Does the Overall Survival of the Resectable Periampullary Carcinomas Correlate with High Expression of p53 and ki67?

Introduction: Periampullary carcinomas represent a group of tumors that develop in a complex area, implying different anatomical structures. The most common histological type of periampullary carcinomas is the adenocarcinoma. The pancreatic type of periampullary adenocarcinomas has the worst prognosis. Immunohistochemical markers, such as ki-67 and p53, can be used in predicting survival. Material and method: we selected the patients with periampullary adenocarcinomas, intestinal or biliopancreatic type, with resectable tumors, and we performed immunohistochemical stains for ki-67 and p53 markers. The overall survival was analyzed according to the expression of immunohistochemical markers, TNM staging, tumor grade and perineural invasion. Results: Sixty-seven patients were included in the study. The median overall survival for the whole cohort was 12 months, with a 2-year survival rate of 25%. High rate of tumor proliferation (ki67 more than 80%) was significantly associated with shorter overall survival (median survival 3 months compared with 17 months for the group with ki67 index less than 80%). A high expression of p53 protein has been associated with low overall survival. The low survival was associated with poorly differentiated tumor grade and lymph node status. Conclusion: Both immunohistochemical expression of ki67 and p53 can be used as prognostic and predictive factors for overall survival of patients with resectable periampullary adenocarcinomas.

Early Spontaneous Graft Intra- and Perihepatic Hematoma after Liver Transplantation.

Hematoma of the graft is a life threatening complication of liver transplantation (LT) and there has been no overt conclusion in the literature about optimal management except in scarcely reported cases. It may be either intrahepatic or subcapsular, then again it may develop spontaneously or following parenchimal injuries or transhepatic percutaneous invasive manoeuvers. In this report we describe a rare case of large spontaneous graft intra- and perihepatic hematoma. A 62 year-old man underwent a whole graft orthotopic liver transplantation (OLT) for decompensated chronic liver disease due to alcoholic cirrhosis. The surgical procedure was uneventful. During the early postoperative course, routine Doppler ultrasound examination and CT-scan revealed an extrahepatic paracaval hematoma, 7 days after transplantation, which was stable and conservatively managed until the 18-th postoperative day, when rapidly expanding intraparenchimal hematoma involving the right hemiliver, several other perihepatic hematomas, significant right pleural effusion and hemorrhagic ascites were described. The patient was successfully treated conservatively (nonsurgically) with slow recovery of the liver allograft and discharged one month later in good general status.

Posterior approach pancreaticoduodenectomy: best option for hepatic artery anatomical variants.

Pancreaticoduodenectomy is the best treatment for the patients with malignant tumors of the pancreatic head. However, the procedure is also recommended in some benign pancreatic tumors. The posterior approach allows early dissection of the superior mesenteric artery, portal vein and retroportal pancreatic lamina, before any pancreatic or digestive transection. We present a 42 year old woman diagnosed with a pancreatic tumor. The clinical and biological data suggested the diagnosis of insulinoma. The computed tomography showed a nodule located in the pancreatic head with a typical vascular pattern for endocrine tumor. The exam also revealed a rare vascular variant, a common hepatic artery which arises from the superior mesenteric artery. A pancreaticoduodenectomy has been performed. We used the posterior approach which allowed the correct dissection and exposure of the abnormal common hepatic artery. The postoperative course was uneventful. Posterior approach during the pancreaticoduodenectomies avoids arterial injuries that might compromise the liver arterial supply. It is especially indicated when preoperative imaging studies diagnose anatomic variants of the hepatic arteries.

Technical tailoring of pancreaticoduodenectomy in patients with hepatic artery anatomic variants.

BACKGROUND: Pancreaticoduodenectomy is the treatment of choice for periampullary and pancreatic head tumors. In case of hepatic artery abnormalities, early pancreatic transection during pancreaticoduodenectomy may prove inappropriate. Early retroportal lamina dissection improves exposure of the superior mesenteric vessels and anatomic variants of the hepatic artery, where safeguarding is mandatory. METHOD: We describe our early retroportal lamina approach in patients with anatomic variants of the hepatic artery before pancreatic transection. RESULTS: This approach was used during 42 pancreaticoduodenectomies with a hepatic artery anatomic variant which was spared in 40 patients. Arterial reconstruction was performed in 2 patients. Five patients with a hepatic artery variant and adenocarcinoma involving the portomesenteric junction required venous resection and reconstruction. CONCLUSIONS: Early retroportal lamina dissection during pancreaticoduodenectomy in patients with hepatic artery anatomic variants enables easier exposure, avoiding injuries that might compromise the liver arterial supply. When the portomesenteric vein is involved, this approach facilitates en bloc "no touch" venous resection and reconstruction.

Removal of an intraperitoneal foreign body using a single port laparoscopic procedure.

BACKGROUND AND OBJECTIVES: To remove a foreign body from the peritoneal cavity in laparoscopic surgery, 2 or 3 ports are usually used. We have recently performed such a removal using a single 10-mm transumbilical port, a 0-degree laparoscope, a Farabeuf retractor, and a laparoscopic grasping forceps. METHODS: Two patients with ventriculoperitoneal shunt catheter (V-P shunt) were admitted to our unit during the last year. They previously had a shunt catheter implanted for hydrocephalus of unknown cause. The complete migration of the ventriculoperitoneal shunt catheter into the peritoneal cavity was observed in these patients 12 and 7 years after the implantation. The laparoscopic removal of the migrated catheter was decided on. Its presence and location were confirmed by the use of a 0-degree laparoscope, through a 10-mm trocar port. The catheter was held and pulled out using a grasping forceps that was pushed in just beside the trocar port. CONCLUSION: The laparoscopic approach enables safe removal of a foreign body in the peritoneal cavity. The procedure can be performed using a single port.