Percutaneous radiofrequency ablation versus surgical radiofrequency-assisted nodulectomy in treatment of small single nodes of hepatocellular carcinoma: our experience.

AIM: Surgical resection usually represents the treatment of choice for solitary hepatocellular carcinoma (HCC) in cirrhotic patients, with well preserved liver function; local ablative strategies are the best treatment option for patients with small tumors who are not candidates for surgical resection or liver transplantation. Several studies showed that percutaneous radiofrequency ablation (RFA) has similar efficacy to surgical nodulectomy in the treatment of early-stage HCC, and is associated with lower complication rates and costs than resection. The aim of this study was to compare the effectiveness of these treatments, in terms of morbidity, overall survival, tumor recurrence and causes of death. METHODS: Between January 2006 and January 2012 we observed 176 patients affected by HCC, 84 underwent curative treatment. The 40 patients presenting single HCC nodes smaller than 3 cm in diameter have been treated with radiofrequency-assisted surgical nodulectomy (N.=20) or with percutaneous radiofrequency (N.=20). RESULTS: No perioperative mortality occurred in the two groups. Perioperative morbidity was 5% in group A (1 case of peritoneal bleeding) and 5% in group B (1 case of hepatic abscess). Disease-free survival was slightly higher in surgically treated patients, but not statistically significative differences have been demonstrated (P<0.06); no local recurrences were observed in surgically treated patients. CONCLUSION: RF and surgical nodulectomy can be either used in treatment of early stage hepatocellular carcinoma; no differences in terms of morbidity, overall and disease free survival were observed; nodulectomy seems to prevent from tumor local recurrence.

Ultrastructural analysis of different-made staplers' staples.

AIM: Recently, Chinese-made mechanical staplers with lower price respect to American-made ones have been introduced in clinical practice. In literature, small case series compare the clinical outcomes of different staplers concluding that the new stapler devices perform as well as the American ones. The aim of this study is to compare with an ultrastructural analysis the staples of different staplers in order to verify the existence of differences that might explain significant price disparity and condition clinical outcomes. METHODS: Each stapler was subjected to morphological analysis, energy dispersive X-Ray spectroscopy, metal release assessment followed by inductively coupled plasma mass spectroscopy. P-values were considered statistically significant when <0.05. RESULTS: Autosuture staples have square section whereas the other American one and Chinese made staples have round sections. Roughness index and chips presence before and after ageing tests were comparable for all samples except for Ethicon Endo-Surgery stapler. Energy dispersive X-Ray spectroscopy showed that all staplers are made of pure Titanium but Ethicon Endo-Surgery staples are made with an alloy. Metal release analysis release statistically significant differences between samples in simulated body fluid 20 days solution (P=0.002) and in Aquaregia at 14 days solution. Discussion. Stapling devices have became routinely used in gastrointestinal surgery mainly because of operative time reduction. Recently, new Chinese-made mechanical staplers, with significantly lower prices, have been introduced in clinical practice. In literature, there are some studies that compare clinical outcomes of American-made and Chinese-made staplers on small groups of patients but doesn't exist any work which consider structural differences between traditional and new devices. In our study, for the first time, we propose a comparison between two American-made staplers and three Chinese-made staplers which evaluate morphology, metal composition and chemical staples release. CONCLUSION: Our study suggest that there are some ultrastructural differences between commercially available staplers with no correlation to price disparity. More studies are needed to confirm our results and to verify if our findings could condition clinical outcomes.

p27Kip1 is inactivated in human colorectal cancer by cytoplasmic localization associated with activation of Akt/PKB.

p27Kip1 is a nuclear member of the Kip/Cip family of cyclin-dependent kinase inhibitors and is a negative cell cycle regulator that is thought to play a role in tumour suppression. Reduced levels of p27Kip1 are frequent in human cancers and these have been associated with poor prognosis. We have analysed p27Kip1 expression and intracellular localization in 70 human colorectal cancers by western blotting and immunohistochemistry and the results related to Akt expression and clinical pathological parameters. p27Kip1 protein expression, as evaluated by western blotting, was absent or reduced in about 63% of colorectal cancers compared with both peritumoral and normal tissue. Cytoplasmic p27Kip1 was detected, by immunohistochemical analysis, in 30% (21 of 70) of cases indicating that translocation of p27Kip1 protein into the cytoplasm may be responsible for p27Kip1 inactivation. The analysis of phosphorylated Akt by western blotting indicated that it was expressed in 38% (8 of 21) of tumours showing cytoplasmic p27Kip1. Patients whose cancer presented accumulation of cytoplasmic p27Kip1 showed poorer outcomes for cancer-related relapse and survival. These results suggest that cytoplasmic p27Kip1 localization, associated or not with Akt activation, may contribute to colorectal tumorigenesis and metastasis and it may be useful as a negative prognostic factor for the outcome of patients with colorectal cancer.

[Open radiofrequency liver resection: technical details]. / Resezione epatica laparotomica con la radiofrequenza: dettagli tecnici.

AIM: Radiofrequency (RF) for the treatment of hepatic neoplasms can be performed through percutaneous, laparoscopic or open surgery. The aim of this study was to point out the details of the role of open RF (ORF). METHODS: Between November 2002 and November 2003, we performed 13 ORFs. Seven patients had an association with chronic liver cirrhosis. With the aid of intraoperative single, internally cooled needle RF, 12 liver resections were performed (7 subsegmentectomies, 3 segmentectomies, 1 left lateral lobectomy, and 1 right lobectomy). In 1 case RF was applied directly to the tumor lesion. In all cases ultrasonography (US) was performed intraoperatively, other lesions were found in 7.7% of the cases. RF energy was applied along the margins of the tumor to create <> before resection with a scalpel. RESULTS: Average operating time for ORF alone was 74.4 minutes (range 30-115 minutes). Mean intraoperative blood loss during the procedure was 104 mL (range 25-250 mL), and blood transfusions were required in 3 patients. Mean hospital stay was 7.9 days (range 6-10 days). Only minor complications were found, and no mortality was observed. No liver recurrence was detected during mean follow-up of 6 months. CONCLUSIONS: This technique is suitable for patients who are at risk of bleeding because it offers a new method for transfusion-free resection, reducing postoperative complications and shorter long-term survival. Adequate follow-up is necessary to judge its true efficacy, in terms of recurrence and survival.

[Prototype of a system for electric conduction at contact with laparoscopic tools]. / Prototipo di sistema di conduzione elettrica per contatto a strumenti ad uso laparoscopico.

The authors present their prototype of a system for electric conduction at contact with laparoscopic tools, devised, designed and produced by them at the Politecnico di Torino, Department of Mechanical Engineering. The system consists of a two sided plate, one side is a non conducting adhesive surface to stick to the surgical glove and the other side is a subtle flexible shell of a conductor. The Authors used the instrument with surgical tools with a metallic handle, during three cholecystectomies. Nowadays all standard laparoscopic tools have the chance and the need to be electrified. Now the way commonly used to electrify a laparoscopic tool is using a wire plugged to a fixed conducting point of the instrument. This prototype has been devised and produced to avoid some discomforts met during the numerous manoeuvres of connecting and disconnecting the wire at the time of a surgical intervention. This device permits the direct transfer (by contact) of electric energy from the wire to surgical tools. The advantage is to be more rapid in changing surgical tools obtaining, immediately an electrified instrument in your hand.

Oxidative damage and transforming growth factor beta 1 expression in pretumoral and tumoral lesions of human intestine.

The aim of this study was to evaluate a possible relationship between oxidative stress and transforming growth factor beta 1 (TGF beta 1) expression in human colon adenocarcinoma. Crohn's disease, an inflammatory pathology of the intestine often regarded to as precancerous, was also examined. Indices of impaired redox balance were monitored in blood and in bioptic samples from 10 adult patients with adenocarcinoma of the colon and from five patients with Crohn's disease. On tissue samples TGF beta 1 mRNA expression was also determined. Ten healthy adults provided normal reference values for plasma indices of oxidative stress, and normal tissue distant from the lesions was used for comparative analysis. Fluorescent adducts with plasma proteins of malonaldehyde (MDA) and 4-hydroxynonenal (HNE) were significantly lower than controls in the plasma from cancer patients and significantly higher in the plasma from Crohn's patients. In adenocarcinoma biopsies, susceptibility to lipid peroxidation processes and TGF beta 1 expression were below the relative control; in Crohn's disease, lipid peroxidation and cytokine expression were both above the relative control. The findings obtained suggest the existence of an association between oxidative damage and fibrogenic cytokine expression in the human intestine. Further studies are needed to conclusively prove the correlation between the two events.

Embryologic bases of extended radical resection in pancreatic cancer.

OBJECTIVE: To analyze whether an embryologic "rationale" exists to the clinical and anatomicopathological data that suggest the execution of extended resections in patients with pancreatic cancer. METHODS: Reconstruction of serial histological sections of 18 human embryos and fetuses regarding the pancreatic region; anatomical microdissections of two 9-month fetuses. RESULTS: The ventral and dorsal pancreatic buds can be identified until the eighth week of development. A close developmental relationship between the dorsal pancreas and the lymphatic and nervous structures in the dorsal mesogastrium is observed. Other lymphatic stations are exclusively related to the ventral pancreas. The posterior fusion of the dorsal mesogastrium is a late event in embryologic development. CONCLUSIONS: The complete fusion of the 2 pancreatic buds occurs later than previously reported in the literature. The close embryologic relations of these buds with the lymphatic and nervous peripancreatic structures may support the need for extended resections in patients with pancreatic cancer.

Extended lymph node dissection for gastric cancer: results of a prospective, multi-centre analysis of morbidity and mortality in 118 consecutive cases.

This study reports interim data on post-operative morbidity, hospital mortality and duration of hospital stay of Italian patients undergoing extended lymph-node dissection combined with a pancreas-preserving technique for gastric cancer. Of the 218 patients admitted to one of eight general and/or university hospitals in North Italy, 118 were enrolled in the trial. Eligible patients presented with proven primary adenocarcinoma of the stomach without clinical evidence of distant, peritoneal and/or liver metastasis, or metastasis in para-aortic and retropancreatic nodes at intraoperative biopsy. Patients underwent the extended procedure as described by the Japanese Research Society for the Study of Gastric Cancer, following the Maruyama pancreas-preserving technique. A strict quality control system was used to ensure the performance of a standard surgical treatment. A surgeon of the reference centre (M.D.), who stayed at the National Cancer Center Hospital in Tokyo to learn the D2 technique from a specialist Japanese surgeon, became the trial supervisor and assisted each surgeon in all the Italian participating centres. The patients were staged according both to the TNM system and to the General Rules for the Gastric Cancer Study in Surgery and Pathology. Post-operative surgical complications developed in 21 patients (17.8%). The non-surgical complication rate was 2.5%. Reoperation was necessary in six patients (5%), all of whom survived. The 30-day mortality rate for the eligible group was 2.5%. The overall hospital mortality was the same. Total gastrectomy was associated with a slightly higher operative mortality (4.5% vs 1.3%). Only one patient died from an anastomotic leak. The rate of leakages was higher after total than after distal gastrectomy (15.9 vs 5.4%); the association of splenectomy and pancreatectomy worsened the morbidity rate. D2 lymphadenectomy with pancreas-preserving technique, when performed at experienced centres, seems a feasible and safe technique for the radical treatment of gastric cancer in selected Western patients.

Questions about the uncertain presence of muscle spindles in the human external anal sphincter.

The verification of the uncertain presence of muscle spindles in the external anal sphincter is important in the comprehension of the pathophysiology of continence. The authors failed to demonstrate these proprioceptive structures in 10 human sphincters examined with different histological techniques, whereas they found some typical muscle spindles in the puborectalis muscles. The possible interpretations of the different results on the subject in the literature together with their functional implications are discussed.

Ileo-colon-rectoplasty. An experimental morpho-functional study on the pig.

A small bowel loop was interposed, isoperistaltically or pouch-shaped between colon and rectum, (ileo-colon-rectoplasty) in 8 pigs to clarify whether the small intestine can push the semi-solid and septic content of the colon, and whether the function and morphology of the loop are modified with respect to the original. A radiographic and histologic study was performed 6 months after the operation. The structural modifications of the interposed small bowel consist of disappearance of folds, villous atrophy, superficial appearance of the glandular crypts, and, only in the isoperistaltic loop, hypertrophy of the muscular layers. Any modification in the morphologic aspect of the pouch has not been observed, as shown by the radiographic barium enema. Therefore the mucosa of the grafted ileum suffered an architectural change caused from the contact with the fecal material. The lack of structural modifications of the muscular layers and the dimensions of the above colon of the interposed ileal pouch represents an indirect proof of the correct function of reservoir ejection. The experimental results obtained confirm the applicability of this technique in the reconstruction of transit after wide resection of the left colon and rectum, for technical reasons, in man.

[The surgical approach to adrenal incidentaloma]. / L'approccio chirurgico all'incidentaloma surrenalico.

In this paper the Authors analyse the indications for treatment of adrenal incidentaloma by making a retrospective review of this series. These indications are compared with recent trends which have emerged in the literature.

Solitary pericardial hydatid cyst.

Hydatid cyst of the heart is an uncommon presentation of human echinococcosis which may lead to life-threatening conditions. Diagnosis should be suspected in every case of cyst-like mass in persons coming from areas where echinococcus granulosus is endemic. Echocardiography, computed tomography and magnetic resonance imaging can help in the differential diagnosis of the lesion. Even if some reports of successful therapy with benzimidazoles have been described, the treatment of choice is the surgical excision of the cyst. Pericardiectomy with cyst removal is feasible with low morbidity and mortality rates even in elder patients. The authors describe the successful surgical management of a single giant pericardial hydatid cyst in a 78-year-old woman from North Africa.

Problems after hysterectomy. A comparative content analysis of 60 interviews with cancer and non-cancer hysterectomized women.

Sixty patients who had undergone hysterectomy for neoplastic pathologies (30 cases) and benign pathologies (30 cases) were interviewed with the aim of understanding the relationship they had with the disease, the loss of the uterus and sexuality. Out of the cancer group 21 cases showed fear of recurrence of the disease, 19 cases showed sexual dysfunctions, while only 9 patients referred to having experienced the loss of the uterus as a traumatic event for their femininity. Non-cancer patients revealed reactive sexual difficulties. Out of this sample, 17 cases described their sexual life as unsatisfying.

[Critical evaluation of preoperative instrumental staging of rectal tumors. Research on the adequate use of US, CT and MR]. / Valutazione critica della stadiazione strumentale preoperatoria dei tumori del retto. Ricerca di un impiego adeguato di US, TC e RM.

Both traditional exams (rectal exploration, rectoscopy, barium enema, CEA) and advanced imaging (31 US, 40 CT and 11 MR) were performed for preoperative evaluation of rectal carcinoma in order to assess the accuracy of radiological imaging in the T and N staging. The results obtained have not been considered satisfactory and it is felt that US, CT and MR should not be employed routinely for rectal staging. Indeed accuracy of US, CT and MR is respectively 64%, 75% and 81% in the T evaluation and 64%, 70% and 64% in the N staging. In order to evaluate the effective usefulness of these three latter imaging techniques a double therapeutical choice was proposed. The first treatment option was suggested on the basis of traditional staging while a second choice was given considering US, TC and MR data also. Operatory findings subsequently allowed a definitive judgement on the influence of the different techniques on treatment selection. US has furnished useful data that could have allowed us to modify treatment in one case while in 5 other cases diagnostic error would have influenced treatment negatively. CT was useful in 5 cases while in 7 cases it would have influenced treatment choice negatively. MR would have been useful in one case and harmful in another. It is concluded that only patients with large neoplasms (stages T3 and T4) benefit from CT and MR staging with the exception of those cases that have tumors above the peritoneal fold or in strict relation with the sphincter structures. US was useful only in evaluating relations of neoplasms of the anterior rectal wall with nearby pelvic structures.

Primary neuroendocrine carcinoma of the liver: difficult diagnosis of a rare neoplasm.

Primary neuroendocrine neoplasms of the liver are extremely rare: about 30 cases only have been described in the literature. We report the case of a 42-year-old woman with a ten-year evolution. According to the previously reported cases, primary neuroendocrine carcinoma of the liver is usually multicentric, often mimicking liver metastases. The demonstration of the hepatic origin of a neuroendocrine carcinoma is often arduous. A careful surgical exploration and a prolonged follow-up are mandatory. The treatment of choice is surgical resection when possible. For progressive and unresectable disease, hepatic arterial chemoembolization may be considered. However, the prognosis of liver neuroendocrine tumours is much more favorable than that of hepatocellular carcinoma and progression has to be demonstrated before instauration of potentially harmful therapies.

[Anatomo-clinical considerations of several cases of pseudocysts of the pancreas]. / Considerazioni anatomo-cliniche su alcuni casi di pseudocisti del pancreas

The aetiology and clinical manifestations most commonly noted in pseudocysts of the pancreas are briefly described. Particular attention is given to the treatments of lesions operated under emergency conditions and the clinical aspects of pancreatic effusions sometimes encountered during the course of the disease.

[The free autologous dermo-adipose graft in the treatment of postoperative laparocele]. / L'innesto libero dermo-adiposo autologo nel trattamento del laparocele post-operatorio

An account of the biological and contentive features of the derma is followed by a proposal for its utilisation in the form of an autologous, free dermo-adipose graft in the management of some forms of post-operative laparocele. Personal experience and technique are explained. Grafts are used both for reinforcement of the wall after simple laparoplasty and in the replacement of missing muscle-aponeurotic planes.

[Suspensory elements of the anal canal. Anatomo-surgical considerations]. / Elementi di sospensione del canale anale. Considerazioni anatomo-chirurgiche.

Continence depends not only on correct muscular function but also on the integrity of the suspensory structures of the anal canal, the latter being the subject of this study performed on embryological and adult specimens. The role of the perineal body as an insertion tendon common to all the striated muscles (pubo-coc-cygeus, superficial striated sphincter) which anchor the anal canal to the surrounding structures is pointed out. The characteristic behaviour of the longitudinal muscle that links the striated musculature to the visceral cylinder is also described.

[Hemorrhoidectomy in muco-hemorrhoidal prolapse using mechanical stapler]. / Emorroidectomia per prolasso muco-emorroidario con suturatrice meccanica.

BACKGROUND: The treatment of hemorrhoids has changed throughout the latter years. In selected cases hemorrhoidectomy with circular stapler, in personal opinion, is the best surgical technique. The goal of the present study is to evaluate the therapeutic results of hemorrhoidectomy by means of the above technique in 150 consecutive cases. METHODS: From March 1997 to November 1999, 150 patients were surgically treated, 84 women and 66 men with a median age of 57 years. 130 patients had III degree, thus with a reducible prolapse, 10 IV degree and 10 patients with II degree hemorrhoids resistant to ambulatory banding and/or sclerotherapy. Every patient was operated with the circular stapler in Day Surgery regimen, and the patients were discharged after 24 hours. RESULTS: Eight immediate hemorrhages were seen, four of which were surgically treated; 10 patients had urinary retention which required an urinary catheter. Healing was complete in the 15-20th day. The follow-up after one month was performed on 140 patients, at 3 months and at one year, on 100 patients. No suture stenosis and no recurrences of the hemorrhoid prolapse were observed. Follow-up after 6, 12 and 24 months on 100 patients was also considered in order to evaluate the results after surgery and late complications or sequelae. Fifteen patients were reevaluated after one and two months with anorectal manometry which did not demonstrate important alterations of the continence. CONCLUSIONS: The advantages of this technique is to carry out a radical surgical procedure in a single event, by means of a rapid and mini-invasive technique, with an earlier physical recovery, with the absence of medication in the postoperative period, and an early social and working reestablishment.