Stefano Puleo

Catheter fracture and cardiac migration: a rare complication of totally implantable venous devices.

Totally implantable venous device (TIVD) are widely used for the treatment of patients requiring long‐term chemotherapy, total parenteral nutrition and fluid replacement. Until today, many kinds of complications have been reported in the literature. We report an unusual case of catheter fracture as a consequence of pinchoff syndrome, and discuss the potential methods to avoid this complication and its evolution. J. Surg. Oncol. 2000;73:172–173.

Simultaneous occurrence of adenoma, focal nodular hyperplasia, and hemangioma of the liver: Are they derived from a common origin?

Abstract  The association between hepatic hemangioma (HH) and focal nodular hyperplasia (FNH) or the association between FNH and hepatic adenoma (HA) has been reported. The authors report a case in which FNH, HH, and HA simultaneously appear in the liver. A 25‐year‐old woman was admitted to the Department of Surgery of the University of Catania (Italy), after presenting pain in the right hypocondrium. No therapy with oral contraceptives, no pregnancy and no abnormalities of the laboratory tests were found. Ultrasonography and computed tomography scans revealed four masses with the characteristics of HH, HA, FNH, and a hydatid cyst located, respectively, in segments II, IV, IV, and V of the liver. The surgical procedures performed were hemangioma and adenoma enucleation and en bloc resection of the FNH, hydatid cyst and gallbladder. No complications were recorded in the postoperative period and the patient was discharged from the hospital after 1 week. A pathological examination confirmed the preoperative diagnosis. To the best of our knowledge, the association of HH, FNH, and HA has never been reported. A common pathogenesis has clearly been demonstrated for hepatocytes and other cell types. The simultaneous presence of these three different kinds of tumor suggest that HH, FNH and HA could be the different expression of the same malformative anomaly.

Bile duct injury during laparoscopic cholecystectomy without intraoperative cholangiography: a retrospective study on 1,100 selected patients.

Background: Whether to routinely or selectively use intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) has been a controversial issue for many years. Many authors maintain that IOC decreases the rate of biliary complications such as bile duct injuries, biliary leak, and missed common bile duct (CBD) stones. However, in contrast to these claims, many centers have opted to perform LC without IOC. In this retrospective study, the results of a series of 1,100 LCs, all of which involved major biliary complications and which were performed without the use of IOC, were reviewed. Methods: Data from 1,100 selected patients (728 females and 372 males) undergoing LC without the use of IOC from January 2003 to November 2011 were analyzed. One hundred and seventy LCs were performed by young surgeons during the learning curve, and 930 by surgeons with over 10 years of experience. Two techniques were used to create pneumoperitoneum: the Veress technique in 319 cases (29%) and the Hasson technique in the remaining 781 cases (71%). Patients with a suspicion of CBD stones were excluded from the study. Results: Two CBD injuries (0.18%) and three biliary leaks (0.27%) were detected among this group. Thirty-three patients (3%) needed conversion to open cholecystectomy. Missed CBD stones were reported in 4 cases (0.36%). There was no postoperative mortality. Conclusion: LC can be performed safely without the use of IOC and with acceptable low rates of biliary complications. An accurate preoperative evaluation of clinical risk factors, precise operative procedures, and conversion to an open approach in doubtful cases are important measures which must be taken to prevent CBD injury.

MDCT anatomic assessment of right inferior phrenic artery origin related to potential supply to hepatocellular carcinoma and its embolization.

PurposeTo prospectively assess the anatomic variation of the right inferior phrenic artery (RIPA) origin with multidetector computed tomography (MDCT) scans in relation to the technical and angiographic findings during transcatheter arterial embolization of hepatocellular carcinoma (HCC).MethodsTwo hundred patients with hepatocellular carcinomas were examined with 16-section CT during the arterial phase. The anatomy of the inferior phrenic arteries was recorded, with particular reference to their origin. All patients with subcapsular HCC located at segments VII and VIII underwent arteriography of the RIPA with subsequent embolization if neoplastic supply was detected.ResultsThe RIPA origin was detected in all cases (sensitivity 100%), while the left inferior phrenic artery origin was detected in 187 cases (sensitivity 93.5%). RIPAs originated from the aorta (49%), celiac trunk (41%), right renal artery (5.5%), left gastric artery (4%), and proper hepatic artery (0.5%), with 13 types of combinations with the left IPA. Twenty-nine patients showed subcapsular HCCs in segments VII and VIII and all but one underwent RIPA selective angiography, followed by embolization in 7 cases.ConclusionMDCT assesses well the anatomy of RIPAs, which is fundamental for planning subsequent cannulation and embolization of extrahepatic RIPA supply to HCC.

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.

Experimental models in microsurgery

The development of experimental microsurgery can be considered the natural evolution of a diffuse need to increase precision in many fields of surgery. Microsurgery accelerated the possibility of deepening many unclear aspects of pathophysiology, using miniaturized and reproducible experimental models. We report briefly on the fundamental principles of microsurgery and the most frequently performed and useful models of experimental microsurgery, especially to employ as training models for surgeons, but also as bases for developing new and always‐welcome models.

Usefulness of microsurgery in the training of the general surgeon

It is a common opinion that general surgery is the first step for whoever approaches a surgical discipline, and that whoever practices training in general surgery should learn the rudiments of each surgical branch. The role of microsurgery in the training of the general surgeon has not been well‐established. Clinical applications of microsurgery in general surgery are few and are rarely required, and have been connected strictly to restricted indications. However, we think that microsurgery could be very useful to the general surgeon because it allows the execution of experimental research on rats, the only possibility permitted by law. In these studies the microsurgeon can perform many times and in a short time the same surgical operation, thus improving his skill, and easily getting familiarity with surgical instruments and sutures.

Three microsurgical courses in Catania

The utilization of microsurgical techniques in the surgical disciplines is now accepted worldwide, and many surgeons should receive the opportunity of learning these techniques. To meet this requirement, microsurgical courses have been organized and comprise both theoretical aspects and, especially, practical demonstrations. A one‐week course usually allows attending surgeons to get familiar with magnification and to perform microvascular anastomoses, vasovasostomy, tubal reconstruction, sciatic nerve suture, and end‐to‐side portacaval shunt, a useful exercise before dealing with rodent organ transplantation. It is important to underline that the skill supplied by these microsurgical courses is not enough to start clinical applications of microsurgery; to this end, training must continue long after the course has been finished.

Colorectal Follow-Up Planning Modified on the Basis of Our Personal Experience

Background: The authors, evaluating the disappointing follow-up results in patients suffering from colorectal carcinoma who had undergone surgery for cure, tried a more rational follow-up. Methods: In a retrospective review about 232 patients who adhered to the follow-up protocol, we evaluated the accuracy rates of CEA, liver ultrasonography and abdominal CT. In the same group of patients, we evaluated the type of correlation between the neoplastic recurrence rate and Astler-Coller’s classification. Results: (1) In detecting hepatic metastases CEA levels furnished sensitivity and negative predictive value more than liver ultrasonography (83.3 vs. 77.8% and 98.4 vs. 98%, respectively); (2) in our series, we obtained a lower recurrence rate in classes A+B1 (7.5%) and B2 (20.8%) and higher in C1+C2 (44.4%) and D (66.7%) (p < 0.01). Conclusion: According to these data we decided to eliminate postoperative liver ultrasonography and customize follow-up protocol on tumor staging and timing of cancer relapse. The authors believe that these changes will not modify the results, but cause less psychophysical stress for the patients and reduce costs by 50%.

Identification of novel targets for the diagnosis and treatment of liver fibrosis

Liver fibrosis is characterized by the excessive deposition of extracellular matrix (ECM) in the hepatic parenchyma and represents an intrinsic response to chronic injury, maintaining organ integrity when extensive necrosis or apoptosis occurs. Hepatic stellate cells (HSCs) are the major cell type responsible for liver fibrosis. Following liver injury, HSCs become activated and transdifferentiate into myofibroblasts (MFBs) that lead to intrahepatic ECM accumulation. In the present study, we performed a meta‑analysis of datasets which included whole-genome transcriptional data on HSCs in the quiescent and activated state from two different rodent species and identified commonly regulated genes. Several of the genes identified, including ECM components, metalloproteinases and growth factors, were found to be well‑known markers for HSC activation. However, other significant genes also appeared to play important roles in hepatic fibrosis. The elucidation of the molecular events underlying HSC activation may be key to the identification of potential novel pharmacological targets for the prevention and treatment of liver fibrosis.