Saverio Latteri

Simultaneous laparoendoscopic rendezvous for the treatment of cholecystocholedocholithiasis

BackgroundDifferent approaches are available for the treatment of combined cholecystocholedocholithiasis including totally laparoscopic (TL) treatment, simultaneous laparoendoscopic treatment, and sequential treatments (ST) combining endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) with cholecystectomy. This review aimed to clarify the issue of the simultaneous laparoendoscopic rendezvous (RV).MethodsA careful analysis of papers was performed to determine the results, technical differences, limits, disadvantages, and advantages of RV compared with other options.ResultsData were collected from 27 papers concerning 795 patients. The overall effectiveness of RV was 92.3%. The morbidity rate was 5.1%, and the mortality rate was 0.37%. Almost all the authors were satisfied with the procedure. The authors’ comparison to ST and TL showed that the advantages outweigh the disadvantages mostly related to logistical problems.ConclusionsThere is confusion concerning the definitions and techniques of RV due to differences in combining surgical and endoscopic steps of the procedure. The results are at least comparable with those of the other available approaches. The effectiveness of RV is greater with reciprocal implementation of surgical and endoscopic procedures. The morbidity and the risk of iatrogenic damage seem lower than with ERCP-ES and the risk of residual stones lower than with TL treatment. The RV procedure is safe and can sometimes be the preferable option, but collaboration between surgeon and endoscopist is mandatory.

Aging and Parkinson's Disease: Inflammaging, neuroinflammation and biological remodeling as key factors in pathogenesis

ABSTRACT In order to better understand the pathogenesis of Parkinsons Disease (PD) it is important to consider possible contributory factors inherent to the aging process, as age‐related changes in a number of physiological systems (perhaps incurred within particular environments) appear to influence the onset and progression of neurodegenerative disorders. Accordingly, we posit that a principal mechanism underlying PD is inflammaging, i.e. the chronic inflammatory process characterized by an imbalance of pro‐ and anti‐inflammatory mechanisms which has been recognized as operative in several age‐related, and notably neurodegenerative diseases. Recent conceptualization suggests that inflammaging is part of the complex adaptive mechanisms (“re‐modeling”) that are ongoing through the lifespan, and which function to prevent or mitigate endogenous processes of tissue disruption and degenerative change(s). The absence of an adequate anti‐inflammatory response can fuel inflammaging, which propagates on both local (i.e.‐ from cell to cell) and systemic levels (e.g.‐ via exosomes and other molecules present in the blood). In general, this scenario is compatible with the hypothesis that inflammaging represents a hormetic or hormetic‐like effect, in which low levels of inflammatory stress may prompt induction of anti‐inflammatory mediators and mechanisms, while sustained pro‐inflammatory stress incurs higher and more durable levels of inflammatory substances, which, in turn prompt a local‐to‐systemic effect and more diverse inflammatory response(s). Given this perspective, new treatments of PD may be envisioned that strategically are aimed at exerting hormetic effects to sustain anti‐inflammatory responses, inclusive perhaps, of modulating the inflammatory influence of the gut microbiota. Graphical abstract Figure. No caption available. HighlightsAging is the major risk factor for Parkinsons Disease.Inflammaging is a basic mechanism in neurodegeneration.Inflammaging could be considered as a hormetic adaptation with opposite effects during the life.Senescent and inflammatory cells (astrocytes, microglia) are present in the brain of PD patients.Gut microbiota dysbiosis is associated with PD.

Adjusting CA19-9 values to predict malignancy in obstructive jaundice: Influence of bilirubin and C-reactive protein

AIM To find a possible relationship between inflammation and CA19-9 tumor marker by analyzing data from patients with benign jaundice (BJ) and malignant jaundice (MJ). METHODS All patients admitted for obstructive jaundice, in the period 2005-2009, were prospectively enrolled in the study, obtaining a total of 102 patients. On admission, all patients underwent complete standard blood test examinations including C-reactive protein (CRP), bilirubin, CA19-9. Patients were considered eligible for the study when they presented obstructive jaundice confirmed by instrumental examinations and increased serum bilirubin levels (total bilirubin > 2.0 mg/dL). The standard cut-off level for CA19-9 was 32 U/mL, whereas for CRP this was 1.5 mg/L. The CA19-9 level was adjusted by dividing it by the value of serum bilirubin or by the CRP value. The patients were divided into 2 groups, MJ and BJ, and after the adjustment a comparison between the 2 groups of patients was performed. Sensitivity, specificity and positive predictive values were calculated before and after the adjustment. RESULTS Of the 102 patients, 51 were affected by BJ and 51 by MJ. Pathologic CA19-9 levels were found in 71.7% of the patients. In the group of 51 BJ patients there were 29 (56.9%) males and 22 (43.1%) females with a median age of 66 years (range 24-96 years), whereas in the MJ group there were 24 (47%) males and 27 (53%) females, with a mean age of 70 years (range 30-92 years). Pathologic CA19-9 serum level was found in 82.3% of MJ. CRP levels were pathologic in 66.6% of the patients with BJ and in 49% with MJ. Bilirubin and CA19-9 average levels were significantly higher in MJ compared with BJ (P = 0.000 and P = 0.02), while the CRP level was significantly higher in BJ (P = 0.000). Considering a CA19-9 cut-off level of 32 U/mL, 82.3% in the MJ group and 54.9% in the BJ group were positive for CA19-9 (P = 0.002). A CA19-9 cut-off of 100 U/mL increases the difference between the two groups: 35.3% in BJ and 68.6% in MJ (P = 0.0007). Adjusting the CA19-9 value by dividing it by serum bilirubin level meant that 21.5% in the BJ and 49% in the MJ group remained with a positive CA19-9 value (P = 0.003), while adjusting the CA19-9 value by dividing it by serum CRP value meant that 31.4% in the BJ group and 76.5% in the MJ group still had a positive CA19-9 value (P = 0.000004). Sensitivity, specificity, positive predictive values of CA19-9 > 32 U/mL were 82.3%, 45% and 59.1%; when the cut-off was CA19-9 > 100 U/mL they were, respectively, 68.6%, 64.7% and 66%. When the CA19-9 value was adjusted by dividing it by the bilirubin or CRP values, these became 49%, 78.4%, 69.4% and 76.5%, 68.6%, 70.9%, respectively. CONCLUSION The present study proposes CRP as a new and useful correction factor to improve the diagnostic value of the CA19-9 tumor marker in patients with cholestatic jaundice.

Ultrasound as point of care in management of polytrauma and its complication

PurposeTraumatic injuries constitute a major risk for patients in emergency units. Point-of-care ultrasound may be a determinant in reducing the deleterious impact of complications and in prognosis.MethodsWe describe the case of a 28-year-old female who reported cranial trauma, abdominal and thoracic trauma, and suspected bilateral fracture of the femur.ResultsUltrasound was useful for evaluating and monitoring multiple organ failure.ConclusionCombining cost-effective advantages with bedside real-time imaging, ultrasound is a powerful adjunct to standard clinical assessment in the management of polytrauma when it is administered at the point of care.SommarioScopole patologie traumatiche rappresentano il maggiore rischio dei pazienti nelle Unità di Emergenza. L’ecografia consentendo una diagnosi precoce sia del tipo di trauma sia delle complicanze che da questo potrebbero derivane, può rappresentare un mezzo importante per la prognosi e per l’eventuale terapia.MetodiA tale scopo, noi presentiamo un caso paradigmatico di una paziente di 28 anni che, a seguito di un incidente, aveva riportato dei traumi al cranio, all’addome e al torace e sospetta frattura bilaterale al femore. Al momento del ricovero la paziente era monitorizzata tramite ecografia. I dati venivano confermati sia dalla sintomatologia clinica obiettiva, sia dalla tomografia assiale computerizzata.Risultatol’uso dell’ecografia ha consentito una diagnosi precoce non solo del tipo di trauma, ma anche ha permesso un corretto intervento terapeutico ed un monitoraggio anche dell’attività cardiaca.ConclusioneL’ecografia presenta vantaggi dal punto di vista costo-beneficio ed è utile sia ai fini diagnostici, sia ai fini terapeutici.

Recurrent Aortoduodenal Fistula

Aortoenteric fistula is defined as a communication between the aorta and an adjacent loop of the bowel and is often the cause of devastating upper gastrointestinal tract bleeding with only few survivors. According to the etiology, the aortoenteric fistulas are classified as primary aortoenteric fistula or secondary aortoenteric fistula (SAEF) after previous aortic surgery. The recurrence of a fistula on a previous SAEF is defined as recurrent aortoenteric fistula and is reported only in a few rare cases occurring within an unpredictable period from the previous surgical treatment. We describe a unique case of recurrent aortoenteric fistula, in which the relationship with recurrence consisted of the presence of the metallic clips of a stapled suture to close the duodenal wall during the previous SAEF repair. A review of the published data on this subject was performed to analyze the clinical features, the overall results, the risk factors of recurrence, and the main technical points of surgical treatment to prevent it.

Reduction of cardiovascular risk in subjects with high lipoprotein (a) levels

Lipoprotein (a) (Lp (a)) is a plasma lipoprotein consisting of a cholesterol rich LDL particle with one molecule of apolipoprotein B100 and one protein apolipoprotein (a) [apo(a)].

Tumor lysis syndrome in an extraskeletal osteosarcoma: a case report and review of the literature

BackgroundThis case report describes a spontaneous tumor lysis syndrome due to a rare solid tumor.Case presentationA 65-year-old white woman had tumor lysis syndrome, which represent a dangerous oncological emergency. This syndrome occurs usually with a hematological tumor, but in this case our patient had a solid tumor, which was a rare extraskeletal osteosarcoma, localized in her pelvic region. She also had lung metastases and bilateral hydronephrosis.After spontaneous tumor lysis syndrome, she had acute renal insufficiency, which was treated with hemodialysis and successively with rasburicase, Kayexalate (sodium polystyrene sulfonate), and febuxostat.ConclusionTumor lysis syndrome represents an oncological emergency, which must be suspected and treated as soon as possible.

Abdominal perineal resection or wilde local excision in primary anorectal malignant melanoma. Case report and review

Introduction Primary anorectal malignant melanoma is a rare and aggressive tumor that carries a poor prognosis. Anorectal melanoma (ARM) is often misdiagnosed as hemorrhoids adenocarcinoma polips and rectal cancer. ARM spreads along sub-mucosal planes and is often to wide-spread for complete resection at time of diagnosis and almost all patients die because of metastases. Presentation of the case A 77-year-old male patient presented a history of recurrent rectal bleeding and whose histopathological diagnosis was melanoma. Discussion The treatment of choice remains controversial. Surgery with complete resection represents the typical treatment. However standard operative procedures related to the area of resection and lymph dissection have yet to be established. Abdominal perineal resection (APR) with or without bilateral inguinal lymphadenectomy or wide local excision (WLE) have been used to manage patients with ARM. Conclusion The higher serum levels of LDH and YKL-40 are suggestive for Anorectal Melanoma diagnosis. The decrease of these findings may be associated with good prognosis. The review of both APR and WLE options suggests no significant difference in survival among patients.

Treatment of cholecysto-choledocolithiasis in elderly patients: personal experience

Background Biliary stones are a common disease in western countries, and its management has changed dramatically over the past decade. Due to the increase of the middle-aged people, a larger number of elderly patients are affected by this disease. Laparoscopic cholecystectomy (LC) represents the gold standard for the treatment of gallbladder stones, and in cholecystectomized patients, the treatment of CBD stones remains the exclusive work of the endoscopist. But if the patient still has the gallbladder with stones, the ideal management of CBD stones remains controversial. There are two treatment options: the two time (LC and pre or postoperative ERCP), and the one time procedures (trans cystic approach and CBD exploration and laparoendoscopic procedure called “rendezvous”:RV). The aim of the work is to analyse our results of the mininvasive treatment of the cholecysto-choledocolithiasis in elderly patients.

Anorectal mucosal melanoma

Anorectal melanoma is an uncommon and aggressive mucosal melanocytic malignancy. Due to its rarity, the pre-operative diagnosis remains difficult. The first symptoms are non-specific such as anal bleeding, anal mass or pain. Although anorectal melanoma carries a poor prognosis; optimal therapeutics strategies are unclear. Surgical resection remains the mainstay of treatment. The optimal surgical procedure for primary tumours is controversial and can vary from wide local excision or endoscopic mucosal resection (EMR) to an abdomino-perineal resection. A high degree of uncertainly exists regarding the benefit of radiation therapy or chemotherapy. The treatment of advanced melanoma is evolving rapidly with better understanding of the disease biology and immunology. Considerable effort has been devoted to the identification of molecular determinants of response to target therapies and immunotherapy.