upregulation of these miRNAs specifically and markedly downregulated the expression of Casp‑8, as well as significantly enhanced the Z-VAD/TNF‑α-induced necroptosis of HCC cells. By contrast, the selective knockdown of miRNA expression led to a significant increase in Casp‑8 levels and a marked reduction in programmed cell necrosis. Intriguingly, the sustained overexpression of Casp‑8 reversed the pro‑necroptotic effects exerted by miRNA mimics. Finally, a strong inverse association between the level of miR‑223 and the expression levels of nucleotide-binding oligomerization domain-like receptor family, pyrin domain-containing-3 inflammasome was observed in our HCC specimens. On the whole, the present study revealed a molecular link between the three‑miRNA signature, comprising miR‑371-5p, miR‑373 and miR‑543, and the negative necroptotic regulator Casp‑8, and presents evidence for its employment as a novel potential diagnostic, prognostic and therapeutic target in HCC.