Metachronous Ampulla of Vater Carcinoma after Curative-Intent Surgery for Klatskin Tumor.

Resection represents the single hope for long-term survival in a patient diagnosed with a hilar cholangiocarcinoma (Klatskin tumor). However, the largest part of these patients develops a recurrent disease. Second metachronous periampullary cancers after a curative-intent surgery for a Klatskin tumor represent an exceptional pathology, and the management of these patients was poorly documented. Hereby, it is presented a 32-year-old patient with bile duct resection, left hemi-hepatectomy and loco-regional lymph nodes dissection, for a type IIIB Bismuth-Corlette Klatskin tumor, which, furthermore, 6 years later, underwent a pancreaticoduodenectomy for a metachronous carcinoma of the ampulla of Vater. The management and outcomes were discussed in the reported case, along with a literature review of the previously published patients. In conclusion, a metachronous periampullary carcinoma after resection of a Klatskin tumor should be distinguished from a loco-regional recurrent disease. While most of the patients with recurrences are suitable to only chemotherapy and or radiotherapy, a second curative-intent surgery (i.e., pancreaticoduodenectomy) is feasible in the largest part of the patients with a metachronous cancer, with good long-term outcomes.

Expression of Xylella fastidiosa RpfF in citrus disrupts signaling in Xanthomonas citri subsp. citri and thereby its virulence.

Xylella fastidiosa and Xanthomonas citri subsp. citri, that cause citrus variegated chlorosis (CVC) and citrus canker diseases, respectively, utilize diffusible signal factor (DSF) for quorum sensing. DSF, produced by RpfF, are similar fatty acids in both organisms, although a different set of genes is regulated by DSF in each species. Because of this similarity, Xylella fastidiosa DSF might be recognized and affect the biology of Xanthomonas citri. Therefore, transgenic Citrus sinensis and Carrizo citrange plants overexpressing the Xylella fastidiosa rpfF were inoculated with Xanthomonas citri and changes in symptoms of citrus canker were observed. X. citri biofilms formed only at wound sites on transgenic leaves and were thicker; however, bacteria were unable to break through the tissue and form pustules elsewhere. Although abundant growth of X. citri occurred at wound sites on inoculated transgenic leaves, little growth was observed on unwounded tissue. Genes in the DFS-responsive core in X. citri were downregulated in bacteria isolated from transgenic leaves. DSF-dependent expression of engA was suppressed in cells exposed to xylem sap from transgenic plants. Thus, altered symptom development appears to be due to reduced expression of virulence genes because of the presence of antagonists of DSF signaling in X. citri in rpfF-expressing plants.

An unclassified congenital bile duct cyst.

Congenital bile duct cysts are rare in adulthood. The most frequently used classification was proposed by Todani in 1977. However, in rare cases, not all the bile duct cysts are suitable to this classification. Hereby, we describe the case of an unclassified and very rare form of congenital bile duct cyst--isolated cystic duct cyst. En-block resection of the cyst, along with gallbladder, is the treatment of choice. Although exceptional, cystic duct cysts should be included in Todani classification so that the surgeons to be aware for this variation.

A case report of pancreatic transection by blunt abdominal trauma.

Posttraumatic pancreatic rupture is associated with high morbidity and mortality. Various management strategies are described, but due to the relative rarity of this pathology no standards exist. We reported a 21 years old male with post traumatic complete rupture of the pancreatic isthmus,devascularization lesion of descending duodenum, right renal artery posttraumatic thrombosis and left lobe of the liver laceration. Laparotomy for hemostasis was initially performed in a different hospital and the patient was then referred to us.Pancreaticoduodenectomy and right nephrectomy were performed. Postoperatively the patient had a pancreaticojejunal anastomosis fistula spontaneously resolved at 45 days.Pancreaticoduodenectomy can in selected cases be a solution in pancreatic trauma.

Technical aspects of biliary reconstruction correlated with biliary complications in 46 consecutive right lobe liver transplantations from living donors.

INTRODUCTION: Biliary complications contribute to a high morbidity rate in patients with right lobe liver transplant from a living donor. We retrospectively evaluated biliary reconstructions and complications in a number of recipients with liver transplant from a living donor, in a single center. PATIENTS AND METHODS: A number of 46 patients (23 males and 23 females aged 9-63) received a right lobe liver graft between 2009 and 2013, with the following types of biliary reconstruction:duct-to-duct choledochocholedochal anastomosis (n=24)or Roux-en-Y hepaticojejunoanastomosis, with or without an external transanastomotic biliary stent. RESULTS: The rate of biliary complications (leakage 15.21%,anastomotic stenosis 4.34%, overall 17.39%) was not statistically significantly influenced by the demographics of the studied lot, by the etiology of the liver disease or by the characteristics of the biliary reconstruction; the only risk factor which showed a statistically significant influence in terms of biliary complications was MELD. CONCLUSION: The type and technique of the biliary reconstruction in LDLT should be adapted depending on the anatomy of the biliary tree of both the donor and recipient, as well as the clinical and laboratory findings of the recipient.

[Geriatric patients with chronic kidney insufficiency: which antalgia?]. / Patients gériatriques insuffisants rénaux chroniques: quelle antalgie ?

Pain is a leading cause of office visits. In the geriatric population, it is known that the prevalence of renal failure increases exponentially with age, modifing the elimination of drugs and of their metabolites. What analgesia should be offered to these patients? The holy grail would be a medication without renal elimination, without toxic metabolites and without nephrotoxicity. Based on the literature we try to propose a specific approach to analgesia in older patients with kidney insufficiency, in order to help practitioners to better prescribe for this group of patients.

Prospective observational study of the non-invasive assessment of immediate postoperative pain using the analgesia/nociception index (ANI).

BACKGROUND: The analgesia/nociception index (ANI), a 0-100 non-invasive index calculated from heart rate variability, reflects the analgesia/nociception balance during general anaesthesia. The aim of this study was to evaluate the ANI in the assessment of immediate postoperative pain in adult patients undergoing general anaesthesia. METHODS: Two-hundred patients undergoing scheduled surgery or endoscopy with general anaesthesia were included in this prospective observational study. Pain intensity was assessed using a 0-10 numerical rating scale (NRS) after arousal from general anaesthesia. Receiver-operating characteristic (ROC) curves were built to assess the performance of ANI to detect patients with NRS>3 and NRS ≥ 7 on arrival in the postoperative care unit. RESULTS: A negative linear relationship was observed between ANI and NRS (ANI=-5.2 × NRS+77.9, r(2)=0.41, P<0.05). At the threshold of 57, the sensitivity and specificity of ANI to detect patients with NRS>3 were 78 and 80%, respectively, with a negative predictive value of 88%, corresponding to an area under the ROC curve (AUC) of 0.86. At the threshold of 48, the sensitivity and specificity of ANI to detect NRS ≥ 7 were 92 and 82%, respectively, with a negative predictive value of 99%, corresponding to a ROC curve AUC of 0.91. CONCLUSIONS: A measurement of ANI during the immediate postoperative period is significantly correlated with pain intensity. The measurement of ANI appears to be a simple and non-invasive method to assess immediate postoperative analgesia.

The Todani classification for bile duct cysts: an overview.

Bile duct cysts are a rare medical condition and are more frequent in children. However, the disease is becoming increasingly common in adults. The modified Todani classification, which is based on anatomical characteristics, is the current standard classification method. However, this classification does not take the following factors into consideration: different epidemiology, pathogenesis, risk of malignant transformation, clinical and imaging aspects, and different therapeutical approaches for all the bile duct cysts. Thus, some clinicians denied its clinical significance and viability. Moreover, some rare variants (i.e., cystic duct cysts) of bile duct cysts were initially not included and were subsequently categorized as type VI. Although it clusters different diseases, the Todani classification of bile duct cysts should also be used in clinical practice because it is simple, reproducible and widely agreed upon, thereby allowing an appropriate comparative analysis between different series of patients who are classified based on this scheme. Exceptional, cystic duct cysts should be included in the Todani classification (as a subtype of type II BDC rather than as a "new" type VI) so that the gastroenterologists, radiologists and surgeons are aware of this variation.

Dorsal pancreas agenesis and ductal adenocarcinoma: surgical implications of an extremely rare association.

It is presented the case of a 44-year-old woman with ductal adenocarcinoma of the pancreatic head with associated dorsal pancreas agenesis. In this case, curative intent surgery implies removal of the whole pancreas with its consequences--parental insulin requirement and exocrine pancreatic insufficiency. A review of the literature on the previously reported cases was performed.

POSSUM, a potentially useful tool for prediction of morbidity in patients undergoing central pancreatectomy.

AIM: Central pancreatectomy is a pancreas-sparing alternative to standard pancreatic resections, and it is associated with substantial morbidity. The aim of the present study is to assess the utility of the POSSUM scoring system in the prediction of the postoperative complications after central pancreatectomy, which would help identify the patients who are at the highest risk of developing complications. METHODS: A retrospective analysis of 24 patients who underwent central pancreatectomies (2002-2010) was performed. The POSSUM score was calculated for each patient and was correlated with observed morbidity. RESULTS: The mean POSSUM score was 32, thus predicting morbidity in 9 out of 24 patients. This risk assessment proved to be quite accurate, as 13 patients (54%) actually developed postoperative complications (chi-squared = 3.2101, p = 0.073). The predictive value of the POSSUM was strongest for the < or = 20%, 60-80% and > or = 80% morbidity risk cohorts (O/E ratio 1). CONCLUSIONS: The identification of a scoring system to predict the development of severe complications after central pancreatectomy may stratify the patients' risk and lead to a tailored approach of this surgical procedure. Although POSSUM seems to predict morbidity after central pancreatectomy, further studies involving larger numbers of patients should be conducted to confirm this effect.

Double blind clinical trial in a series of 115 patients with seborrheic dermatitis: prevention of relapses using a topical modulator of Toll like receptor 2.

AIM: Seborrheic dermatitis is a chronic inflammatory disease aggravated by Malassezia species. Toll-like receptors (TLR) are part of innate immune system that can be activated by yeasts. Previous studies showed that an association of Umbelliferae extract with a lipid (TLR2-Regul™) decreases the IL-8 expression in human skin in contact with M. furfur. The aim of this study was to assess the activity of a topical formulated with TLR2-Regul™ in the prevention of seborrheic dermatitis (SD) relapses. METHODS: Immune-competent SD adult patients were treated for SD (topical imidazoles or steroids). Cleared patients were randomized and received a topical containing TLR2-Regul™ (A) or its vehicle (B). Erythema, scales and pruritus were assessed during two months. RESULTS: The study included 115 patients, mean age 43.4, sex ratio m/f 1.5. At week 4 the relapse rate was 26% (N.=15) in group A and 43% (N.=25) in group B. At W8 the relapse rate was 21% (N.=12) in group A and 40% (N.=23) (P=0.0309). CONCLUSION: In this series of 115 adults with seborrheic dermatitis, patients treated with a topical containing TLR-Regul™ showed a significantly less relapse rate compared with the excipient group (P<0.05). TLR modulation could represent a new therapeutic approach in the prevention of seborrheic dermatitis relapses.

Emergency pancreaticoduodenectomy in a patient with an ampullary adenocarcinoma associated with severe acute pancreatitis: a case report.

Emergency pancreatico-duodenectomy is an infrequent surgical procedure. Herein, it is reported the case of a 58-year old man with ampullary carcinoma revealed by acute necrotizing pancreatitis. Due to clinical features, an emergency two-step pancreatico-duodenectomy was performed, accomplished by pancreatic and peripancreatic necrosectomy. The distal remnant pancreas was drained as an external pancreatic fistula. A time later, after complete remittance of local inflammation, the pancreas was anastomosed to the jejunum. The postoperative outcome was uneventful, the patient being disease-free at more than 5 years after surgery. Thus, pancreatico-duodenectomy is a feasible and safe operation when performed in tertiary hepato-bilio-pancreatic centers, in selected cases.

[Biliary complications following liver transplantation]. / Complicatiile biliare post transplant hepatic.

The biliary complications (BC) were always considered the "Achilles heel" of liver transplantation, being one of the leading causes of postoperative morbidity. The technique of the biliary reconstruction depends on the surgical procedure and it has a major impact on the patients and the graft evolution. The most frequent types of BC were stenoses, leaks, bilomas, cholangitis, etc. As an incidence, there is a peak of BC in the first 6 months after the transplant, a third of them appearing in the first month. Among the major BC risk factors, the most important are: hepatic artery pathology, the use of partial liver graft, bilioplasty and the number of biliary ducts and anastomoses. The BC management can be conservative, interventional or surgical depending on the type of BC. Along with the improvement of the interventional radiological and endoscopic methods, a large number of BCs are successfully treated non-surgically. There are still a few circumstances in which surgery is mandatory such as important persistent biliary leaks, even more when a partial liver graft was used or in association with hepatic artery pathology when re-transplantation is required. Multiple or serial biliary stenoses can lead to surgical revision. Although BC plays an important role in the patients postoperative morbidity, by early diagnosis and through numerous therapeutic methods promptly applied, there is no major impact on mortality.

[Gastrointestinal stromal tumor with primary hepatic unique location--clinical case]. / Tumora gastrointestinala stromala cu localizare hepatica primara unica--caz clinic.

The gastrointestinal stromal tumors are mesenchymal tumors whose primary extradigestive location is very rare (less than 10% primary liver localization). We present a clinical case of primary hepatic location of GIST in a 28 year-old patient. The discovery of this tumor is a chance, the patient presenting for non-specific dyspeptic syndrome and epigastralgia. During the presentation an abdominal ultrasound is performed which identifies an whell-delineated hepatic mass - 5/4 cm. Clinical and paraclinical investigations (CT, EDS, EDI, examination of the intestinal lumen with the videocapsula), confirm the diagnosis of unique hepatic mass of segments III-IV. The diagnosis is confirmed intraoperatory and we perform an atypical liver resection of segments III-IV (with 1 cm safety-margin). The histopatologic exam: GIST.

Prognostic and predictive potential molecular biomarkers in colon cancer.

An important objective in nowadays research is the discovery of new biomarkers that can detect colon tumours in early stages and indicate with accuracy the status of the disease. The aim of our study was to identify potential biomarkers for colon cancer onset and progression. We assessed gene expression profiles of a list of 10 candidate genes (MMP-1, MMP-3, MMP-7, DEFA 1, DEFA-5, DEFA-6, IL-8, CXCL-1, SPP-1, CTHRC-1) by quantitative real time PCR in triplets of colonic mucosa (normal, adenoma, tumoral tissue) collected from the same patient during surgery for a group of 20 patients. Additionally we performed immunohistochemistry for DEFA1-3 and SPP1. We remarked that DEFA5 and DEFA6 are key factors in adenoma formation (p<0.05). MMP7 is important in the transition from a benign to a malignant status (p <0.01) and further in metastasis being a prognostic indicator for tumor transformation and for the metastatic potential of cancer cells. IL8, irrespective of tumor stage, has a high mRNA level in adenocarcinoma (p< 0.05). The level of expression for SPP1 is correlated with tumor level. We suggest that high levels of DEFAS, DEFA6 (key elements in adenoma formation), MMP7 (marker of colon cancer onset and progression to metastasis), SPP1 (marker of progression) and IL8 could be used to diagnose an early stage colon cancer and to evaluate the prognostic of progression for colon tumors. Further, if DEFA5 and DEFA6 level of expression are low but MMP7, SPP1 and IL8 level are high we could point out that the transition from adenoma to adenocarcinoma had already occurred. Thus, DEFA5, DEFA6, MMP7, IL8 and SPP1 consist in a valuable panel of biomarkers, whose detection can be used in early detection and progressive disease and also in prognostic of colon cancer.

Surgical treatment of chronic pancreatitis--a 14 years experience.

BACKGROUND: Operative treatment of chronic pancreatitis is indicated for patients with intractable pain after failed medical and endoscopic treatment, or in the presence of complications of the disease. AIMS: This study evaluates a single-center experience with operative management of chronic pancreatitis over a period of time of 14 years, regarding indication, surgical technique, early and late results. PATIENTS AND METHODS: The records of 265 consecutive patients who underwent surgery for chronic pancreatitis between 1995 and 2008 were retrospectively reviewed and analyzed. Long-term outcomes were assessed by patient survey, with a median follow-up of 40 months. RESULTS: 265 patients underwent 275 operations for chronic pancreatitis with the main indication abdominal pain (46.8%), followed by suspected malignancy in 24.8% and recurrent episodes of acute pancreatitis in 18.6%. Resection procedures 54.5% (150), drainage procedures 1.09% (3), bypass and denervation procedures 44.36% (122) and exploratory laparotomy 3.27% (9) were performed with an overall morbidity of 22% and an in-hospital mortality rate of 2.64%. After a median follow-up of 40 months survival information was available for 137 patients (51.69%) with a 5-and actuarial survival rate of 74.7% and quality of life improvement in most patients, especially in the resected group. CONCLUSION: Our results suggest that in chronic pancreatitis the type of surgery has to be individualized in each patient (resection VS drainage) and organ preserving operations are safe and effective in providing long-term pain relief and in treating CP-related complications

[Liver transplantation--indications, surgical technique, results--the analysis of a clinical series of 200 cases]. / Transplantul hepatic--indicati, tehnica, rezultate-analiza unei serii clinice de 200 de cazuri.

INTRODUCTION: Initially considered experimental, liver transplantation (LT) has become the treatment of choice for the patients with end-stage liver diseases. MATERIAL AND METHODS: Between April 2000 and October 2009, 200 LTs (10 reLTs) were performed in 190 patients, this study being retrospective. There were transplanted 110 men and 80 women, 159 adults and 31 children with the age between 1 and 64 years old (mean age--39.9). The main indication in the adult group was represented by viral cirrhosis, while the pediatric series the etiology was mainly glycogenosis and biliary atresia. There were performed 143 whole graft LTs, 46 living donor LTs, 6 split LTs, 4 reduced LTs and one domino LT RESULTS: The postoperative survival was 90% (170 patients). The patient and graft one-year and five-year survivals were 76.9%, 73.6% and 71%, 68.2%, respectively. The early complications occurred in 127 patients (67%). The late complications were recorded in 71 patients (37.3%). The intraoperative and early postoperative mortality rate was 9.5% (18 patients). CONCLUSIONS: The Romanian liver transplantation program from Fundeni includes all types of current surgical techniques and the results are comparable with those from other international centers.

[Exotic snake bites in Switzerland]. / Morsures de serpents exotiques en Suisse.

Exotic snake bites are not rare in Switzerland. Treatment can be challenging for medical staff particularly as rapid and focused management are critical to improve patient outcome. The case of a young herpetologist bitten by an exotic venomous snake is used to review measures to be taken before arrival at the emergency department and to highlight key points of management. Resources for the obtention of expert advice and antivenoms are also reported.