Roberta Gelmini

Estrogen Receptor Classification for Hepatocellular Carcinoma: Comparison With Clinical Staging Systems

PURPOSE Several scoring systems to evaluate patients with hepatocellular carcinoma (HCC) exist. A good scoring system should provide information on prognosis and guide therapeutic decisions. The presence of variant liver estrogen receptor (ER) transcripts in the tumor has been shown to be the strongest negative predictor of survival in HCC. The aim of this study was to compare the predictive value of the commonly applied clinical scoring systems for survival of patients with HCC with that of the evaluation of ER in patients with HCC (molecular scoring system). MATERIALS AND METHODS HCC was staged according to the Okuda classification, Barcelona Clinic Liver Cancer classification, Italian classification system (CLIP), French classification, and ER status in 96 patients. Analysis of survival was performed according to the Kaplan-Maier test and was made for each classification system and ER. A comparison between classifications was made by univariate and multivariate analysis. RESULTS Among the clinical classification systems, only the CLIP was able to identify patient populations with good, intermediate, and poor prognosis. On multivariate analysis, ER classification was shown to be the best predictive classification for survival of patients with HCC (P <.0001). This difference was the result of a better allocation of patients with ominous prognosis (variant ER) having nevertheless good clinical score. CONCLUSION The evaluation of the presence of wild-type or variant ER transcripts in the tumor is the best predictor of survival in patients with HCC. Its accuracy in discriminating patients with good or unfavorable prognosis is significantly greater than that of the commonly used scoring systems for the staging of HCC.

Sutureless and stapleless laparoscopic splenectomy using radiofrequency : LigaSure device

BackgroundBleeding is the main complication and cause of conversion during laparoscopic splenectomy (LS). We present the advantages of the LigaSure vessel sealing system added to the lateral approach for achieving safe vascular control.MethodsWe performed 63 consecutive LS in a 3-year period using LigaSure in two affiliated university hospitals. We employed a right semilateral position technique with dissection of the spleen and vessel sealing using LigaSure. Forty-two patients had benign hematological disease, 19 had malignant disease, and two had splenic cysts.ResultsA total of 58 LS were completed with five conversions due to hilar bleeding (three cases), difficult dissection (one), and massive splenomegaly (one). In all but five patients, blood loss was less than 100 ml. No transfusions were needed. There were five postoperative complications: portal thrombosis (one case), hemoperitoneum (two), surgical wound infection (one), and pleural effusion (one).ConclusionsThe use of LigaSure, and the semilateral position, results in a gain of time and safety. Furthermore, average intraoperative bleeding is very low.

Reproductive status is associated with the severity of fibrosis in women with hepatitis C.

Introduction Chronic hepatitis C is the main cause of death in patients with end-stage liver disease. Prognosis depends on the increase of fibrosis, whose progression is twice as rapid in men as in women. Aim of the study was to evaluate the effects of reproductive stage on fibrosis severity in women and to compare these findings with age-matched men. Materials and Methods A retrospective study of 710 consecutive patients with biopsy-proven chronic hepatitis C was conducted, using data from a clinical database of two tertiary Italian care centers. Four age-matched groups of men served as controls. Data about demographics, biochemistry, liver biopsy and ultrasonography were analyzed. Contributing factors were assessed by multivariate logistic regression analysis. Results Liver fibrosis was more advanced in the early menopausal than in the fully reproductive (P<0.0001) or premenopausal (P = 0.042) group. Late menopausal women had higher liver fibrosis compared with the other groups (fully reproductive, P<0.0001; premenopausal, P = <0.0001; early menopausal, P = 0.052). Multivariate analyses showed that male sex was independently associated with more severe fibrosis in the groups corresponding to premenopausal (P = 0.048) and early menopausal (P = 0.004) but not late menopausal pairs. In women, estradiol/testosterone ratio decreased markedly in early (vs. reproductive age: P = 0.002 and vs. premenopausal: P<0.0001) and late menopause (vs. reproductive age: P = 0.001; vs. premenopausal: P<0.0001). In men age-matched with menopausal women, estradiol/testosterone ratio instead increased (reproductive age group vs. early: P = 0.002 and vs. late M: P = 0.001). Conclusions The severity of fibrosis in women worsens in parallel with increasing estrogen deprivation and estradiol/testosterone ratio decrease. Our data provide evidence why fibrosis progression is discontinuous in women and more linear and severe in men, in whom aging-associated estradiol/testosterone ratio increase occurs too late to noticeably influence the inflammatory process leading to fibrosis.

Mesenteric Cystic Neoformations: Report of Two Cases

The authors present two case reports of mesenteric cystic neoformations which they themselves observed and, with the help of the literature regarding this pathology, discuss the problems of both diagnosis and treatment.

Laparoscopic cholecystectomy with Harmonic scalpel.

This study suggests that the Harmonic scalpel is a safe and effective instrument for laparoscopic cholecystectomy, because it provides complete hemobiliary stasis.

Laparoscopic Splenectomy: Conventional Versus Robotic Approach—A Comparative Study

BACKGROUND Laparoscopic splenectomy is accepted as a safe approach in the surgical treatment of blood disorders worldwide. Compared with the laparotomic technique, it is associated with a lower risk of intraoperative bleeding, less postoperative pain, and faster discharge times. The advent of robotic surgery (RS) has changed the concept of minimally invasive surgery because, in addition to allowing a three-dimensional view, it permits greater freedom of movement and higher levels of accuracy than laparoscopic surgery (LS). The aim of this study was to comparatively evaluate whether RS presents advantages over LS in spleen surgery. METHODS In two Surgical Units with experience in laparoscopic splenectomy, over a 7-year period, two groups of 45 patients underwent LS and RS. The two groups were well matched for demographic characteristics, indications, and spleen size. RESULTS No statistically significant differences were found regarding intraoperative blood loss, conversion rate to laparotomy, food intake, drain removal, postoperative complications, and median time to discharge. On the contrary, statistically increased differences were observed in median operative time and costs. In both groups, the transfusion and mortality rate was 0%. At the 6-month follow-up no surgical complications were observed. CONCLUSIONS Although RS offers a three-dimensional view, greater freedom of movement, and higher levels of accuracy, it is associated with longer operative times and higher costs. It can consequently be concluded that with the intrinsic limits of the study design used, at the current time, RS does not have any significant advantage over LS in splenectomy.

Laparoscopic approach of gastric gastrointestinal stromal tumors (GISTs): is it still a courageous choice? Report of two cases.

Gastrointestinal stromal tumors (GISTs) are a well-defined clinicopathologic and molecular tumor entity, representing the most common gastrointestinal mesenchymal neoplasm. Differential diagnosis between GIST and other mesenchymal malignancies is crucial, given the successful management using targeted therapy in metastatic GIST. The mainstay of treatment remains surgery, complete tumor resection being the most important independent prognostic factor. Videolaparoscopic approach is still controversial for the high risk of tumor rupture or bleeding. Here we report 2 cases of GIST surgically resected using a videolaparoscopic approach and discuss the efficacy of this technique in selected patients.

Chronic and recurrent benign lymphadenopathy without constitutional symptoms associated with human herpesvirus-6B reactivation

Chronic/recurrent behaviour may be encountered in some distinct atypical or malignant lymphoproliferations, while recurrences are not generally observed in reactive/benign lymphadenopathies. We retrospectively analysed a consecutive series of 486 human immunodeficiency virus‐negative adults, who underwent lymphadenectomy. Neoplastic and benign/reactive histopathological pictures were documented in 299 (61·5%) and 187 (38·5%) cases, respectively. Of note, seven of the 111 (6·3%) patients with benign lymphadenopathy without well‐defined aetiology, showed chronic/recurrent behaviour, without constitutional symptoms. Enlarged lymph nodes were round in shape and hypoechoic, mimicking lymphoma. Reactive follicular hyperplasia and paracortical expansion were observed. Human herpesvirus (HHV)‐6B positive staining in follicular dendritic cells (FDCs) was documented in all seven patients. Serological, molecular and immunological examinations suggested HHV‐6B reactivation. Among the remaining 104 cases with reactive lymphoid hyperplasia in the absence of well‐known aetiology and without recurrences, positivity for HHV‐6B on FDCs was found in three cases, whereas in seven further patients, a scanty positivity was documented in rare, scattered cells in inter‐follicular regions. Immunohistochemistry for HHV‐6A and HHV‐6B was invariably negative on 134 lymph nodes, with either benign pictures with known aetiology or malignant lymphoproliferative disorders, tested as further controls. Future studies are warranted to investigate a potential association between HHV‐6B reactivation and chronic/recurrent benign lymphadenopathy.

TUBERCULOUS PERITONITIS IN NO RISK PATIENTS: DIAGNOSTIC APPROACH

Background:  Incidence of tubercoulosis is increasing in Western countries particularly in immigrants from endemic areas and in patients with HIV or immunocompromised. The disease is unusual in patients without risk factors. In these conditions the diagnosis of tuberculous peritonitis is often delayed, resulting in high morbidity and mortality.

A new device for ultrasound-guided peripheral venous access

Background: In patients with difficult peripheral venous access, alternative techniques require expertise and are invasive, expensive, and prone to serious adverse events. This brought us to designing a new venous catheter (JLB® Deltamed, Inc.) for the cannulation of medium and large bore veins; it is echogenic, and available in different lengths (60 / 70 / 80 mm) and Gauges (14 / 16 / 17 / 18). Methods: We led a multi-center observational convenience sampling study to evaluate safety and effectiveness of JLB. Data was collected from June 2015 to February 2018. Inclusion criteria were age ⩾ 18, difficulty in obtaining superficial venous access in the veins of the arm, need for rapid infusion, or patient’s preference. Results: We enrolled 1000 patients, mean age 66.8 years. In total, 951 (95.1%) had the device placed in internal jugular vein, 28 in basilic or cephalic vein, 15 in femoral vein, 5 in axillary vein (infra-clavicular tract), and 1 in the external jugular vein. The procedure was performed by attending physicians or emergency medicine residents under US guidance. Mean procedure time (from disinfection to securing) was approximately 240 s. Mean attempts number was 1.21. Early complications (<24 h) occurred in four patients, consisting in two soft tissue hematoma, one phlebitis, and one atrial tachyarrhythmia. No major complications (such as pneumothorax) were reported. Mean indwelling time was 168 h (7 days); early occlusion/dislocation occurred in four cases. Conclusion: According to preliminary data, the application of JLB appears to be safe, cost-effective, and rapid to place bedside.