Bile duct injury during laparoscopic cholecystectomy without intraoperative cholangiography: a retrospective study on 1,100 selected patients.

BACKGROUND: Whether to routinely or selectively use intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) has been a controversial issue for many years. Many authors maintain that IOC decreases the rate of biliary complications such as bile duct injuries, biliary leak, and missed common bile duct (CBD) stones. However, in contrast to these claims, many centers have opted to perform LC without IOC. In this retrospective study, the results of a series of 1,100 LCs, all of which involved major biliary complications and which were performed without the use of IOC, were reviewed. METHODS: Data from 1,100 selected patients (728 females and 372 males) undergoing LC without the use of IOC from January 2003 to November 2011 were analyzed. One hundred and seventy LCs were performed by young surgeons during the learning curve, and 930 by surgeons with over 10 years of experience. Two techniques were used to create pneumoperitoneum: the Veress technique in 319 cases (29%) and the Hasson technique in the remaining 781 cases (71%). Patients with a suspicion of CBD stones were excluded from the study. RESULTS: Two CBD injuries (0.18%) and three biliary leaks (0.27%) were detected among this group. Thirty-three patients (3%) needed conversion to open cholecystectomy. Missed CBD stones were reported in 4 cases (0.36%). There was no postoperative mortality. CONCLUSION: LC can be performed safely without the use of IOC and with acceptable low rates of biliary complications. An accurate preoperative evaluation of clinical risk factors, precise operative procedures, and conversion to an open approach in doubtful cases are important measures which must be taken to prevent CBD injury.

Lymph node ratio and liver metachronous metastases in colorectal cancer.

AIM: The authors seek to assess whether the lymph node ratio (the ratio of positive nodes divided by the total number of retrieved nodes) could predict the risk of metachronous liver metastases. MATERIAL AND METHODS: A homogeneous group of 280 patients, followed-up for at least 5 years, was evaluated. In order to highlight the groups with the highest risk of metachronous liver metastases, patients were divided into four quartiles groups in relation to the LNR. RESULTS: The number of lymph nodes sampled in group "stage I" was significantly lower. Even if statistical significance between the global LNR and the development of liver metastases has not been reached, the subdivision into quartiles has made it possible to highlight that in the more advanced ratio groups, a higher incidence of metachronous liver metastases (p <0.028) was registered and was a different distribution of patients with or without liver metastasis in function of quartiles (P =0.01). DISCUSSION: The LNR has enabled us to prognosticate patients who are at greater risk of developing metachronous liver metastases. The lower lymph node sampling in the patients with less advanced staging (I) and in patients with nodenegative cancer (I+II) who developed liver metastases, leads us to believe that some patients have been understaged. CONCLUSION: We believe that the LNR, especially in cases of adequate lymph node sampling, is a useful gauge to better sub-stratify "node-positive" patients. KEY WORDS: Colorectal cancer, Liver metastases, Lymph node ratio.

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

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

Myoepithelial hamartoma of the stomach simulating a gastric carcinoma. A case report.

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

Emerging therapeutic targets for the treatment of hepatic fibrosis.

Fibrosis represents a response to chronic injury, aimed at maintaining organ integrity. Hepatic fibrosis is mainly related to chronic viral hepatitis B or C (HBV or HCV), alcoholic and nonalcoholic steatohepatitis (NASH), and biliary diseases. A deep understanding of the cellular and molecular mechanisms underlying liver fibrosis has enabled the development of 'pathogenetic tailored' therapeutic interventions. However, effective drugs to prevent or revert hepatic fibrosis are still lacking. In this review, we discuss the cellular populations and the molecular pathways involved in liver fibrogenesis as well as the novel approaches currently being tested in clinical trials.

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

INTRODUCTION: Choroidal melanoma is the most common primary intraocular malignant tumour and the second most common type of primary malignant melanoma in the body. Biologically, cutaneuous and ocular melanoma may be considered different, in terms of both metastatic diffusion and metastatic latency. The principal target organ for metastasis of the ocular melanoma is the liver.This distinctive behaviour is also sustained by different metastatic latency, as some patients present with metastatic ocular melanoma several years after the treatment of the primary tumor. PRESENTATION OF CASE: A 60 year-old male who had undergone left ocular enucleation for choroid melanoma 20 years ago was referred to our department with a three months history of diffuse abdominal pain, fever, weight loss and massive ascites. Abdominal ultrasonography (US) and total body computed tomography (CT) scan were performed and revealed diffuse liver metastases, associated with peritoneal carcinosis, bilateral adrenal metastases and a large mass in the left kidney compatible with another secondary localization. An ultrasound guided fine needle agobiopsy (FNA) of liver lesions was performed and the pathological findings led to the diagnosis of liver metastasis from choroidal melanoma. The patient died a few weeks later for hepatic failure. DISCUSSION: Currently, there is no consensus regarding the optimal follow-up in terms of screening modality or time interval after the treatment of the primary ocular melanoma. CONCLUSION: Patients with gastrointestinal symptoms and a history of choroidal melanoma should be investigated for the presence of gastrointestinal or liver metastases, although the original primary malignancy was diagnosed years before the patient's presentation.

Identification of novel targets for the diagnosis and treatment of liver fibrosis.

Liver fibrosis is characterized by the excessive deposition of extracellular matrix (ECM) in the hepatic parenchyma and represents an intrinsic response to chronic injury, maintaining organ integrity when extensive necrosis or apoptosis occurs. Hepatic stellate cells (HSCs) are the major cell type responsible for liver fibrosis. Following liver injury, HSCs become activated and transdifferentiate into myofibroblasts (MFBs) that lead to intrahepatic ECM accumulation. In the present study, we performed a meta­analysis of datasets which included whole-genome transcriptional data on HSCs in the quiescent and activated state from two different rodent species and identified commonly regulated genes. Several of the genes identified, including ECM components, metalloproteinases and growth factors, were found to be well­known markers for HSC activation. However, other significant genes also appeared to play important roles in hepatic fibrosis. The elucidation of the molecular events underlying HSC activation may be key to the identification of potential novel pharmacological targets for the prevention and treatment of liver fibrosis.

[Uncommon abdominal sites of hydatid disease. Our experience with the surgical treatment of 15 cases]. / L'idatidosi addominale a rara localizzazione. La nostra esperienza nel trattamento chirurgico di 15 casi.

The aim of this retrospective study is to report on a series of 15 patients with abdominal hydatid disease in uncommon sites submitted to surgery in our unit over the period 1974-2003. Eight women and 7 men (mean age: 48.4 years) were included in the study. The hydatid cysts were located in the peritoneum in 8 patients, in the spleen in 5, in the kidney in 1 and in the retroperitoneum in 1. In 4 cases the peritoneal cysts were solitary, while 4 patients in this subgroup presented multiple cysts and 2 had concomitant liver hydatidosis. The splenic cysts were solitary in 2 cases, associated with a hepatic cyst in 2 and with a lung cyst in 1. The renal and retroperitoneal cysts were both solitary. The diagnosis was made at operation in 3 cases, while in 12 patients it was made by serological tests, ultrasonography and/or CT. All patients were operated on: we performed a total cystectomy in 7 patients with peritoneal cysts and in the patient with a retroperitoneal location, splenectomy in the 5 splenic cysts and a partial cystectomy with external drainage of the residual cavity in 1 peritoneal cyst and in the renal location. The postoperative course was regular with no mortality and no major morbidity in 14 patients, while 1 patient submitted to splenectomy developed a subphrenic abscess that required surgical drainage. Two recurrences occurred in patients with peritoneal cysts 71 and 20 months, respectively, after the first operation and these were managed by total cystectomy. The diagnosis of uncommon abdominal sites of hydatid disease is more accurate today because of the new imaging techniques, which are often able to show specific radiological signs of hydatid disease. The treatment of choice is surgical and complete removal of the cyst is the gold standard, but its feasibility is related to the location of the cyst.

[Our experience with the use of a plastic prosthesis and self-expanding stents in the palliative treatment of malignant neoplastic stenoses of the esophagus and cardia. Comparative analysis of results]. / La nostra esperienza con le protesi plastiche e gli stent autoespansibili nel trattamento palliativo delle stenosi neoplastiche maligne dell'esofago e del cardias. Analisi comparativa dei risultati.

Rapid palliation of malignant dysphagia is usually possible by means of the endoscopic implantation of a plastic prosthesis, but this device has a high morbidity rate. Recently, expandable metal stents have become available and may reduce the morbidity and mortality rates. The aim of this retrospective study was to evaluate self-expanding metal stents compared with conventional plastic prosthesis in malignant strictures of the oesophagus and cardia. One hundred and thirteen endoscopic tube implantations were carried out in 120 patients with malignant stenosis of the oesophagus and cardia using a plastic prosthesis over the period 1980-1993 (72 cases) and self-expanding metal stents over the period 1993-2001 (48 cases). The underlying causes of strictures were oesophageal or cardial cancer in 108 cases and oesophageal invasion by lung cancer in 12. The indications for endoscopic intubation were advanced tumour stage and/or risk factors which made resection inadvisable. The stents used in the conventional group were the Celestin pulsion tube in 18, the Atkinson prosthesis in 23 and the Wilson-Cook tube in 27, while the Ultraflex stent was always employed in the other group. Dysphagia was scored according to the Atkinson and Ferguson classification and the preoperative median score (3.6) was comparable in the two groups. The technical success rate was 94.4% with the plastic prosthesis (68/72) and 93.7% with the self-expanding metal stents (45/48) because in 4 and 3 patients, respectively, it proved impossible to implant the stent. After intubation the dysphagia score was improved in both groups (median score = 0.9) and the functional success rates were 85.2% (58/68) and 88.8% (40/45), respectively, while 10 and 5 patients showed no improvement of symptoms. The early complication rate was 5.9% (4/68) in the conventional stent group (1 perforation, 2 severe bleedings and 1 stent proximal migration) and nil in the other group. Late complications occurred in 14 (20.6%) (7 food obstruction, 4 neoplastic obstructions and 3 dislodgements) and 9 patients (20%) (3 neoplastic obstructions, 1 food obstruction, 3 distal migrations and 2 bleedings), respectively, but all the complications were easily corrected. Three deaths occurred with the plastic prosthesis (4.4%), while the mortality was nil with the metal stents. The median survival times were 183 (range: 58-486) and 151 days (range; 25-545), respectively. Our experience suggests that endoscopic placement of self-expanding metal stents is effective and safe for the management of dysphagia in malignant strictures of the oesophagus and cardia and has to be preferred to conventional plastic prostheses for easier implantation. The technical and functional success rates are similar in both groups, but the acute complication and mortality rates of the Ultraflex prosthesis are lower as compared to the traditional prosthesis.

Ileo-colic endometriosis: a rare localization of a frequent disease. Case report.

Endometriosis is a common entity affecting females of reproductive age. Clinical manifestations are not specific, making the preoperative diagnosis difficult to establish. Intestinal endometriosis is common, but ethiology is unknown. The complications of intestinal endometriosis include intestinal obstruction, perforation, hemorrhagic ascites, protein-losing enteropathy, anasarca, and intussusception. We report a case of a young woman, 26 years old, that for 3 years had a conditioned life by monthly sub-occlusion due to a small-bowel obstruction for an ileocaecal endometriosis. A high index of suspicion is required to have a diagnosis of this rare localization of endometriosis.

A rare case of pancreatic cancer presenting as pseudoachalasia.

"Pseudo" (or secondary) achalasia is a rare entity that it isn't easily distinguishing from idiopathic achalasia by manometry, radiological examination and endoscopy. Usually a neoplastic process of the esophago-gastric region is associated with this clinical condition. However, it has been reported that other neoplastic processes may lead to the development of pseudoachalasia, such as mediastinal masses, gastrointestinal tumours (pancreas, liver, biliary tract and other organs) and non gastrointestinal malignancies. We present a case of pseudoachalasia in which the primary cause of the disease was not an esophago-gastric cancer.