Teresa Rosanna Portale

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.

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.

Gastrointestinal carcinoid tumor and chylous ascites, a rare association with a poor prognosis. A case report

Gastrointestinal carcinoid is a rare tumor. The association of this tumor with chylous ascites is uncommon. A review of the English-language literature carried out in 2002 identified only 15 cases. We report a case of chylous ascites, gastrointestinal carcinoid tumor and elevated blood levels of CA-125 in a patient who did not respond to chemotherapy.

Evaluation of fibrosis in cirrhotic elderly patients with HCC

BackgroundHepatocellular carcinoma (HCC) is usually associatedwith liver cirrhosis and is the principal cause of deathamong patients with cirrhosis [1]. Apart from livertransplantation that may cure both conditions, treat-ment of HCC and cirrhosis is complex because of theneed to be oncologically radical but simultaneously con-servative. Hepatectomy is considered an invasiveapproach and has a marginal role in the treatment ofHCC [2,3]. The value of hepatic fibrosis is considered apredictive factor of outcome in patients with HCCundergoing liver resection [4].Materials and methodsA retrospective analysis of 77 cirrhotic patients, 42 ofthem with hepatocellular carcinoma, observed from2008 to 2010 was performed. The mean age was 65.2years old with 46 men and 31 women. As regards cir-rhosis etiology, 51 patients presented cirrhosis HCV-related, 9 HBV-related, 3 alcohol-related, 2 HBV-HDVco-infections and 12 other etiology. Liver function wasassessed according to the Child-Pugh classification: 60patients were in Child A, 13 in Child B and 4 in ChildC. In all patients liver stiffness measurement (LSM) wasperformed using transient elastography (Fibroscan

Our experience in surgery for colorectal cancer in elderly patients

Background The effectiveness of surgery for colorectal cancer depends on it being carried out safely, which allows most patients to return to productive lives. Since colorectal cancer is a major cause of morbidity and mortality in elderly people [1], this study was designed to evaluate the outcomes of surgery in elderly patients. Materials and methods In the period 1973-2003, in our institution, we surgically managed 931 patients for colorectal cancer; 48 patients, 28 males and 20 females, aged 80 years and over (mean age 83.7 years). The tumor was located in the left colon in 20 cases (41.6%), in the rectum in 11 (22.9%) and in the right colon in 17 patients (35.4%). 33 patients (68.7%) were treated with colonic resection and primary anastomosis, 8 (16.6%) with Hartmann resection, 5 (10.4%) with colostomy, 1 (2%) with abdominal perineal resection and 1 (2%) with anastomosis between ileum and transverse colon without resection. The stage was A in 7 patients, B in 22, C in12 and D in 7. Results The operative mortality rate was 0. The infection of the surgical wound occurred in 10 patients, whereas 4 cases of bronchopneumonia took place (8.3%). We had also registered 1 anastomotic leak in a male patient with left colon cancer (2.08%). The median hospital stay was 13.1 days (range 9-22 days) and the 5 year survival was 56.2% (27/48). No patients had adjuvant therapy Conclusions

MYOEPITHELIAL HAMARTOMA OF THE STOMACH SIMULATING A GASTRIC CARCINOMA. A CASE REPORT

Myoepithelial hamartoma is a very rare submucosal tumor of the stomach. Magnus-Alsleben first described 5 cases of this tumor in 1903. More recently (1993) Vandelli et al. published a review of the literature comprising only 33 cases. Histologically, the tumor is characterized by hypertrophic smooth muscle bands surrounding diverse epithelial elements that can be arranged in different ways: as a simple glandular structure, Brunners gland, pancreatic ducts and occasionally pancreatic acinus. We report a case of myoepithelial hamartoma of the stomach simulating a gastric carcinoma.

Delayed presentation of a metastatic choroidal melanoma to the liver: The latency of an elective metastatic localization

Highlights • Biologically, cutaneous and ocular melanoma may be considered different, in terms of both metastatic diffusion and metastatic latency.• The principal target organ for metastasis of the ocular melanoma is the liver.• This distinctive behaviour is also sustained by a different metastatic latency to the liver.• In ocular melanoma synchronous disease accounts for less than 1% of the cases, the majority of patients will develop liver metastasis during the subsequent follow-up period and some of these will present with metastatic ocular melanoma to the liver several years after the treatment of the primary tumor.

Laparoscopic surgery in elderly patients with sliding hiatal hernia

Background Surgery is recommended as treatment for the sliding hiatal hernia (SHH) in order to create a barrier to reflux of gastric contents into the esophagus and into the upper airways where could cause aspiration pneumonia. The aim of this study was to evaluate the results of laparoscopic surgery in elderly patients over 65 years, with SHH with typical and atypical respiratory symptoms, who have been followed up for 5 years.

The influence of age in decision-making of patients with HCC

BackgroundHepatocellular carcinoma (HCC) is usually associated withliver cirrhosis and is the principal cause of death amongpatients with cirrhosis [1]. Apart from liver transplantationthat may cure both conditions, treatment of HCC and cir-rhosis is complex because of the need to be oncologicallyradical but simultaneously conservative. Hepatectomy isconsidered an invasive approach and has a marginal rolein the treatment of HCC [2,3]. A retrospective analysis of62 patients affected by HCC observed from 2000 to 2008was performed. The treatment choice was compared withthe treatment schedule proposed by BCLC. Among thesepatients, 27 (43.5%) were over 70 years old; of these 16were men and 11 women. Regarding Child classification18 patients (66.6%) were CHILD A, 8 (29.6 %) CHILD Band 1 (3.8%) CHILD C. We evaluated the influence of agein our clinical behaviour, exploiting the BCLC guidelines.In 9 (33.3 %) cases patients were treated according toBCLC algorithm but mainly with percutaneous ablationtherapies, while in the remaining18 (66.7%) cases therewas an undertreatment in 15 (83.3 %) patients and anovertreatment in 3 (16.7 %). About the undertreatmentcases we didn’t perform hepatic resection or liver trans-plantation such as BCLC suggests mainly because ofadvanced age (> 70 years old). With regard to the over-treatment we performed 3 transarterial embolizationsrather than sorafenib or symptomatic therapy because thegeneral conditions of patients were fairly good.ConclusionsBCLC algorithm is considered the most important sta-ging system for patients with HCC. This classificationuses variables related to tumour stage, liver functionalstatus, physical status but not the age of patients. Thisconcept is very important because decision-making ofhepatic surgeons often depends on age of patient.Although there are many papers in scientific literaturethat confirm the safety of surgery in elderly patients, itis also true that the risk of local and general complica-tionsisveryhigh.Thepresenceofcomorbidityandrefusal of patients to undergo surgery or liver transplan-tation are often the main reason for our clinical beha-viour. In the management of these patients we have toconsider the age and risk-benefit ratio.

Management of colorectal cancer follow-up in elderly patients

Background Follow-up of surgically treated colorectal cancer patients is not supported by objectively certain data. Despite the thousands of investigations reported in the literature, only six randomized prospective studies and two meta-analysis of randomized studies provide data suggesting clear conclusions until today. The main goal of colorectal follow-up is to improve patient survival by early diagnosis of recurrence during the asymptomatic stage when radical surgical treatment is more viable [1]. However the reduction of global mortality from colorectal cancer achieved by follow-up, radical second-surgery and therefore new and definite patient recovery calculated in our patients in follow-up on 5 years disease free interval was only 2.6 % according to the findings of other authors [2,3]. In our recent study carried out on a group of 280 patients in our follow-up the average age was 69.5 demonstrating that the age must be carefully considered in order to establish the follow-up timing and modality and to calculate the cost-benefit ratio. In our experience the far from brilliant results obtained led us to change our follow-up in 2006 and make it less intensive, tailoring it to the stage of the disease, the reliability of the diagnostic methods, times of recurrences and no less important, the age of patients. In the aged obviously the surgical and/or adjuvant and neoadjuvant treatments are to be considered with caution and local and general controindications to every type of therapy carefully evaluated. The age is a fundamental part of ASA, POSSUM and PST and could condition the therapeutical strategies. On the other hand many reports confirm the possibility of performing safe operation for liver and lung metastases or local recurrences in the elderly without a statistical higher rate of morbidity and mortality compounding with younger adults. Lastly, in our policy we have considered the agreement of elderly patients to modality and timing of follow-up on the basis of a study carried out with the collaboration of a psychological team. On the basis of those experiences we also believe that in some patients and circumstances a major involvement of family doctors substituting the institutional follow-up staff is necessary.