Circulating miRNA Expression Profiles and Machine Learning Models in Association with Response to Irinotecan-Based Treatment in Metastatic Colorectal Cancer.

Colorectal cancer represents a leading cause of cancer-related morbidity and mortality. Despite improvements, chemotherapy remains the backbone of colorectal cancer treatment. The aim of this study is to investigate the variation of circulating microRNA expression profiles and the response to irinotecan-based treatment in metastatic colorectal cancer and to identify relevant target genes and molecular functions. Serum samples from 95 metastatic colorectal cancer patients were analyzed. The microRNA expression was tested with a NucleoSpin miRNA kit (Machnery-Nagel, Germany), and a machine learning approach was subsequently applied for microRNA profiling. The top 10 upregulated microRNAs in the non-responders group were hsa-miR-181b-5p, hsa-miR-10b-5p, hsa-let-7f-5p, hsa-miR-181a-5p, hsa-miR-181d-5p, hsa-miR-301a-3p, hsa-miR-92a-3p, hsa-miR-155-5p, hsa-miR-30c-5p, and hsa-let-7i-5p. Similarly, the top 10 downregulated microRNAs were hsa-let-7d-5p, hsa-let-7c-5p, hsa-miR-215-5p, hsa-miR-143-3p, hsa-let-7a-5p, hsa-miR-10a-5p, hsa-miR-142-5p, hsa-miR-148a-3p, hsa-miR-122-5p, and hsa-miR-17-5p. The upregulation of microRNAs in the miR-181 family and the downregulation of those in the let-7 family appear to be mostly involved with non-responsiveness to irinotecan-based treatment.

Single Dose of Sildenafil and Atorvastatin Increase Skin Survivability, but only Atorvastatin Increase Nitric Oxide in Rat Ischeamia Reperfusion Model.

Background: Ischeamia reperfusion injury is a frequent challenge during tissue reconstruction. Atorvastatin and Sildenafil, have been studied for their protective and/or therapeutic effects on various organ systems subjected to IRI. The aim of the present study was to compare a single dose of Atorvastatin and Sildenafil pretreatment on acute oxidative/nitrosative stress and the subsequent dermal flap necrosis. Materials and Methods: Forty-five Sprague-Dawley rats, were randomly allocated into three equal groups(n=15): Group A: Control rats treated with intraperitoneal saline, Group B: Sildenafil group, and Group C: atorvastatin group. All rats underwent flap elevation and inferior epigastric artery occlusion thirty minutes after drug administration. Myeloperoxidase activity, malondialdehyde levels and inducible nitric oxide synthase activity were evaluated 12 hours after reperfusion. Flap survivability was analysed 7 days after the procedure. Results: Statistically significant reduction was detected in sildenafil and atorvastation. Measurements of myelopyroxidase followed a similar pattern, interestingly malonadehyde levels measured to be significantly lower in the sildenafil group. Contrary, iNOS activity atorvastatin was significantly elevated in atorvastatin group. Conclusion: The single dose of atorvastatin or sildenafil increase flap survivability almost equally, however only atorvastatin enhances significantly iNOS expression.

Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline.

ESGE recommends offering stone extraction to all patients with common bile duct stones, symptomatic or not, who are fit enough to tolerate the intervention.Strong recommendation, low quality evidence.ESGE recommends liver function tests and abdominal ultrasonography as the initial diagnostic steps for suspected common bile duct stones. Combining these tests defines the probability of having common bile duct stones.Strong recommendation, moderate quality evidence.ESGE recommends endoscopic ultrasonography or magnetic resonance cholangiopancreatography to diagnose common bile duct stones in patients with persistent clinical suspicion but insufficient evidence of stones on abdominal ultrasonography.Strong recommendation, moderate quality evidence.ESGE recommends the following timing for biliary drainage, preferably endoscopic, in patients with acute cholangitis, classified according to the 2018 revision of the Tokyo Guidelines:- severe, as soon as possible and within 12 hours for patients with septic shock- moderate, within 48 - 72 hours- mild, elective.Strong recommendation, low quality evidence.ESGE recommends endoscopic placement of a temporary biliary plastic stent in patients with irretrievable biliary stones that warrant biliary drainage.Strong recommendation, moderate quality of evidence.ESGE recommends limited sphincterotomy combined with endoscopic papillary large-balloon dilation as the first-line approach to remove difficult common bile duct stones. Strong recommendation, high quality evidence.ESGE recommends the use of cholangioscopy-assisted intraluminal lithotripsy (electrohydraulic or laser) as an effective and safe treatment of difficult bile duct stones.Strong recommendation, moderate quality evidence.ESGE recommends performing a laparoscopic cholecystectomy within 2 weeks from ERCP for patients treated for choledocholithiasis to reduce the conversion rate and the risk of recurrent biliary events. Strong recommendation, moderate quality evidence.

A Duplicated Gallbladder in a Patient Presenting with Acute Cholangitis. A Case Study and a Literature Review.

Gallbladder duplication can present a clinical challenge primarily due to difficulties with diagnosis and identification. Recognition of this anomaly and its various types is important since it can complicate a gallbladder disease or a simple hepatobiliary surgical procedure. The case report of a 63-year-old woman who presented with cholangitis and underwent a successful laparoscopic management of symptomatic gallbladder duplication is described, emphasizing several important considerations. Using ERCP, MRCP and 3D reconstructions the two cystic ducts with one common bile duct were identified. A review of the literature in referral of this variant, its anatomical classifications and significance to clinical and surgical practice is included. In conclusion, gallbladder anomalies should be anticipated in the presence of a cystic lesion reported around the gallbladder when evaluating radiologic studies. In case of surgery, preoperative diagnosis is essential to prevent possible biliary injuries or reoperation if accessory gallbladder has been overlooked during initial surgery. Laparoscopic cholecystectomy remains feasible for intervention can be safely done and awareness is necessary to avoid complications or multiple procedures.

Immune-related intestinal pseudo-obstruction associated with nivolumab treatment in a lung cancer patient.

Immune checkpoint inhibition therapy using targeted monoclonal antibodies is a new therapeutic approach with significant survival benefit for patients with several cancer types. However, their use can be associated with unique immune-related adverse effects as a consequence of impaired self-tolerance due to loss of T-cell inhibition via a nonselective activation of the immune system. Nivolumab is an anti-PD-1 immune checkpoint inhibitor that was recently developed for cancer immunotherapy with remarkable responses in nonsmall cell lung cancer patients. We present a 62-year-old Caucasian male with recurrent lung adenocarcinoma and currently under third-line therapy with nivolumab, who was admitted in our hospital with abdominal distension. Radiologic findings were consistent with small bowel ileus. After four days of conservative treatment, the patient underwent exploratory laparotomy where no cause of ileus was discovered. Postoperative the ileus persisted and considering that an adverse effect of the immune checkpoint inhibition therapy occurred, the patient received high-dose prednisone resulting in gradual improvement of symptoms. Immune checkpoint inhibitors may induce adverse effects to unaffected organ systems and tissues including the skin, gastrointestinal, hepatic, pulmonary, and endocrine system. The mainstay treatment consists of immunosuppression with corticosteroids in the majority of cases. As the clinical use of immune checkpoint inhibitors is expanding rapidly, there is an emergence of unique immune-related adverse effects in a growing patient population. Gaining early awareness is essential in these patients in order to ensure prompt diagnosis and management.

Deep sedation for endoscopic cholangiopancreatography with or without pre or intraprocedural opioids: A double-blind randomised controlled trial.

BACKGROUND: Propofol alone or combined with opioids is considered the drug of choice for sedation during endoscopic retrograde cholangiopancreatography (ERCP). OBJECTIVE: To investigate the effect of pre or intraprocedural opioids on propofol requirement during deep sedation for ERCP, and on recovery, pain and cognitive function postoperatively. DESIGN: Three-arm, double-blinded randomised controlled trial. SETTING: Aretaieio University Hospital, February 2011 to July 2013. PATIENTS: One hundred and eighty adults aged between 45 and 75 years. INTERVENTIONS: Deep sedation with propofol (target bispectral index 40 to 70) was performed. In the remifentanil group (R), patients received intranasal placebo before ERCP, and remifentanil 0.1 ml kg(-1) h(-1) (concentration 10 µg ml(-1)) during ERCP. In the fentanyl group (F), patients received intranasal fentanyl 200 µg before ERCP and placebo during ERCP. In the placebo group (P), patients received intranasal placebo before ERCP and placebo during ERCP. MAIN OUTCOME MEASURES: The primary outcome was total propofol requirement. Secondary outcomes were recovery [assessed using the Ramsay Sedation Scale score and Observer's Assessment of Alertness/Sedation Score (OAAS)] at 30 min; postoperative pain [assessed using a visual analogue pain scale (VAS; 0 to 100 mm)]; and cognitive function [assessed using a MiniMental state test (max. 25 points) 30 min before and 30 min after ERCP]. RESULTS: Fifty-seven patients were included in group R, 59 in group F and 57 in group P. Propofol requirements for deep sedation were similar in all groups (13 mg kg(-1); P = 0.97). Ramsay Sedation Scale scores and OAAS scores were similar in all groups (P = 0.18 and P = 0.55, respectively). Postoperative median pain VAS differed among the groups (P = 0.007): 10 in group R, 0 in group F, five in group P. Cognitive function was high pre and postprocedure (median MiniMental state test 23 to 24) and not different among the groups. CONCLUSION: The addition of pre or intraprocedural opioids had no effect on propofol requirement for deep sedation, but patients who received fentanyl had less minor pain. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01304342.

Clinical presentation and management of gastro-intestinal and pancreatic secondary metastatic tumors.

PURPOSE: As progress regarding the treatment has occurred over recent years in oncology, more patients with metastatic disease are presented for diagnosis and further management. The purpose of this study was to reveal the incidence, location and to describe the clinical characteristics and outcome in a series of patients diagnosed with pancreatic, small and large bowel metastatic tumors that underwent metastasectomy. METHODS: A total of 12 patients (7 male and 5 female) diagnosed with extrahepatic gastrointestinal (GI) and pancreatic metastases from 2001 to 2013 were operated for resection of secondary metastatic tumors to the small and large bowel and the pancreas. Four out of 12 patients were asymptomatic and a secondary tumor was detected during follow up. RESULTS: The median interval revealing the metastatic tumor since the management of the primary tumor was 6.5 years (range 1-27). Primary tumors were malignant melanoma (4 patients), renal cell carcinoma (RCC; 2 patients), leiomyosarcoma of the uterus (2 patients), lobular breast cancer, mesenchymal chondrosarcoma of the skull, endometrial adenocarcinoma and a non-Hodgkin lymphoma (one case each). The median follow-up was 15 months (range 4-120). CONCLUSIONS: Metastatic secondary tumors have to be considered especially when the patient's medical history includes a previous malignancy. They may also occasionally present as the initial manifestation of an occult primary lesion leading to diagnostic difficulty. Although radical surgery is the most effective approach, treatment and survival grossly depend on histological type and the stage of the primary disease. Hence, management of these patients should be individualized by a multidisciplinary team.

Significance of serum and bile tumor markers in the diagnostic approach of patients with malignant pancreatobiliary disease.

PURPOSE: Serum and bile tumor markers are under intense scrutiny for the diagnosis of malignant disease. The purpose of our study was to report the usefulness of serum and bile tumor markers for the discrimination between benign and malignant pancreatobiliary diseases. METHODS: Between March 2010 and May 2013, 95 patients with obstructive jaundice or history of biliary obstruction, were included in the study. During ERCP, bile samples were obtained for measurement of tumor markers CEA, CA19- 9, CA125, CA72-4 and CA242. Serum samples were taken before ERCP for the same measurements. The patients were divided into two groups: patients with malignant disease and patients with benign disease. RESULTS: Serum tumor marker levels were significantly higher in patients with malignant disease. Serum CA242 and CA19-9 exhibited the highest diagnostic accuracy (76.8% and 73.7%, respectively). CA125 and CA72-4 levels in bile samples were significantly higher in patients with malignant disease. Bile CA125, CEA and CA72-4 achieved the best diagnostic accuracy (69, 65 and 65), respectively). The combined detection of CA19-9, CA242 in serum and CA125, CA72-4 in bile along with total bilirubin levels, showed the best diagnostic accuracy (81%). CONCLUSIONS: Serum and bile tumor markers, when studied alone, lack the diagnostic yield to discriminate benign from malignant pancreatobiliary diseases. In cases of diagnostic dilemmas the combination of serum and bile markers might be helpful.

Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement.

This Position Paper is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the diagnosis and management of iatrogenic perforation occurring during diagnostic or therapeutic digestive endoscopic procedures. Main recommendations 1 ESGE recommends that each center implements a written policy regarding the management of iatrogenic perforation, including the definition of procedures that carry a high risk of this complication. This policy should be shared with the radiologists and surgeons at each center. 2 In the case of an endoscopically identified perforation, ESGE recommends that the endoscopist reports: its size and location with a picture; endoscopic treatment that might have been possible; whether carbon dioxide or air was used for insufflation; and the standard report information. 3 ESGE recommends that symptoms or signs suggestive of iatrogenic perforation after an endoscopic procedure should be carefully evaluated and documented, possibly with a computed tomography (CT) scan, in order to prevent any diagnostic delay. 4 ESGE recommends that endoscopic closure should be considered depending on the type of perforation, its size, and the endoscopist expertise available at the center. A switch to carbon dioxide insufflation, the diversion of luminal content, and decompression of tension pneumoperitoneum or tension pneumothorax should also be done. 5 After closure of an iatrogenic perforation using an endoscopic method, ESGE recommends that further management should be based on the estimated success of the endoscopic closure and on the general clinical condition of the patient. In the case of no or failed endoscopic closure of the iatrogenic perforation, and in patients whose clinical condition is deteriorating, hospitalization and surgical consultation are recommended.

Non-functioning pancreatic endocrine tumors: eleven-year experience in a single institute.

PURPOSE: Non-functioning pancreatic endocrine tumors (NF-PETs) comprise the majority of pancreatic endocrine tumors. We present our experience from the management of 18 patients with NF-PET. METHODS: From May 2002 to June 2013, 18 patients were admitted in our hospital for the management of NF-PETs. We analyzed their clinical presentation, preoperative evaluation, surgical and postoperative management and the outcome. RESULTS: The tumor was located in the pancreatic head in 13 (72%) patients and in the body and tail of the pancreas in the remaining 5 (28%). Four patients (22%) had stage IIIa, 7 (39%) stage IIIb and 7 (39%) stage IV. Twelve (67%) patients with pancreatic head tumor underwent pancreatoduodenectomy (PD). In one case (5%), the tumor was deemed unresectable and the remaining 5 (28%) patients underwent distal pancreatectomy and splenectomy (DPSP). Four (22%) patients with unilobar metastatic liver disease underwent hemihepatectomy or segmentectomy. Perioperative mortality was 0%. Postoperatively, all stage IV patients received peptide receptor radionuclide treatment (PRRT). The 5-year overall survival rate was 61%, with a median survival of 71 months, whereas the 5-year overall survival rate after diagnosis of hepatic metastases was 45%. CONCLUSION: Surgical resection is the gold standard for the treatment of NF-PETs. A formal resection appears to be the standard procedure when malignancy is verified or suspected. Aggressive surgery should be undertaken in patients with locally advanced or metastatic NF-PETs, as it may prolong survival. In stage IV patients, intra-arterial PRRT, after super-selective catheterization of the hepatic artery, is a promising therapeutic modality.

Chronic constipation in Parkinson's disease: clinical features and molecular insights on the intestinal epithelial barrier.

Background: Chronic constipation (CC) is a severe symptom in Parkinson's disease (PD), with an unclear pathogenesis. Abnormalities of the enteric nervous system (ENS) and/or intestinal epithelial barrier (IEB) may be pathophysiologically relevant in PD patients with CC. We investigated possible molecular changes of the IEB in PD/CCs compared with CCs and controls. Methods: Twelve PD/CCs (2 female, age range 51-80 years), 20 CCs (15 female, age range 27-78 years), and 23 controls (11 female, age range 32-74 years) were enrolled. Ten PD/CCs and 10 CCs were functionally characterized by anorectal manometry (AM) and transit time (TT). Colon biopsies were obtained and assessed for gene and protein expression, and localization of IEB tight junction markers claudin-4 (CLDN4), occludin-1 (OCCL-1), and zonula occludens-1 (ZO-1) by RT-qPCR, immunoblot and immunofluorescence labeling. Results: PD/CCs were clustered in 2 functional categories: patients with delayed TT and altered AM (60%), and a second group showing only modifications in AM pattern (40%). Gene expression of CLDN4, OCCL-1 and ZO-1 was higher in PD/CCs than controls (P<0.05). Conversely, PD/CCs showed a trend to decrease (P>0.05) in CLDN4 and OCCL-1 protein levels than controls, whereas ZO-1 protein was comparable. In PD/CCs compared with controls, decreasing tendency of vasoactive intestinal polypeptide mRNA, protein and immunoreactive fiber density were observed, although the difference was not statistically significant. Conclusion: Transit and anorectal dysfunctions in PD/CCs are associated with difference in ZO-1, OCCL-1 and CLDN4 expression, thus supporting the role of an altered IEB as a contributory mechanism to possible neuronal abnormalities.

Neuroendocrine differentiation in embryonal type hepatoblastoma.

Hepatoblastoma, a malignant tumor which arises occasionally in older children but very rarely in adults, exhibits divergent differentiation with embryonal cells, fetal hepatocytes and immature elements. This report describes an embryonal type hepatoblastoma with neuroendocrine differentiation in a 16-year-old patient, which was diagnosed postoperatively. Clinical and radiologic work-up failed to reveal a primary gastrointestinal malignancy and no primary lesions were detected in any other organ. This feature of hepatoblastoma is considered to be a multidirectional differentiation of the small epithelial or stem cells of the liver. At 2-year follow up, the patient remains symptom-free, with normal laboratory and diagnostic imaging studies, and no recurrent or metastatic disease identified.

Obstructive jaundice due to ampullary metastasis of renal cell carcinoma.

Renal cell carcinoma is often characterized by the presence of metachronous metastases in unusual sites. The presence of isolated metastases is treated with surgical excision with good anticipated results. On the other hand, systemic chemotherapy is administered in the context of metastatic spread, usually sunitib or sorafenib. In such cases, however, the presence of symptomatic foci calls for minimal intervention.We present a case of a 77-year-old patient who presented with obstructive jaundice due to an ampullary mass. Endoscopic excision and biopsy set the diagnosis of metastatic renal cell carcinoma. Consequently, imaging studies revealed the presence of multiple foci in the lungs and bone. Therefore, pancreatoduodenectomy was excluded and the patient underwent endoscopic ampullectomy and was set to oral sunitinib. Interestingly, despite generalized spread, local control was achieved until the patient succumbed to carcinomatosis.Painless obstructive jaundice in a patient with history of renal cancer and negative computed tomography scanning for pancreatic or other causes of obstruction should alert for prompt investigation for an ampullary metastasis.

Nivolumab-Induced Colitis in a Patient With Esophageal Adenocarcinoma: A Case Report.

Nivolumab is an immune checkpoint inhibitor used in the treatment of several types of cancer. Among the adverse effects of this drug, immune-mediated colitis (IMC) has been described. However, in contrast to other checkpoint inhibitors, such as ipilimumab, drug-induced colitis due to nivolumab is not commonly reported. We report the case of a 59-year-old male who had undergone surgical resection for gastroesophageal junction adenocarcinoma, had been on nivolumab during the past five months, and presented with worsening diarrhea. Colonoscopy demonstrated local edema and mild colitis in a region of the colonic mucosa located 30 cm distal to the ileocecal valve. Biopsies revealed acute moderate colitis. The patient responded well to loperamide and dietary modifications. Although nivolumab rarely causes IMC, this occurrence requires proper management in order to avoid further complications.

Granulomatous Peritonitis Secondary to Primary Sclerosing Cholangitis.

Primary sclerosing cholangitis (PSC) is a rare, chronic, and progressive disease of the liver characterized by cholestasis due to multifocal bile duct strictures. PSC can lead to liver fibrosis, and in 10-20% of cases, it leads to cholangiocarcinoma and end-stage liver disease. However, the pathogenesis of the disease is not clearly understood. For the diagnosis of PSC, both imaging and liver biopsy can be used. No medical treatment has managed to prevent the progression of the disease. Consequently, in the case of late-stage disease, liver transplantation is considered the best treatment option. PSC may lead to different complications including bacterial cholangitis, cholangiocarcinoma, and cirrhosis. Nevertheless, to our knowledge, there are no reports of granulomatous peritonitis secondary to PSC. Granulomatous peritonitis may be a result of infectious, malignant, and idiopathic inflammatory diseases. It is also considered a rare postoperative complication, due to cornstarch from surgical glove powder, in laparoscopic procedures. Here, we report the case of a 39-year-old male patient with PSC, in which cholangiocarcinoma and peritoneal carcinomatosis were clinically suspected. Despite that, histological findings and staining methods of the surgically removed peritoneal masses demonstrated granulomatous peritonitis.

Signaling pathways associated with bone loss in inflammatory bowel disease.

Inflammatory bowel disease (IBD) is a chronic inflammatory disorder of the gastrointestinal tract characterized in many patients by extraintestinal manifestations. One of the most common comorbidities seen in IBD patients is a significant reduction in their bone mass. The pathogenesis of IBD is mainly attributed to the disrupted immune responses in the gastrointestinal mucosa and putative disruptions in the gut microbiomes. The excessive inflammation of the gastrointestinal tract activates different systems, such as the RANKL/RANK/OPG and the Wnt pathways linked with bone alterations in IBD patients, thereby suggesting a multifactorial etiology. The mechanism responsible for the reduced bone mineral density in IBD patients is thought to be multifactorial, and, so far, the principal pathophysiological pathway has not been well established. However, in recent years, many investigations have increased our understanding of the effect of gut inflammation on the systemic immune response and bone metabolism. Here, we review the main signaling pathways associated with altered bone metabolism in IBD.

An Automated Prognostic Model for Pancreatic Ductal Adenocarcinoma.

Pancreatic ductal adenocarcinoma (PDAC) constitutes a leading cause of cancer-related mortality despite advances in detection and treatment methods. While computed tomography (CT) serves as the current gold standard for initial evaluation of PDAC, its prognostic value remains limited, as it relies on diagnostic stage parameters encompassing tumor size, lymph node involvement, and metastasis. Radiomics have recently shown promise in predicting postoperative survival of PDAC patients; however, they rely on manual pancreas and tumor delineation by clinicians. In this study, we collected a dataset of pre-operative CT scans from a cohort of 40 PDAC patients to evaluate a fully automated pipeline for survival prediction. Employing nnU-Net trained on an external dataset, we generated automated pancreas and tumor segmentations. Subsequently, we extracted 854 radiomic features from each segmentation, which we narrowed down to 29 via feature selection. We then combined these features with the Tumor, Node, Metastasis (TNM) system staging parameters, as well as the patient's age. We trained a random survival forest model to perform an overall survival prediction over time, as well as a random forest classifier for the binary classification of two-year survival, using repeated cross-validation for evaluation. Our results exhibited promise, with a mean C-index of 0.731 for survival modeling and a mean accuracy of 0.76 in two-year survival prediction, providing evidence of the feasibility and potential efficacy of a fully automated pipeline for PDAC prognostication. By eliminating the labor-intensive manual segmentation process, our streamlined pipeline demonstrates an efficient and accurate prognostication process, laying the foundation for future research endeavors.

Ceftriaxone Administration Associated with Lithiasis in Children: Guilty or Not? A Systematic Review.

Lithiasis is a known side effect of ceftriaxone administration in children. Sex, age, weight, dosage, and duration of intake have been reported as risk factors for the formation of calcification or stones in the bile and urine excretory systems of children who received ceftriaxone. The purpose of this systematic review is to investigate the reported effects of ceftriaxone administration in pediatric patients who were admitted to a hospital due to infection, the likelihood of gallstones, nephroliths, or precipitations in both the biliary and urinary systems, as well as investigate the relationship with their mother's history during pregnancy. Original studies and literature reviews from the PubMed database were included in the study. No time limit related to research or publication was set for the articles. The results were evaluated, aiming to understand the outcomes and identify any predisposing factors relevant to this side effect. Of the 181 found articles, 33 were appropriate for inclusion in the systematic review. The administered dose of ceftriaxone presented variability. Symptoms, such as abdominal pain and vomiting, were associated with ceftriaxone-related lithiasis in many cases. It was noted that most of the results were the outcomes of retrospective observation and not of prospective randomized research. Definitively, more randomized control studies with long-term outcomes are needed to identify the exact association between ceftriaxone and lithiasis in children.

Two cases of primary splenic hydatid cyst in Greece.

Cystic disease of the spleen is an uncommon entity in general population. Most cases result from parasitic infection by Echinococcus granulosus, a form called splenic hydatid disease (SHD), with a reported frequency of 0.5-6.0% within abdominal hydatidosis. On the contrary, an isolated splenic involvement of hydatid disease is very uncommon even in endemic regions. Two cases of primary SHD managed with open and laparoscopic radical surgery in our department are reported herein. Primary SHD is a rare entity with non-specific symptoms underlying clinical suspicion by the physician for prompt diagnosis. Surgical treatment is the mainstay therapy, while laparoscopic approach when feasible is safe, offering the advantages of laparoscopic surgery.

Splenic Artery Ligation: An Ontable Bail-Out Strategy for Small-for-Size Remnants after Major Hepatectomy: A Retrospective Study.

It has been reported that the prevention of acute portal overpressure in small-for-size liver grafts leads to better postoperative outcomes. Accordingly, we aimed to investigate the feasibility of the technique of splenic artery ligation in a case series of thirteen patients subjected to major liver resections with evidence of small-for-size syndrome and whether the maneuver results in the reduction of portal venous pressure and flow. The technique was successful in ten patients, with splenic artery ligation alleviating portal hypertension significantly. Three patients required the performance of a portocaval shunt for the attenuation of portal hypertension. Portal inflow modulation via splenic artery ligation is a technically simple technique that can prove useful in the context of major hepatectomies as well as in liver transplantations and the early evaluation and modification of portal venous pressure post hepatectomy can be used as a practical tool to guide the effect of the intervention.