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.

Laparoscopic Cholecystectomy in Cirrhotic Patients.

Laparoscopic cholecystectomy is the gold standard procedure in patients with cirrhosis and symptomatic gallbladder disease or acute cholecystitis. In this retrospective study we evaluated laparoscopic cholecystectomy in patients with cirrhosis based on Child-Pugh score as a predictor of morbidity. In the First Surgical Clinic of Iasi, from 01 jan 2010 to 31 jan 2020, we performed 111 laparoscopic cholecystectomies in Child-Pugh A, B, and C cirrhotic patients. Intraoperative difficulty (grade 3 Cuschieri) was experienced in 32 patients (28.8%). Highly vascular sub hepatic adherences have been reported in a quarter of all patients. Intraoperative incidents were more frequent 27 (24.3%) compared to laparoscopic cholecystectomy performed in other patient groups. The conversion rate to open cholecystectomy was 6.3% (7 cases). Mean operative time was 84 min. Mean duration of hospitalization stay was 4.7 days. The morbidity rate was 16.2% of patients and included bleeding, intraabdominal fluid collections and wound complications more common in patients with Child-Pugh Cirrhosis B and C. The results are dependent of the perioperative management of the liver function.

Abdominal Actinomycosis Mimicking Colon Cancer.

Introduction: Abdominal actinomycosis is a rare granulomatous inflammatory disease caused by a Gram-positive anaerobic bacterium Actinomyces israelii, manifesting as inflammatory mass, or abscess formation. Evolution is slow and steady in inflammatory contiguous extension without limit organ that lends itself to confusion with abdominal malignancies. Methods: We performed a retrospective study on the patients with abdominal actinomycosis operated in the First Surgical Clinic, "St. Spiridon" University Hospital Iasi; between 1980 - 2018 there have been 13 cases (4 men and 9 women) with a mean age 44.07 years admitted for abdominal tumors (7 cases) or pelvic inflammatory disease (6 cases). Results: We identified as predisposing factors: IUD maintained over 10 years (6 cases), foreign bodies 2 cases (a toothpick probably perforated colon, gallstones lost in peritoneum), diabetes (3 cases), immunodepression. All cases were operated by laparotomy (9 cases) or laparoscopic approach (4 cases). We describe five of these cases of actinomycosis that had been mimicking a colon cancer: ileo - cecal - 3 cases, transverse colon - one case and on the greater omentum - one case, followed by specific treatment with penicillin, with good evolution. Conclusions: Abdominal actinomycosis should always be included in the differential diagnosis of abdominal tumors. Preoperative diagnosis, difficult but possible, can avoid surgery. Treatment with antibiotics is necessary for the healing of the disease. Postoperative control is mandatory, with relapses possible.

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.

Laparoscopic Treatment of Intraabdominal Cystic Lymphangioma.

UNLABELLED: The abdominal cystic lymphangioma (CL) in adults is a rare benign tumor of the lymphatic system. METHODS: We report a retrospective study from January 2002 to Decemberr 2014 concerning 18 patients who underwent surgical removal of a CL, 9 patients with laparoscopic approach included. The localization, size, and number, diagnostic, treatment and results have been reported for patients approached laparoscopically. RESULTS: There were 8 women and 1 man with median age at diagnosis was 35,6 years (range 20-51 years). Clinically, the main symptom was an abdominal pain found in 8 patients (88.8%). Physical examination revealed an abdominal mass in 5 patients (55.5%). The CL was asymptomatic in four patients; the discovery of CL was performed preoperatively during an ultrasound for another pathology (n=3) or intraoperatively (n=1). US exam CT scan usually allow the preoperative diagnosis. The most common site was shared equally between the mesentery (n = 3; 33%) and left retroperitoneum (n = 3;33%), followed by the right retroperitoneum and the posterior cavity of the lesser omentum and great omentum, each one case. The most common procedures performed were: laparoscopic total cystectomy of a closed cyst in two patients and evacuation of larger cysts followed by total cystectomy in seven patients. No conversion, no mortalities and no morbidity was noted. Mean hospital stay was 3.4 days. No recidive after 28 months in the average after treatment. CONCLUSIONS: The laparoscopic approach is the gold standard in the treatment of intraabdominal CL.We recommend complete surgical excision to avoid recurrence.

Atypical hepatic resection technique for hepatocellular carcinoma using radiofrequency Habib™ 4X Device.

INTRODUCTION: The number of liver resections significantly increased worldwide in the last 20 years. In many hepatic tumours, liver resection remains the best therapeutic option. A difficult intraoperative goal is to obtain a safe haemostasis on the transection plane. Technological innovation in recent decades allowed the development of different tools that allow better control of bleeding, faster and easier haemostasis. METHODS: We prospectively reviewed the patients diagnosed with hepatocellular carcinoma who underwent an atypical liver resection using a radio frequency (RF) ablation. SURGICAL TECHNIQUE: We used a Habib™ 4X bipolar, handheld, disposable RF ablation device. The technique is similar to parenchymal approach, but after the operative ultrasound exam to confirm the tumour and resection plane and liver mobilisation, we perform a plane of coagulative necrosis around the tumour using Habib™ 4X. The parenchyme is then sectioned using the scalpel. RESULTS: 19 patients with hepatocellular carcinoma were included in this study. The mean operative blood loss volume was 170±90.7 ml. The mean operation time was 118±58 min. The postoperative morbidity rate was 32% (n=6) and the reintervention rate was 5.3% (n=1). We encountered no postoperative deaths. The overall mean postoperative stay was 11.6±5.1 days. CONCLUSION: Bipolar radiofrequency device Habib™ 4X allows a shorter operative time with minimal blood loss and low rate of morbidity and mortality.

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.

Protective or Risk Factors for Postoperative Pancreatic Fistulas in Malignant Pathology.

INTRODUCTION: Malignant tumors are associated with a low incidence of postoperative pancreatic fistulas. The presence of peritumoral fibrosis is considered the protective factor for the development of postoperative pancreatic fistulas after pancreatic resections for pancreatic ductal adenocarcinomas. METHODS: We analyzed a series of 109 consecutive patients with pancreatic resections for malignant pathology: pancreatic ductal adenocarcinomas and periampullary adenocarcinomas. The incidence of postoperative pancreatic fistulas has been reported in tumor histological type, in the presence of peritumoral fibrosis, and in the association between adenocarcinomas and areas of acute pancreatitis. The data obtained were processed with the statistical analysis program SPSS, and statistically significant p were considered at a value <0.05. RESULTS: For the entire study group, the incidence of postoperative pancreatic fistulas was 11.01%. The lowest incidence was observed in the group of patients with pancreatic ductal adenocarcinomas (4.06% vs. 25.72% in the group with periampullary adenocarcinoma), with a p = 0.002. The presence of peritumoral fibrous tissue was observed in 49.31% of cases without pancreatic fistulas, and in 54.54% of cases that developed this postoperative complication (p = 0.5). Also, the peritumoral fibrous tissue had a uniform distribution depending on the main diagnosis (56.14% in pancreatic ductal adenocarcinoma group vs. 37.04% in periampullary adenocarcinoma group, with a p = 0.08). In the group of patients who associated areas of acute pancreatitis on the resections, the incidence of postoperative pancreatic fistulas was 7.8 times higher (30% vs. 3.8%, p = 0.026). CONCLUSIONS: Peritumoral fibrous tissue was not a factor involved in the developing of postoperative pancreatic fistulas. The association of adenocarciomas with areas of acute pancreatitis has led to a significant increase in postoperative pancreatic fistulas, which is a significant and independent risk factor.

Ulcerated intussuscepted jejunal lipoma-uncommon cause of obscure gastrointestinal bleeding: A case report.

BACKGROUND: Intestinal lipomas are rare benign gastrointestinal (GI) tumors, usually asymptomatic, but may become symptomatic as the result of some complications such as intussusception, intestinal obstruction, volvulus or bleeding. They can occur at any site along the entire GI tract, more frequent in colon and rarely in small intestine. The patient reported here is a very rare case of jejunal lipoma, ulcerated and intussuscepted, diagnosed in an adult investigated for a chronic iron deficiency anemia (IDA), and successfully managed by segmental jejunal resection. CASE SUMMARY: A 63-year-old male was referred to "St. Spiridon" Hospital, Institute of Gastroenterology and Hepatology, Iasi, to investigate an obscure GI bleeding with an IDA. After upper GI endoscopy and colonoscopy were performed, excluding potentially bleeding lesions, videocapsule endoscopy was then carried out, revealing fresh blood and a protruding lesion in proximal jejunum, findings confirmed by a single-balloon enteroscopy. Multiple biopsies were taken from the lesion, but histological results were inconclusive. Then, contrast - enhanced computed tomography was performed showing jejunal polypoid mass with homogenous fat density, suggestive for lipoma. A week later a laparotomy was performed revealing the intussuscepted jejunal segment which was resected en bloc, and sent for further histopathologic analysis. The patient made an uneventful recovery and was discharged seven days later, and at six months follow-up he had no complains and his hemoglobin returned to normal value. CONCLUSION: Lipomas are very rarely located in the jejunum, usually asymptomatic, but they may lead to complications such as intussusception and bleeding. Surgical resection remains the treatment of choice.

Emergency Backwards Whipple for Bleeding: Formidable and Definitive Surgery.

INTRODUCTION: During the past decades, the safety of pancreatoduodenectomy has improved, with low mortality and reduced morbidity, particularly in centers with extensive experience. Emergency pancreatoduodenectomy is an uncommon event, for treatment of pancreaticoduodenal trauma, bleeding, or perforation. We herein present a single center experience concerning nontrauma emergency pancreatoduodenectomy for pancreaticoduodenal bleeding. METHODS: From January 2007 to December 2015, from a population of 134 PD (70 males and 64 females, mean age 62.2, range 34-82), 5 patients (3.7%; 2 males and 3 females, mean age 64, range 57-70) underwent one-stage emergency pancreatoduodenectomy for uncontrollable nontrauma pancreaticoduodenal bleeding in our tertiary center. RESULTS: All the 5 patients underwent a backwards Whipple with a morbidity of 60% and a mortality of 20% (1/5). The other 4 patients were recovered and discharged with a median postoperative length of stay of 17 days (range 14-23). CONCLUSION: Emergency pancreatoduodenectomy is a definitive life-saving procedure allowing for a rapid control of bleeding when other less invasive approaches (transcatheter arterial embolization or interventional endoscopy) are exhausted, unavailable, or unsafe. It should be particularly considered in neoplastic disease and tailored by surgeons with a high level of experience in pancreatic surgery.