From near-zero to zero fluoroscopy catheter ablation procedures.

AIMS: The use of electroanatomical mapping (EAM) systems can reduce radiation exposure (RX) and it can also completely eliminate the use of RX. Radiation exposure related to conventional radiofrequency ablation procedures can have a stochastic and deterministic effect on health. The main aim of this study was to evaluate the safety and feasibility of an entirely nonfluoroscopic approach to catheter ablation (CA) using EAM CARTO3. METHODS: In 2011 we started an RX-minimization programme in all procedures using the CARTO system with the deliberate intention to not resort to the aid of RX unless strictly necessary. We divided procedures into two groups (group 1: from 2011 to 2013; group 2: from 2014 to 2017). The only exclusion criteria were the need for transseptal puncture, and nonidiopathic ventricular tachycardia (VT). RESULTS: From a total of 525 procedures, we performed CA entirely without RX in 78.5% of cases. From 2011 to 2013, we performed CA without RX in 38.5% of cases; from 2014 to 2017, we performed 96.2% of cases with zero RX. The use of RX was significantly reduced in group 2 (group 2: 1.4 ± 19.6 seconds vs group 1: 556.92 ± 520.76 seconds; P < .001). These differences were irrespective of arrhythmia treatment. There were no differences between the two groups in acute success, complications, or duration of procedures. CONCLUSION: CA of supraventricular tachycardia and VT entirely without RX, guided by the CARTO system, is safe, feasible, and effective. After an adequate learning curve, CA can be performed entirely without RX.

Synchronous totally laparoscopic management of colorectal cancer and resectable liver metastases: a single center experience.

PURPOSE: The simultaneous management of primary colorectal cancer and synchronous liver metastases has been reported extensively in open surgery. Data regarding feasibility, safety, and outcomes of the laparoscopic procedure is emerging from the experience of a few surgical centers. This paper aims at discussing the technique and results of a one-step laparoscopic approach for colorectal cancer and liver metastases resection on a series of 35 patients. METHODS: Between January 2008 and December 2013, 18 males and 17 females (median age 71 years) underwent colorectal and hepatic laparoscopic resection for colorectal metastatic cancer. RESULTS: Thirty-five colorectal resections and 66 liver resections were performed; no conversion to open surgery has been indicated. Median blood loss was 200 ml, median operative time 240 min, and median hospital stay was 8 days (range 4-30). According to Clavien-Dindo classification, two class II complications, two class IIIb complications, and one class IV complication were recorded. Two high-risk patients died within 30 days from surgery. CONCLUSIONS: This series confirms the feasibility of synchronous laparoscopic colorectal and hepatic resections. To ensure the best outcomes, a careful selection of patients is needed. However, most patients can benefit from this surgical approach.

Asbestos between science and myth. A 6,000-year story.

Asbestos was used in making pottery in Eastern Finland from around 4000 B.C. In the ancient era and in the Middle Ages, magic properties were frequently attributed to this mineral. In the first century A.D., the Latin encyclopaedist Pliny the Elder reported in his Historia Naturalis that asbestos protects against all poisonings, particularly that of magicians. Moreover, asbestos was often found in places of worship, in Rome as well as in Athens and in Jerusalem. In the Middle Ages asbestos was identified with some animals, such as the salamander and certain white rodents. With such appearance, the mineral  had a huge success in Western as well as in Eastern literature and the fine arts. Marco Polo (1254-1324) in the Milione tried to deny that asbestos was a salamander. Despite its noxious effects, asbestos continues to be used in much of the world. In the 21st century it seems to be maintaining its quality as a magic stone.

Pleural mesothelioma: epidemiological and public health issues. Report from the Second Italian Consensus Conference on Pleural Mesothelioma.

Malignant mesothelioma is closely connected to asbestos exposure, with epidemiological patterns closely reshaping the geography and history of asbestos exposure. Mechanisms of causation and of interaction of asbestos fibres with pleura are complex and currently not yet completely understood. Curative efforts so far provided little results. Italy shows one of the highest incidence of MM and developed a network of specialized cancer registries in order to monitor disease occurrence and describe its epidemiology in details. The second Italian Consensus Conference on Pleural Mesothelioma convened in Torino on November 24th-25th, 2011. Besides the main consensus report summarizing the contribution of the different expertises, that was published elsewhere, the participants in 'Public Health and Epidemiology' section decided to report in major details the evidence and the conclusions regarding epidemiology, causative mechanisms and the public health impact of the disease.

Malignant mesothelioma of the pleura in nonagenarian patients.

AIMS AND BACKGROUND: Malignant mesothelioma developing at very old ages is a rare event. The reasons for such late development were investigated. METHODS: A series of 811 malignant mesothelioma of the pleura, diagnosed at the Trieste and Monfalcone Hospitals, in northeastern Italy, in the period 1968-2008 were reviewed. Eight cases regarding patients aged 90 years or more were selected. In such cases, occupational histories were re-examined, and additional data could be obtained from the patients' relatives. Routine lung sections obtained at necropsy were examined for asbestos bodies. In 2 cases, asbestos bodies had been isolated after chemical digestion of lung tissue. RESULTS: The group included 7 men and one woman, aged between 90 and 93 years. All 8 patients had long-term histories of occupational exposure to asbestos, mostly in shipyards. Latency periods, elapsed between first exposure to asbestos and tumor manifestation, ranged between 64 and 75 years. Asbestos bodies were found on routine lung sections in 6 cases. Isolation of lung asbestos bodies showed 72,000 bodies per gram of dried tissue in a 90-year-old man, who had worked in the shipyards for 34 years, and 150 bodies per gram in a 93-year-old woman, who had worked in the shipyards for 23 years. CONCLUSIONS: In this group of cases, the late development of mesothelioma can not be attributed to mild exposure to asbestos or to unusually late exposures. Very long latency periods even in people heavily exposed suggest an individual resistance to the oncogenic effects of asbestos.

Non-Hodgkin Lymphoma and Pleural Mesothelioma in a Person Exposed to Asbestos.

Non-Hodgkin lymphoma and pleural mesothelioma may co-exist in the same patient. A large cell non-Hodgkin lymphoma of the inguinal lymph nodes was diagnosed in a 73-year-old woman. The patient was treated by chemotherapy. She did not receive radiotherapy. The patient had been exposed to asbestos having worked in a cotton mill and in a distillery. Four years after the diagnosis of lymphoma, she presented with a left pleural effusion. Large biopsies of the pleura showed a malignant mesothelioma, biphasic type, and pleural plaques. Epidemiological studies about the asbestos-lymphoma relationship gave conflicting results. The lymphoma-mesothelioma association is not exceptional, and suggests that asbestos plays a role in the etiology of both malignancies.

Malignant mesothelioma of the pleura and other malignancies in the same patient.

AIMS AND BACKGROUND: The co-existence of mesothelioma, mostly asbestos-related, and other primary malignancies has repeatedly been reported. The present study evaluated the frequency of such an occurrence. METHODS: In the period October 1979-June 2002, 215 cases of malignant pleural mesothelioma were diagnosed at the Hospital of Monfalcone, Italy. All the cases of the above series, examined at necropsy (169), were included in the study. Occupational histories had been obtained from the patients or from their relatives by personal or telephone interviews. In 132 cases, asbestos bodies were isolated after chemical digestion of lung samples. The thoracic cavities were examined for pleural plaques. RESULTS: Additional malignancies were observed in 32 cases (18.9%). Multiple tumors were synchronous in 22 cases, metachronous in 8 cases, and synchronous and metachronous in 2. Four different tumors were found in 2 cases, 3 malignancies were detected in 6 patients, and 2 malignancies in the remaining 24. The most frequent additional malignancies were prostate adenocarcinoma (7 cases), non-Hodgkin lymphoma or chronic lymphocytic leukaemia (5 cases), bladder carcinoma (4 cases), kidney carcinoma (4 cases), large bowel carcinoma (4 cases), and liver cell carcinoma (4 cases). All the patients had histories of exposure to asbestos, mostly in shipbuilding. Lung asbestos body burdens ranged between 60 and 230,000 per gram of dried tissue. Pleural plaques were found in 26 cases. CONCLUSIONS: In contrast with other series of the literature, in the present cases the co-existence of mesothelioma and other malignancies appeared as a relatively frequent event. The lack of a control group does not allow definite conclusions about the meaning of the occurrence. However, the co-existence of certain tumors with asbestos-related mesothelioma suggests that mesothelioma and associated malignancies might share some etiologic factors (asbestos and others).

Malignant mesothelioma: global incidence and relationship with asbestos.

Mesothelioma incidence varies markedly from one country to another. The highest annual crude incidence rates (about 30 cases per million) are observed in Australia, Belgium, and Great Britain. A lot of data indicate a relationship between mesothelioma and asbestos. The hot areas for mesothelioma exactly correspond to the sites of industries with high asbestos use, such as shipbuilding and asbestos-cement industry. However, in many countries with high asbestos consumption, mesothelioma incidence is low. The reasons for this fact are not clear. The latency periods elapsing between first exposure to asbestos and development of mesothelioma are mostly longer than 40 yr. An inverse relationship exists between intensity of asbestos exposure and length of the latency period. Mesothelioma generally develops after long-time exposures to asbestos. Some recent studies show that the risk increases with the duration of exposure. Possible co-factors in the pathogenesis of asbestos-related mesothelioma include genetic predisposition, diets poor in fruit and vegetables, viruses, immune impairment, recurrent serosal inflammation. The study of co-morbidity in mesothelioma could give an insight into the pathogenesis of the tumor. While a levelling-off in mesothelioma incidence has been registered in some countries, a worsening of the epidemic is predictable in large parts of the world.

A rare case of Bouveret's syndrome presenting with upper gastrointestinal bleeding.

We report a case of duodenal obstruction caused by a large gallstone wedged in the duodenal bulb (Bouveret's syndrome), presenting with acute upper gastrointestinal bleeding and successfully treated by surgery following a failed attempt at endoscopic retrieval of the stone. Haemorrhage is a very rare form of presentation. After an extensive review of the literature, the therapeutic options and surgical strategies (one-stage and two-stage procedure) are critically discussed.

Celiac axis compression syndrome: laparoscopic approach in a strange case of chronic abdominal pain in 71 years old man.

Celiac Axis Compression Syndrome by the Median Arcuate Ligament is a very rare condition characterized by chronic postprandial abdominal pain (angina abdominis), nausea, vomiting, which occurs mostly in young patients. The main treatment is a surgical procedure that consists of the division of the arcuate ligament combined with the section of the close diaphragmatic crus and the excision of the celiac plexus. Actually laparoscopic management is feasible and safe.

Laparoscopic perspectives for distal biliary obstruction.

BACKGROUND: In patients affected by distal biliary obstruction deemed unsuitable for pancreatoduodenectomy, biliary diversion is the only proposable option. Defined goals of this treatment are: relief from jaundice preventing its related complications, reduction of in-hospital stay and adequate control of pain. Palliation can be obtained either by surgical or conservative procedures (endoscopic stenting or percutaneous treatment). Considering early complications' incidence, surgical approach has always been reserved for low surgical risk patients with longer survival perspectives, while recently developed long-lasting patency stents enlarged mini-invasive application resort. Comparative studies on these therapeutic options favour the conservative one in respect of conventional open surgery, but data on minimally invasive surgery to pursue palliative aims are lacking. We present our six-years casuistic and results referring to laparoscopic biliary diversions. METHODS: We analyzed results obtained in distal biliary neoplastic obstruction management between December 2008 and November 2014. During this period, selected patients considered unsuitable for pancreatoduodenectomy were scheduled to receive a laparoscopic biliary decompression. Perioperative variables and 30-days postoperative outcomes have been prospectively collected. RESULTS: In the six-years period, 12 patients affected by distal biliary neoplastic obstruction were submitted to laparoscopic palliative bypass. Four procedures were proposed for distal biliary cancer, one for advanced periampullary cancer and seven for pancreatic head cancer. Ten hepatico-jejunal bypasses and two choledochoduodenostomies have been performed. No conversions to open surgery were encountered in this series. Main operative time was 85 min, main blood loss was 75 ml and main hospitalization was 4.5 days. According to Clavien Dindo Classification one class II and one class IIIb complications occurred. CONCLUSIONS: Although the restricted number of patients, our results suggest that laparoscopic biliary bypass could be a valid option in managing distal biliary obstructions, resulting in low perioperative morbidity, effective long term palliation of symptoms and improved quality of life.

Assessment of tumor-associated trypsin inhibitor (TATI) as a marker of renal function.

BACKGROUND: Low molecular weight (LMW) proteins have been proposed for renal function assessment. This study aimed to ascertain the usefulness of tumor-associated trypsin inhibitor (TATI), a LMW protein (6.200 d), as a glomerular filtration rate (GFR) marker. The results were compared with those of beta2-microglobulin and of creatinine (Cr). METHODS: Renal handling of TATI labelled with 125I was first studied in rats. Then, in 198 patients, serum TATI levels and GFR (99mTc-DTPA clearance, bladder cumulative method) were determined. To evaluate urine excretion, the fractional TATI clearance was determined in 63 patients. RESULTS: In rats, total body scan showed a large amount of radioactivity in the kidneys, but not in other organs. The duration of radioactivity demonstrated a peak-time of 11 min. In human beings, the relationship between TATI and GFR was similar to that of beta2-microglobulin and Cr. The increase in TATI with declining renal function was statistically significant, vs. patients with GFR > 100 mL/min, already in the group with GFR 80-100 mL/min (p < 0.05, Bonferroni-Dunn test). The beta2-microglobulin increase was significant in the group with GFR 60-80 mL/min and of Cr in the group with GFR 40-60 mL/min. In patients with renal failure (GFR < 20 mL/min) TATI increased, vs. patients with GFR > 100 mL/min, 13x, beta2-microglobulin 8x and Cr 5x. Urinary excretion of TATI, expressed as fractional clearance, was very low increasing when GFR fell < 40 mL/min. CONCLUSIONS: The kidney plays an important role in the handling of TATI. When GFR fell, the increase in blood levels of TATI was sooner and higher than that of beta2-microglobulin and CR. Consequently, TATI can be added to the group of renal function markers.

Retrospective clinical study of Osseotite implants: zero- to 5-year results.

PURPOSE: Over the last few years, particular attention has been paid to the implant surface and its influence on the formation and maintenance of surrounding bone. The surface of Osseotite implants (Implant Innovations) is produced by a process of thermal etching, which produces a surface with an average roughness that is twice that of machined implants produced by the same manufacturer. In addition to reducing osseointegration time, this factor appears to favor its maintenance over time. This study presents the results of a clinical trial of Osseotite implants. MATERIALS AND METHODS: Five hundred fifty-five Osseotite implants were placed in 244 patients over 5 years, between September 1996 and September 2001. The average follow-up period from implant placement was 26 months (SD 13.1). RESULTS: After the first surgical stage, 8 failures were noted in 6 patients. Life table analysis showed a cumulative survival rate of 98.5%, but no implant was lost after prosthetic loading, with a 100% survival rate both for the mandible and for the maxilla. For the prosthetic loading time, only the implants with more than 12 months of loading were considered, obtaining an average prosthetic loading time of 34 months (SD 9.2). DISCUS SION: The implant survival rate after loading was 100% both in the anterior and posterior regions, and no difference was noted in relation to the different types of prostheses, or length and width of implants. CONCLUSION: The results obtained in this retrospective study population revealed an acceptable survival rate for these implant-supported restorations.

Concurrent malignant mesothelioma of the pleura and hepatocellular carcinoma in the same patient: a report of five cases.

Five cases are reported in which malignant mesothelioma of the pleura and hepatocellular carcinoma co-existed in the same patient. The group included four men and one woman, aged between 58 and 86 years. The diagnosis was established at necropsy. In one case the association was clinically suspected. All mesotheliomas were asbestos-related. Liver cirrhosis co-existed in four cases, two of them positive for HCV markers. A lot of elements suggest that the above association is not a fortuitous coincidence. In particular, asbestos could favour liver cancerogenesis by inducing immune impairment.

Familial mesothelioma of the pleura--a report of 40 cases.

A survey of 610 pleural mesotheliomas disclosed 40 familial cases. The diagnosis was histologically based in 39 cases, and confirmed by necropsy in 30. Occupational data were collected from the patients or from their relatives by personal interviews. Routine lung sections were examined for asbestos bodies in 32 cases. In 15 cases asbestos bodies were isolated after chemical digestion of lung tissue. Familial mesotheliomas included 31 men and 9 women (age range 44-93 yr, mean 70.7, median 71.0). In 15 families there were blood relations between (or among) the members involved. All the patients had been exposed to asbestos, mostly in the shipyards. Asbestos bodies were found on routine lung sections in 27 cases. Asbestos bodies after isolation ranged from 70 bodies to about 900,000/g dried lung tissue. Latency periods (time intervals between first exposure to asbestos and diagnosis) ranged between 25 and 70 yr (mean 52.0, median 54.0). The occurrence of mesothelioma among subjects with blood relations suggests that genetic factors might play a role in determining the susceptibility to asbestos-related cancer. Familial cases among persons without blood relations raise the question if environmental factors that members of a family share, may act as co-factors in asbestos-related mesothelioma.

Global mesothelioma epidemic: Trend and features.

BACKGROUND: Mesothelioma incidence has taken epidemic proportions in various countries. The trend of the epidemic remains undefined. OBJECTIVE: To collect the most recent available data on mesothelioma incidence in order to determine the present trend of the epidemic. MATERIALS AND METHODS: Data of the Cancer and Mesothelioma Registries have been reviewed. In addition, numerous researchers were contacted to obtain supplementary information. RESULTS: The highest incidence rates are reported from some countries in Europe (United Kingdom, The Netherlands, Malta, Belgium), and in Oceania (Australia, New Zealand). Relatively low incidence/mortality rates are reported from Japan and from Central Europe. In many countries a trend to increase continues to be observed. Data are not available for the mostly populous countries. CONCLUSION: Mesothelioma epidemic does not show signs of attenuation. The lack of data for a large majority of the world does not allow that the consciousness of the risks related to asbestos exposure is reached.

Pleural mesothelioma in a couple of brothers.

Malignant mesotheliomas of the pleura, epithelial type, were observed in two brothers. Both the patients had histories of severe exposure to asbestos, having worked as insulators. The latency periods in the two cases were 26 and 38 years, respectively. Available literature data suggest that mesothelioma occurrence among blood-related people is favored by a genetic predisposition.