CD133 and CD44 cell surface markers do not identify cancer stem cells in primary human gastric tumors.

Emerging evidence suggests that tumors contain and are driven by a cellular component that displays stem cell properties, the so-called cancer stem cells (CSCs). CSCs have been identified in several solid human cancers; however, there are no data about CSCs in primary human gastric cancer (GC). By using CD133 and CD44 cell surface markers we investigated whether primary human GCs contain a cell subset expressing stem-like properties and whether this subpopulation has tumor-initiating properties in xenograft transplantation experiments. We examined tissues from 44 patients who underwent gastrectomy for primary GC. The tumorigenicity of the cells separated by flow cytometry using CD133 and CD44 surface markers was tested by subcutaneous or intraperitoneum injection in NOD/SCID and nude mice. GCs included in the study were intestinal in 34 cases and diffuse in 10 cases. All samples contained surface marker-positive cells: CD133(+) mean percentage 10.6% and CD133(+)/CD44(+) mean percentage 27.7%, irrespective of cancer phenotype or grade of differentiation. Purified CD133(+) and CD133(+)/CD44(+) cells, obtained in sufficient number only in 12 intestinal type GC cases, failed to reproduce cancer in two mice models. However, the unseparated cells produced glandular-like structures in 70% of the mice inoculated. In conclusion, although CD133(+) and CD133(+)/CD44(+) were detectable in human primary GCs, they neither expressed stem-like properties nor exhibited tumor-initiating properties in xenograft transplantation experiments.

Shouldice technique versus other open techniques for inguinal hernia repair.

BACKGROUND: Inguinal hernia repair is the most frequent operation in general surgery. There are several techniques: the Shouldice technique is sometimes considered the best method but different techniques are used as the "gold standard" for open hernia repair. Outcome measures, such as recurrence rates, complications and length of post operative stay, vary considerably among the various techniques. OBJECTIVES: To evaluate the efficacy and safety of the Shouldice technique compared to other non-laparoscopic techniques for hernia repair. SEARCH METHODS: We searched MEDLINE, EMBASE, and The Cochrane Central Register of Controlled Trials (CENTRAL), April 2008 and updated the searches September 2011, for relevant randomised controlled trials. SELECTION CRITERIA: Any randomised or quasi-randomised controlled trials (RCT) on the treatment of primary inguinal hernia in adults were considered for inclusion. DATA COLLECTION AND ANALYSIS: All abstracts identified by the search strategies were assessed by two independent researchers to exclude studies that did not meet the inclusion criteria. The full publications of all possibly relevant abstracts were obtained and formally assessed. Missing or updated informations was sought by contacting the authors. MAIN RESULTS: Sixteen trials contributed to this review. A total of 2566 hernias were analysed in the Shouldice group with 1121 mesh and 1608 non-mesh techniques. The recurrence rate with Shouldice techniques was higher than mesh techniques (OR 3.80, 95% CI 1.99 to 7.26) but lower than non-mesh techniques (OR 0.62, 95% CI 0.45 to 0.85). There were no significant differences in chronic pain, complications and post-operative stay. Female were nearly 3% of included patients. AUTHORS' CONCLUSIONS: Shouldice herniorrhaphy is the best non-mesh technique in terms of recurrence, though it is more time consuming and needs a slightly longer post-operative hospital stay. The use of mesh is associated with a lower rate of recurrence. The quality of included studies, assessed with jaded scale, were low. Patients have similar characteristic in the treatment and control group but seems more healthy than in general population, this features may affect the dimension of effect in particularly recurrence rate could be higher in general population. Lost to follow-up were similar in the treatment and control group but the reasons were often not reported. The length of follow-up vary broadly among the studies from 1 year to 13.7 year.

Laparoendoscopic single site (LESS) versus classic video-laparoscopic cholecystectomy: a randomized prospective study.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the gold-standard for the treatment of gallbladder stone disease. In recent years laparoendoscopic single site surgery (LESS) has gained greater interest and diffusion for the treatment of gallstones and also in bariatric and colonic surgery. However, no randomized controlled trials are present in the literature that confirm the clinical advantages of LESS compared with the classic laparoscopic procedures. For this reason, we present the preliminary results of this randomized prospective study regarding the feasibility and safety of LESS cholecystectomy versus classic laparoscopic technique. METHODS: Between October 2009 and April 2010, 50 patients were randomly assigned to three-port classic laparoscopic cholecystectomy (n = 25) or LESS procedure (n = 25). Exclusion criteria were: (1) previous abdominal surgery, (2) signs of acute cholecystitis, choledocholithiasis, or acute pancreatitis, (3) ASA grade III or more, (4) lack of written informed consent, and (5) BMI ≥ 30 Kg/m(2).All the patients' details were recorded: age, weight, height, body mass index, operative time, length of hospital stay, patients' pain and wound satisfaction score. Abdominal pain was registered at 6, 12, and 24 h postoperatively. Wound satisfaction score (very unsatisfied = 1, unsatisfied = 2, acceptable = 3, satisfied = 4, very satisfied = 5) was registered for each patient at the seventh postoperative day. RESULTS: No differences were registered between the two groups about gender, age, weight, height, and BMI. Also postoperative hospital stay was similar (P = 0.71). In three patients (1 in group A and 2 in group B) a 5-mm trocar was added. Intraoperative cholangiography was performed in five patients (2 in group A and 3 in group B). Mean operative time was significantly longer in LESS procedures (41.3 ± 12.0 versus 35.6 ± 5.8; P = 0.04). Abdominal postoperative pain was similar in LC and LESS cholecystectomy. Wound satisfaction score showed statistically significant differences between the two groups: in LESS group, patients were more satisfied with the presence of a small umbilical medication (P < 0.05). CONCLUSION: In this randomized prospective study, we conclude that LESS cholecystectomy is an excellent alternative to traditional three-port cholecystectomy for patients with uncomplicated disease, and no previous abdominal surgery. Although no differences are present about hospital stay and postoperative pain compared with classic laparoscopic cholecystectomy, in our experience LESS has had a significant impact on patients' wound satisfaction.

Detection of colo-rectal liver metastases: prospective comparison of contrast enhanced US, multidetector CT, PET/CT, and 1.5 Tesla MR with extracellular and reticulo-endothelial cell specific contrast agents.

BACKGROUND: To compare contrast-enhanced US (CE-US), multidetector-CT (MDCT), 1.5 Tesla MR with extra-cellular (Gd-enhanced) and intracellular (SPIO-enhanced) contrast agents and PET/CT, in the detection of hepatic metastases from colorectal cancer. MATERIALS AND METHODS: A total of 34 patients with colo-rectal adenocarcinoma underwent preoperatively CE-US, MDCT, Gd- and SPIO-enhanced MR imaging (MRI), and PET/CT. Each set of images was reviewed independently by two blinded observers. The ROC method was used to analyze the results, which were correlated with surgical findings, intraoperative US, histopathology, and MDCT follow-up. RESULTS: A total of 57 hepatic lesions were identified: 11 hemangiomas, 29 cysts, 1 focal fatty liver, 16 metastases (dimensional distribution: 5/16 < 5 mm; 3/16 between 5 mm and <10 mm; 8/16 ≥ 10 mm). Six of 34 patients were classified as positive for the presence of at least one metastasis. Considering all the metastases and those ≥ 10 mm, ROC areas showed no significant differences between Gd- and SPIO-enhanced MRI, which performed significantly better than the other modalities (P < 0.05). Considering the lesions <10 mm, ROC areas showed no significant differences between all modalities; however MRI presented a trend to perform better than the other techniques. Considering the patients, ROC areas showed no significant differences between all the modalities; however PET/CT seemed to perform better than the others. CONCLUSIONS: Gd- and SPIO-enhanced MRI seem to be the most accurate modality in the identification of liver metastases from colo-rectal carcinoma. PET/CT shows a trend to perform better than the other modalities in the identification of patients with liver metastases.

Shouldice technique versus other open techniques for inguinal hernia repair.

BACKGROUND: Inguinal hernia repair is the most frequent operation in general surgery. There are several techniques: the Shouldice technique is sometimes considered the best method but different techniques are used as the "gold standard" for open hernia repair. Outcome measures, such as recurrence rates, complications and length of post operative stay, vary considerably among the various techniques. OBJECTIVES: To evaluate the efficacy and safety of the Shouldice technique compared to other non-laparoscopic techniques for hernia repair. SEARCH STRATEGY: We searched MEDLINE, EMBASE, and The Cochrane Central Register of Controlled Trials (CENTRAL), April 2008, for relevant randomised controlled trials. SELECTION CRITERIA: Any randomised or quasi-randomised controlled trials (RCT) on the treatment of primary inguinal hernia in adults were considered for inclusion. DATA COLLECTION AND ANALYSIS: All abstracts identified by the search strategies were assessed by two independent researchers to exclude studies that did not meet the inclusion criteria. The full publications of all possibly relevant abstracts were obtained and formally assessed. Missing or updated informations was sought by contacting the authors. MAIN RESULTS: Sixteen trials contributed to this review. A total of 2566 hernias were analysed in the Shouldice group with 1121 mesh and 1608 non-mesh techniques. The recurrence rate with Shouldice techniques was higher than mesh techniques (OR 3.80, 95% CI 1.99 to 7.26) but lower than non-mesh techniques (OR 0.62, 95% CI 0.45 to 0.85). There were no significant differences in chronic pain, complications and post-operative stay. Female were nearly 3% of included patients. AUTHORS' CONCLUSIONS: Shouldice herniorrhaphy is the best non-mesh technique in terms of recurrence, though it is more time consuming and needs a slightly longer post-operative hospital stay. The use of mesh is associated with a lower rate of recurrence. The quality of included studies, assessed with jaded scale, were low. Patients have similar characteristic in the treatment and control group but seems more healthy than in general population, this features may affect the dimension of effect in particularly recurrence rate could be higher in general population. Lost to follow-up were similar in the treatment and control group but the reasons were often not reported. The length of follow-up vary broadly among the studies from 1 year to 13.7 year.

Diagnosis and therapeutic management of cystic dystrophy of the duodenal wall in heterotopic pancreas. A case report and revision of the literature.

CONTEXT: Cystic dystrophy in heterotopic pancreas is a rare and serious condition. Diagnosis is difficult because of non-specific clinical manifestations and radiologic and endoscopic imaging are pivotal. Therapeutic management is still under debate. CASE REPORT: We describe a case of cystic dystrophy of the duodenal wall in heterotopic pancreas complicated with chronic pancreatitis and pancreatic cystadenoma. DISCUSSION: Computed tomography and magnetic resonance are very useful in demonstrating the presence of cysts in a thickened duodenal wall but, for the most part, endoscopic ultrasonography is the most useful imaging examination. The choice of different therapeutic options is still under debate; although some authors have proposed a medical approach using octreotide or endoscopic treatment for selected patients, a pancreaticoduodenectomy is usually proposed for symptomatic patients. CONCLUSION: When surgery is needed, a pancreaticoduodenectomy is preferred, reserving by-pass procedures for high risk patients. Because of the non-specific clinical manifestation and the very difficult diagnosis and therapeutic management, these patients should be studied and treated in specialized and dedicated centers.

Pancreaticoduodenectomy as the primary therapeutic choice in cystic dystrophy of the duodenal wall in heterotopic pancreas.

On the basis of a review of the literature and description of a clinical case, the aim of this paper was to evaluate the role of pancreaticoduodenectomy as the primary therapeutic choice in a rare, serious condition such as cystic dystrophy of the duodenal wall in heterotopic pancreas. The diagnosis is difficult because of the non-specific clinical manifestations, and radiological and endoscopic imaging are decisive. Computed tomography and magnetic resonance are very useful for demonstrating the presence of cysts in a thickened duodenal wall but endoscopic ultrasonography is the most useful imaging examination. The choice of therapeutic option is still debated. Although some Authors have proposed a medical approach using octreotide or endoscopic treatment for selected patients, pancreaticoduodenectomy is usually proposed for symptomatic patients. When surgery is needed, pancreaticoduodenectomy should be preferred, reserving by-pass procedures for high-risk patients. Because of the non-specific clinical manifestations and the very difficult diagnostic and therapeutic management, these patients need to be studied and treated in specialised, dedicated centres.

Contrast-free endoscopic stent insertion in malignant biliary obstruction.

AIM: To present a case series of MRCP-guided endoscopic biliary stent placement, performed entirely without contrast injection. METHODS: Contrast-free endoscopic biliary drainage was attempted in 20 patients with malignant obstruction, unsuitable for resection on the basis of tumor extent or medical illness. MRCP images were used to confirm the diagnosis of tumor, to exclude other biliary diseases and to demonstrate the stenoses as well as dilation of proximal liver segments. The procedure was carried out under conscious sedation. Patients were placed in the left lateral decubitus position. The endoscope was inserted, the papilla identified and cannulated by a papillotome. A guide wire was inserted and guided deeply into the biliary tree, above the stenosis, by fluoroscopy. A papillotomy approximately 1 cm. long was performed and the papillotome was exchanged with a guiding-catheter. A 10 Fr, Amsterdam-type plastic stent, 7 to 15 cm long, was finally inserted over the guide wire/guiding catheter by a pusher tube system. RESULTS: Successful stent insertion was achieved in all patients. There were no major complications. Successful drainage, with substantial reduction in bilirubin levels, was achieved in all patients. CONCLUSION: This new method of contrast-free endoscopic stenting in malignant biliary obstruction is a safe and effective method of palliation. However, a larger, randomized study comparing this new approach with the standard procedure is needed to confirm the findings of the present study.

Endoscopic approach to malignant strictures at the hepatic hilum.

Hilar tumors have proven to be a challenge to treat and manage because of their poor sensitivity to conventional therapies and our inability to prevent or to detect early tumor formation. Endoscopic stent drainage has been proposed as an alternative to biliary-enteric bypass surgery and percutaneous drainage to palliate malignant biliary obstruction. Prosthetic palliation of patients with malignant hilar stenoses poses particular difficulties, especially in advanced lesions (type II lesions or higher). The risk of cholangitis after contrast injection into the biliary tree in cases where incomplete drainage is achieved is well known. The success rate of plastic stent insertion is around 80% in patients with proximal tumors. Relief of symptoms can be achieved in nearly all patients successfully stented.

Actively bleeding Dieulafoy's lesion of the small bowel identified by capsule endoscopy and treated by push enteroscopy.

Dieulafoy's lesion is an unusual cause of recurrent GI bleeding. This report describes a case of actively bleeding Dieulafoy's lesion of the small bowel in which the diagnosis was made by capsule endoscopy, followed by treatment with the use of push enteroscopy. The case illustrates that capsule endoscopy and enteroscopy are highly complementary in patients with small bowel diseases.

Conventional colonoscopy and magnified chromoendoscopy for the endoscopic histological prediction of diminutive colorectal polyps: a single operator study.

AIM: To accurately differentiate the adenomatous from the non-adenomatous polyps by colonoscopy. METHODS: All lesions detected by colonoscopy were first diagnosed using the conventional view followed by chromoendoscopy with magnification. The diagnosis at each step was recorded consecutively. All polyps were completely removed endoscopically for histological evaluation. The accuracy rate of each type of endoscopic diagnosis was evaluated, using histological findings as gold standard. RESULTS: A total of 240 lesions were identified, of which 158 (65.8%) were non-neoplastic and 82 (34.2%) were adenomatous. The overall diagnostic accuracy of conventional view, and chromoendoscopy with magnification was 76.3% (183/240) and 95.4% (229/240), respectively (P<0.001). CONCLUSION: The combination of colonoscopy and magnified chromoendoscopy is the most reliable non-biopsy method for distinguishing the non-neoplastic from the neoplastic lesions.

Accuracy of single phase contrast enhanced multidetector CT colonography in the preoperative staging of colo-rectal cancer.

AIM: The optimal acquisition time for staging colo-rectal carcinoma with a contrast enhanced multidetector CT colonography (CE CTC) has not yet been established. A dual phase with both arterial and portal venous acquisition has been proposed. The purpose of our study is to assess the value of single portal venous phase CE CTC in the preoperative staging of colo-rectal carcinoma. MATERIALS AND METHODS: Fifty two (30 M, 22 F; aged 35-82 years) consecutive patients with a histologically proven diagnosis of colo-rectal adenocarcinoma or a highly suspected colo-rectal cancer on conventional colonoscopy underwent a four-slice CE CTC. The procedure was performed 70s (portal phase) after the intravenous bolus (3 ml/s) administration of 120 ml iodinated non-ionic contrast agent (370 mg iodine/ml). Scans were performed using the following parameters: 2.5mm beam collimation, pitch 1.25, 120 kV, 200 mAs, rotation time 0.75 s. Images were reconstructed with an effective thickness of 3.2mm at intervals of 1.6mm. Two radiologists independently evaluated the depth of tumour invasion into the colo-rectal wall (T), regional lymph node involvement (N), and extracolonic metastases (M). Disagreement was resolved by means of a consensus decision. The pathological results served as the standard of reference. Assessment was made of sensitivity, specificity and accuracy, as well as positive and negative predictive values were assessed. RESULTS: CE CTC correctly staged the pT of 52/56 (93%) and the N of 40/56 (71%) lesions, as well as properly identifying 13/14 (93%) extracolonic findings. CONCLUSION: The single portal venous phase CE CTC scanning protocol enables satisfactory preoperative assessment of T, N and M staging in patients with colo-rectal cancer.

Surgery or endoscopy for treatment of postcholecystectomy bile duct strictures?

BACKGROUND: Surgery is considered the treatment of choice for postoperative biliary strictures. Recently, endoscopic stent placement has been proposed as an alternative to surgical management in selected patients. METHODS: In this retrospective study, 157 patients with postoperative biliary strictures were included. Eighty patients (group A) were treated endoscopically and 77 by surgery (group B). Baseline characteristics of patients were comparable in both groups. Endoscopic therapy consisted of placement of endoprostheses, with trimonthly elective exchange for a 1-year period. Surgical therapy consisted of constructing a biliary-digestive anastomosis in normal ductal tissue. Data were evaluated according to intention-to treat analysis. RESULTS: Successful treatment was achieved in 54% of group A and 73% of group B (P <0.001). Overall 31% of patients developed complications in group A and 23% of patients in group B (P <0.05). However, the rates of severe complications were comparable in both groups (11% versus 13%; P = not significant) In group A the mortality rate was 0% compared with 8% of group B (P <0.05). Recurrent stenosis was evidenced in 6% of patients of group A and 5% of patients of group B. CONCLUSIONS: Surgery provides a better long-term outcome over the endoscopy, because of patients with total obstruction are not amenable to endoscopic approach. When successfully done, endoscopic results are similar to surgical results with less mortality.

Endoscopic drainage of pancreatic pseudocysts: a long-term follow-up study of 49 patients.

BACKGROUND/AIMS: Endoscopic drainage is one of the non-surgical treatment modalities for pancreatic pseudocysts. The aim of the current study was to assess the safety and the utility of endoscopic treatment of pancreatic pseudocysts. Prognostic factors for the outcome were evaluated in a prospective analysis. METHODOLOGY: Forty-nine consecutive symptomatic patients were included in the study. Transmural drainage was used in 30 patients and transpapillary drainage in 19 patients. RESULTS: Successful drainage was achieved in 27/30 (90%) patients after transmural drainage and in 16/19 (84.2%) patients after transpapillary drainage. Twelve (24.5%) patients had complications: 2 patients had bleeding, 2 patients had mild pancreatitis, 8 patients had cyst infection, in relation to the presence of necrosis (5 patients) or clogging of the stent (3 patients). Nine patients (20.9%) had recurrence of pseudocysts. Endoscopic drainage was a definitive treatment in 37/49 (75.5%) patients (median follow up: 25.9 months). CONCLUSIONS: Endoscopic drainage provides a successful and safe minimally invasive approach to pancreatic pseudocyst management.

Leaks from laparoscopic cholecystectomy.

BACKGROUND/AIMS: Significant postoperative bile leaks occur in approximately 1% of patients. The goal of endoscopic therapy is to eliminate the transpapillary pressure gradient, thereby permitting preferential transpapillary bile flow rather than extravasation at the site of leak. METHODOLOGY: Sixty-four patients were retrospectively evaluated. Endoscopic treatment comprised endoscopic sphincterotomy followed by insertion of a naso-biliary drainage or a stent. Retained stones were extracted by standard procedures. RESULTS: The site of bile extravasation was the cystic duct in 50 cases, ducts of Luschka in 4 cases, common bile duct in 6 cases and common hepatic duct in 4 cases. Retained bile duct stones were detected in 21 cases and papillary stenosis in 4 cases. Endoscopic sphincterotomy was performed in 25 cases, with stones extraction and nasobiliary drainage in 21 cases, and placement of stent in the remainder. Bile leaks resolved in 96.9% of patients, after endoscopic procedure. Two cases of mild pancreatitis were evidenced from endoscopic treatment. CONCLUSIONS: Endoscopic management is the treatment of choice of postcholecystectomy bile leaks.

Long-term follow-up after endoscopic biliary stent placement for bile duct strictures from laparoscopic cholecystectomy.

BACKGROUND/AIMS: The outcome of endoscopic biliary stent insertion for postoperative bile duct stenosis was retrospectively evaluated. METHODOLOGY: Fifty-seven patients with biliary stenosis from laparoscopic cholecystectomy were included from February 1992 to January 2000. One to three stents were inserted for an average of 12.4 months, with stent exchange every 3 months to avoid cholangitis caused by clogging. RESULTS: Successful stent insertion was achieved in 43/57 (75.4%) patients. Stent insertion failed in 10 patients with complete and in 4 patients with incomplete biliary obstruction. Early complications occurred in 4 patients. Late complications occurred in 5/43 patients. Five patients experienced recurrence of stenosis. CONCLUSIONS: Endoscopic treatment should be the initial management of choice for postoperative bile duct stenosis.

A spontaneous strangulated transomental hernia: Prospective and retrospective multi-detector computed tomography findings.

Transomental hernias are among the rarest type of all internal hernias which overall account for less than 6% of small bowel obstructions. Most transomental hernias occurring in adults are either iatrogenic or post-traumatic. More rarely, a spontaneous herniation of small bowel loops may result from senile atrophy of the omentum. We report a case of an 86-year-old male who presented with signs and symptoms of small bowel obstruction but had no past surgical or traumatic abdominal history. At contrast-enhanced multi-detector row computed tomography (CT), a cluster of fluid-filled dilated small bowel loops could be appreciated in the left flank, with associated signs of bowel wall ischemia. Swirling of the mesenteric vessels could also be appreciated and CT findings were prospectively considered consistent with a strangulated small bowel volvulus. At laparotomy, no derotation had to be performed but up to 100 cm of gangrenous small bowel loops had to be resected because of a transomental hernia through a small defect in the left part of the greater omentum. Retrospective reading of CT images was performed and findings suggestive of transomental herniation could then be appreciated.

Volvulus of the ascending colon in a non-rotated midgut: Plain film and MDCT findings.

Colonic volvulus is a relatively uncommon cause of large bowel obstruction usually involving mobile, intra-peritoneal, colonic segments. Congenital or acquired anatomic variation may be associated with an increased risk of colonic volvulus which can occasionally involve retro-peritoneal segments. We report a case of 54-year-old female who presented to our Institution to perform a plain abdominal film series for acute onset of cramping abdominal pain. Both the upright and supine films showed signs of acute colonic obstruction which was thought to be due to an internal hernia of the transverse colon into the lesser sac. The patient was therefore submitted to a multi-detector contrast-enhanced computed tomography (CT). CT findings were initially thought to be consistent with the presumed diagnosis of internal hernia but further evaluation and coronal reformatting clearly depicted the presence of a colonic volvulus possibly resulting from a retro-gastric colon. At surgery, a volvulus of the ascending colon was found and a right hemi-colectomy had to be performed. However, a non rotated midgut with a right-sided duodeno-jejunal flexure and a left sided colon was also found at laparotomy and overlooked in the pre-operative CT. Retrospective evaluation of CT images was therefore performed and a number of CT signs of intestinal malrotation could be identified.