Diagnosis and surgical treatment of extrahepatic portal vein aneurysm: A case report.

Extrahepatic portal vein aneurysm is a relatively uncommon entity. We reported the case of a 51-year-old man, who was incidentally diagnosed with an asymptomatic 52 × 65 mm portal vein aneurysm, which was located at the main trunk of the portal vein, just before its bifurcation. The patient was treated with partial clamping of the portal vein aneurysm and aneurysmorrhaphy. Postoperative course was uneventful. Surgical intervention should be considered for patients with large, symptomatic or expanding portal vein aneurysms.

Stenting of a gastroduodenal artery aneurysm: report of a case.

We present a case of gastroduodenal artery stenting in a patient with recurrent episodes of pancreatitis due to gastroduodenal artery aneurysm. Stenting was performed under local anesthesia using a 6 × 38-mm primary covered Advanta V12 vascular stent graft. The procedure was successful and the patient is asymptomatic 21 months later. Endovascular treatment of gastroduodenal artery aneurysm should be considered a promising alternative to open surgery, due to lower mortality and morbidity.

Cold snare polypectomy vs. hot snare polypectomy vs. argon plasma coagulation for small (5-9mm) left-sided colorectal polyps: a prospective randomized trial.

OBJECTIVE: To compare recurrence rates among three endoscopic treatment modalities for 5-9 mm left-sided colorectal polyps. METHODS: Consecutive adults referred for elective colonoscopy (1/2015-1/2018) with at least one polyp of eligible size (5-9 mm) located distally to the splenic flexure were randomly assigned (1:1:1) to one of three treatment modalities: (1) cold snare polypectomy (CSP), (2) hot snare polypectomy (HSP) and (3) argon plasma coagulation (APC) ablation (50-60 W, flow: 2 l/min). The polyp site was marked with an endoscopic tattoo, and a follow-up colonoscopy with scar biopsies was performed >6 months after the index procedure. Outcomes were polyp recurrence rate and occurrence of complications. RESULTS: One hundred nineteen patients were enrolled, of whom 112 (62.5% males, mean age 61.1 ± 9.9 years) with 121 polyps (CSP, 39; HSP, 45; APC, 37) returned for follow-up colonoscopy. Mean polyp size was 6.7 ± 0.91 mm, 58% were located in the sigmoid, 33% in the rectum and 8% in the descending colon. The majority of polyps resected by CSP or HSP were neoplastic (tubular adenomas: 25.9%, tubulovillous adenomas: 11.1% and sessile serrate adenomas/polyps: 17.5%). No cases of delayed bleeding or perforation occurred. Scar biopsies at follow-up colonoscopy (performed after a mean interval of 13.4 ± 3.8 months) revealed 7 (5.8%) cases of polyp recurrence, showing no significant difference among the three treatment groups [CSP, 3/39 (7.7%); HSP, 1/45 (2.2%); APC, 2/37 (5.4%); P = 0.51). CONCLUSIONS: CSP, HSP and APC-ablation are effective and well-tolerated treatment modalities for 5-9 mm left-sided colorectal polyps. The present randomized study did not detect any difference in polyp recurrence rate among the three endoscopic techniques.

Intestinal preconditioning ameliorates ischemia-reperfusion induced acute lung injury in rats: an experimental study.

BACKGROUND: Phospholipases A(2) (PLA(2)) have been implicated in the pathogenesis of acute respiratory distress syndrome (ARDS) induced by intestinal ischemia-reperfusion (IIR). Intestinal ischemic preconditioning (IIP) has been shown to improve intestinal tolerance to subsequent sustained ischemia and limit the systemic inflammatory response. We tested the effect of IIP on the intestinal ischemia-reperfusion-induced ARDS, with particular focus on PLA(2). METHODS: Rats were randomized into three groups: (1) sham surgery group (sGroup), 45 min sham intestinal ischemia-4 h reperfusion, (2) IIR group (IIRGroup), 45 min intestinal ischemia-4 h reperfusion, (3) IIP group (ipGroup), three cycles of intestinal ischemia for 4 min and reperfusion for 10 min followed by 45 min intestinal ischemia-4 h reperfusion. At the end of each experiment, blood gases were obtained and bronchoalveolar lavage (BAL) followed. Biochemical (total protein, PLA(2), PAF-AcH) and cytological parameters of the BAL fluid were quantified. Plasma MDA was measured as an indicator of systemic oxidative stress. Comparisons between groups were made using one-way ANOVA followed by post hoc comparison with a Tukey test or Mann-Whitney test when appropriate. Differences were considered significant if P < 0.05. RESULTS: Alveolar-arterial O(2) gradient values and wet to dry lung ratio were significantly (P < 0.05) increased in the IIRGroup and this increase was prevented in the ipGroup. Following the same pattern, BAL total protein, PLA(2), and PAF-AcH were significantly lower in the ipGroup. Ischemic preconditioning significantly abolished neutrophil count in BAL fluid. Plasma MDA was significantly lower in the ipGroup. Despite a significant tissue polymorphonuclear reduction, no significant lung or intestinal histologic damage score changes were revealed. CONCLUSIONS: Intestinal preconditioning protects IIR-induced lung injury, partly by modulating the arachidonic acid cascade.

Liver transplantation in pigs: NO, oxygen free radicals, pulmonary hemodynamics.

BACKGROUND: We determined the alterations of nitric oxide (NO) and oxygen free radicals during orthotopic liver transplantation (OLT) in healthy pigs and investigated their relationship to pulmonary hemodynamics. MATERIALS AND METHODS: Fourteen pigs served as donors and recipients for 7 OLT, under general anesthesia. Hemodynamic monitoring included: systemic and mean pulmonary arterial pressure, pulmonary capillary wedge pressure, cardiac output, cardiac index, pulmonary (PVR) and systemic vascular resistance. Serum NO concentration and serum total antioxidant capacity (TAC), which indirectly quantifies the oxygen free radicals in the serum were determined by spectroscopic method of luminol-dependent chemiluminescence, before laparotomy, before reperfusion, 30 and 60 min postreperfusion. RESULTS: PVR increased significantly during the anhepatic phase and remained at high levels at 30 and 60 min postreperfusion (P = 0.046). NO concentration decreased significantly until 60 min postreperfusion (P = 0.009). TAC decreased throughout the whole period of our measurements (P = 0.002). A significant positive correlation was found between NO concentration, TAC, and PVR (P = 0.026 and P < 0.01, respectively, Spearman correlation). CONCLUSIONS: Our study showed a significant correlation between increased PVR, reduced NO concentration, and increased serum oxygen free radicals levels in the early reperfusion period in healthy pigs undergoing OLT.

HPV infection and breast cancer. Results of a microarray approach.

OBJECTIVES: Human papilloma virus (HPV) has been implicated in several types of epithelial cancer. The role of HPV in breast carcinogenesis has been a matter of debate fueled by conflicting reports in recent years. The aim of this study is to identify the prevalence of breast and cervical HPV infection in cancer patients by using a modern microarray approach. MATERIALS AND METHODS: In the present prospective study, 201 breast cancer patients were included. For each patient a detailed medical history was taken and during the operation, under sterile conditions, samples were collected, from the tumour, the healthy adjacent breast tissue and any positive sentinel lymph nodes. In addition, for each patient a cervical sample was also collected. All samples were analysed for DNA of 24 types of HPV using a microarray technique. RESULTS: Despite the high sensitivity of the technique used, no HPV DNA was identified in any of the breast or lymph node samples. Our analysis showed that patients with HPV positive cervical samples (28 cases) were more likely to have tumors with positive progesterone receptors (p=0.041) and were also more likely to have two or three positive lymph nodes (p=0.002). CONCLUSION: In the present study, a combination of careful sample collection and a very sensitive microarray approach showed no correlation between HPV and breast cancer. However some characteristics of the breast tumors were different among patients with HPV DNA in their cervical samples.

"Solitary" necrotic nodule of the liver: an enigmatic entity mimicking malignancy.

AIM: The aim of the study is to further investigate the clinicopathological features of solitary necrotic nodules. MATERIAL AND METHODS: Twenty-three archived cases of solitary necrotic nodule of the liver, which were preoperatively misdiagnosed as liver metastases were studied. The pathological findings were correlated with the clinical data of the patients. RESULTS: The nodules were solitary in 20 cases and multiple (2) in three cases, and measured from 0.5-1.5 cm in diameter. Twenty-one cases were located in the right lobe of the liver (91.6%) and two in the left lobe (8.69%). Twenty nodules were found in the subcapsular region (86.95%), while three nodules were located within the hepatic parenchyma (13.04%). More then half of our cases (12) were accompanied by extended calcification. Granulomatous tissue resembling "burnt-out" parasitic granulomas was found in three cases. CONCLUSIONS: Solitary necrotic nodules of the liver often mimic malignancy in abdominal imaging. Thus, permanent histopathology of the operative specimen remains the only accurate method of diagnosis. Their pathogenesis is most likely variable, and most reported cases are linked either to a parasitic or a vascular origin. Despite the designation of these lesions as "solitary" they may occasionally be multiple. In addition to the standard histological criteria of solitary necrotic nodules, the relatively small size (15 mm or less) and the frequent presence of calcifications seem to further characterize this enigmatic entity. Solitary necrotic nodule should be included in the differential diagnosis of small liver lesions with extensive necrosis.

Challenging diagnostic and therapeutic modalities for leiomyosarcoma of inferior vena cava.

Leiomyosarcoma of the inferior vena cava (IVCL) is a rare malignant tumour originating from the smooth muscle cells of the media with intra- or extra-luminal growth. The type of the lesion is further divided into three levels in relation to hepatic and renal veins respectively. The aim of this review was to evaluate the results of surgical treatment of IVCL with special reference to the extent of its histological spread and to analyse the recent literature in order to provide an update on the current concepts of diagnostic and therapeutic management of this entity. IVCL's patients may present with non-specific complaints such as dyspnoea, malaise, weight loss, nausea, vomiting, fever and abdominal pain. Haematogenous metastasis is frequent. At a later stage, IVCL may also spread through lymphatic. Multiple diagnostic imaging techniques have been proposed for accurate preoperative diagnosis, including Doppler ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI), individually or in combination with cavography echocardiography or CT-guided biopsy. Despite recent research on the therapeutic strategies against IVCL, surgical resection appears the only potentially curative approach. Unfortunately, a mere minority of patients is eligible to undergo surgical intervention. In addition, surgical removal of IVCL does not necessarily guarantee patient's long-term survival. Alternative therapies, such as radio- and chemo-therapy often proved insufficient. Debate continues regarding the optimal management of the IVC after tumour resection, with primary repair, ligation and IVC reconstruction all have been utilized with varying success.

Metastatic Liver Disease Associated with Gastrointestinal Stromal Tumors: Controversies in Diagnostic and Therapeutic Approach.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are the most frequent mesenchymal lesions of the GI tract. They are considered to originate from neoplastic transformation of either the intestinal pacemaker cells of Cajal or the precursor pluripotential stem cells. The genetic basis of GIST growth is an activating mutation of two receptor tyrosine kinases. Recent epidemiologic studies demonstrate that the GIST prevalence is approximately 20/1000000/year. Although GISTs develop in every part of the GI tract, stomach remains the most common localization. About 80 % of the patients experience tumor recurrence or hepatic metastasis after radical resection. GIST liver metastases are usually multiple, large in diameter, and localized in both lobes. In addition, GISTs are usually completely asymptomatic, discovered incidentally. Symptoms are not typical and depend on the location, size, and aggressiveness of the tumor. DISCUSSION: Diagnostic evaluation is based on imaging techniques, such as computed tomography, magnetic resonance imaging, positron emission tomography, and endoscopic ultrasound. Despite recent research on the therapeutic strategies against GISTs, surgical resection appears the only potentially curative approach. For the advanced metastatic disease, imatinib, a tyrosine kinase inhibitor, has been proposed neoadjuvantly with the surgery performed after the adequate reduction of tumor burden. The aim of this review was to evaluate the results of surgical treatment for metastatic GIST with special reference to the extent of its histological spread and to present the recent literature in order to provide an update on the current concepts of advanced surgical management of this entity.

Adjuvant systemic therapy protocol for Dukes' B2 and C resectable colon carcinoma.

AIMS AND BACKGROUND: Trials of adjuvant systemic therapy in high risk patients with Dukes' B2 and C colon cancer utilizing 5-fluorouracil-based regimens have been ongoing since the 1960s. The aim of this study was to compare the combination of 5-FU and leucovorin with the combination of 5-FU and alfa-2b interferon (IFN) in patients who had undergone "curative" resection foronocarcinoma. STUDY DESIGN: A total of 322 patients with histologically proven adenocarcinoma of the colon, Dukes' stage B2 and C, were entered in the study. They were randomized to A) leucovorin 20 mg/m2 rapid intravenous injection and 5-FU 425 mg/m2 IV days 1-5 every 28 days for six cycles or B) 5-FU 600 mg/m2 24-hour infusion for five days, then 600 mg/m2 IV once a week and IFN 5 MU subcutaneously three times a week for six months. RESULTS: There was no statistically significant difference in either disease-free survival or overall survival. Toxicity was the same in the two groups with the exception of flu-like syndrome, which was universal in IFN-treated patients. CONCLUSIONS: There was no difference in disease-free survival or overall survival between the two combinations in any patient subset. Toxicity was greater with the 5-FU+IFN combination because of the flu-like syndrome. These data do not support the use of IFN in combination with 5-FU as systemic adjuvant therapy for patients with locally advanced colon carcinoma.

Hereditary pancreatitis: dilemmas in differential diagnosis and therapeutic approach.

INTRODUCTION: Hereditary pancreatitis (HP) is a rare, heterogeneous familial disease and should be suspected in any patient who has suffered at least two attacks of acute pancreatitis for which there is no underlying cause and unexplained chronic pancreatitis with a family history in a first- or second-degree relative. Genetic factors have been implied in cases of familial chronic pancreatitis. The most common PRSS1 mutations worldwide are the R122H and N29I variants. CLINICAL FEATURES: HP usually appears with an acute, a recurrent acute, and a chronic phase, referring to the inflammation of the pancreas and the symptoms' onset and duration. The clinical features of acute pancreatitis begin in childhood and last less than 6 months. HP carries a 50-70-fold increased risk of pancreatic cancer within 7-30 years of disease onset. HP diagnosis is defined by the presence of a detected cationic trypsinogen gene mutation (with or without clinical or radiological manifestations of chronic pancreatitis) or when the patient's family satisfies the requirements of the EUROPAC. TREATMENT: With regard to the therapeutic approach, pancreatic enzyme replacement therapy and analgesics are offered to control pain. In addition, endoscopic and surgical intersections are reserved for all relevant complications. Unfortunately, surgical removal of affected pancreatic tissue does not necessarily guarantee the patient's long-term survival. Furthermore, the prognostic factors and the efficacy of extended resection remain controversial.

Outcome following major hepatic resection in the elderly patients.

Recent advances in operative techniques, anaesthesiologic management and intensive care have greatly reduced morbidity and mortality of major hepatectomy allowing a progressive broadening of its indications by including patients with chronic liver disorders as well as elderly subjects. It is apparent that with the aging population, more elderly patients are being referred for surgery. Selecting appropriate candidates for surgical resection is therefore crucial to maximize the benefit derived from surgery. Nevertheless, it is not clear whether advanced age itself increases surgical risk or additional age-independent variables are associated with higher operative morbidity. Regardless of the indications for surgery and the extent of planned liver resections, this population is more likely to suffer from relevant disorders. Previous studies on the safety of major liver resections in the elderly patients cite morbidity and mortality rates of approximately 30-40% and 4-5% respectively. In addition, hepatic resections for hepatocellular carcinoma or colorectal liver metastases have been reported as safe in the elderly as in the younger population. Nevertheless, a small number of investigations studied the outcome of major hepatectomy in the population over 70 years of age. The aim of our study was to evaluate overall experience with liver resections in the elderly population by comparing the early as well as the long-term outcome of the procedure in 70 years and older versus the less than 70 age group and to identify whether the age of patients alone is associated with increased rate and severity of postoperative complications.

Primary hepatic lymphoma: dilemmas in diagnostic approach and therapeutic management.

Primary hepatic lymphoma (PHL) is a very rare malignancy and is characterized by liver involvement at presentation with no affectation of the spleen, lymph nodes, peripheral blood, bone marrow, or other tissues until at least 6 months after diagnosis. PHL should be considered in the differential diagnosis in a patient with space-occupying liver lesions and normal levels of alpha-fetoprotein and CEA. A computed tomography (CT) scan is the commonly used modality for staging lymphomas. The widespread use of positron emission tomography/CT results in the improvement in the accuracy of detecting the extent of disease, response evaluation, and prognostication. The liver biopsy, due to its pleomorphic appearances in the needle biopsy specimen, can be very challenging. Current literature favors the combination of chemotherapy as the frontline treatment for its least invasiveness and improved survival. Favorable prognosis of PHL can be obtained by early surgery combined with chemotherapy in strictly selected patients. However, the optimal therapy is still unclear and the outcomes are uncertain.

Familial pancreatic cancer: challenging diagnostic approach and therapeutic management.

BACKGROUND: Familial predisposition characterizes up to 10% of the patients with pancreatic cancer (PC). Although many syndromes have been associated with an increased risk for PC, familial pancreatic cancer (FPC) accounts for the majority of hereditary cases. FPC is defined by families with at least a pair of first-degree relatives (FDRs) who have been diagnosed with PC and do not fulfill the criteria of other inherited tumor syndromes. METHODS AND RESULTS: Genetic counseling is of great importance to estimate the prevalence and recommend further molecular testing. Regarding the screening program for individuals with increased risk for PC, a consortium summit stated that candidates for screening are FDRs of patients with PC from a familial kindred with at least two affected FDRs, patients with Peutz-Jeghers syndrome and p16, BRCA2, and hereditary nonpolyposis colorectal cancer (HNPCC) mutation carriers. It was also agreed that initial screening should include endoscopic ultrasonography (EUS) and/or magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography (MRCP) instead of computed tomography (CT) or endoscopic retrograde cholangiopancreatography (ERCP). CONCLUSIONS: However, the optimal age of initial screening remains undefined. Furthermore, a multidisciplinary assessment is required to determine whether surgical interventions should be performed at high-volume specialty centers. The aim of this study is to collect all the recent information considering the genetic basis, screening protocols, and treatment of FPC in order to provide an update on the current contemporary concepts of therapeutic management of the disease.

Rectum sarcoma: challenging diagnostic and therapeutic modalities.

INTRODUCTION: Sarcomas are malignant tumors that arise from mesenchymal tissue at any of the body sites. They incorporate the wide category of GISTs and are classified in various histological types. Histological grading is another indicator of the degree of malignancy, the probability of distant metastases, and survival but remains a poor definition of local recurrence. DISCUSSION: The size and depth of invasion are the most important prognostic factors. Since they grow within the intestinal wall, the symptoms are usually few or late, leading to delays in diagnosis. Most common signs are rectal bleeding, abdominal or anal pain, diarrhea, tenesmus and weight loss. The diagnostic and staging protocol of stromal tumors of the rectum includes mainly endoscopic surveillance, computed tomography, and magnetic resonance imaging. Therefore, rectum sarcoma (RS) consists one of the most biologically virulent cancers and is difficult to cure by conventional procedures. The treatment is primarily surgical, where possible, and should guarantee complete clearance of the tumor, which often requires an aggressive approach. Unfortunately, the minority of patients is eligible to undergo surgical intervention. In addition, surgical removal of RS does not necessarily indicate a patient's long-term recovery. Alternative therapies, such as radio- and chemotherapy, proved insufficient. Elucidation of its molecular basis may prove useful in developing and identifying prognostic biomarkers.

Retroperitoneal schwannomas: dilemmas in diagnostic approach and therapeutic management.

INTRODUCTION: Schwannomas are rare tumors arising from Schwan cells of the peripheral nerve sheath. The majority of the cases are sporadic and familial clustering is often observed in association with von Rechlinghausen's disease. Cases of intrasacral (osseous) and spinal tumors have also been described. Histologically, schwannomas are distinguished by the presence of areas of high and low cellularity called Antoni A and B tissue, respectively. CLINICAL PRESENTATION: Clinical features are highly non-specific and depend on the location and size of the lesion, with abdominal pain and neurological deficit being the most common abnormalities. Radiological studies are fundamental in the diagnostic evaluation of RSs. THERAPEUTIC MANAGEMENT: Despite recent research on the therapeutic strategies against RS, surgical resection appears the only potentially curative approach. Unfortunately, a mere minority of patients is eligible to undergo surgical intervention. In addition, surgical removal of RS does not necessarily guarantee patient's long-term survival. Laparoscopic approach and enucleation of the tumor have been suggested as well. Alternative therapies, such as radio- and chemotherapy often proved insufficient. The aim of this review was to evaluate the results of surgical treatment for RS with special reference to the extent of its histological spread and to analyze the recent literature in order to provide an update on the current concepts of therapeutic management of this entity.

Does ductal lavage assert its role as a noninvasive diagnostic modality to identify women at low risk of breast cancer development?

OBJECTIVE: Ductal lavage (DL) involves evaluation of the ductal system of the breast for detection of intra-ductal carcinomas and precursor lesions by collecting breast epithelial cells using a small-gauge catheter inserted into a ductal orifice on the nipple. The aim of this survey was to analyze cytologic features of samples obtained from low-risk women with DL and to elucidate the efficacy of this diagnostic modality in evaluating fluid production, cannulating and determining atypical breast epithelial cells. METHODS: Into this prospective study were consecutively registered 80 women between ages 28 to 67. Nipple aspiration was performed to identify all fluid-yielding ducts. According to the grading of specific features the interpretation of the sample included: normal/benign (category, 0), mild atypical (category, I), markedly atypical (category, II) or malignant (category, III) disorders. RESULTS: Ninety five percent (316/334) of the nipple aspirate fluid samples were classified as category 0, 4.8% (16/334) as category I and 0.2% (2/334) as category II changes. Category III disorders were not detected. Therefore, in 80% of the women examined results were within normal limits while 17.5% of the participants presented mild atypical and 2.5% markedly atypical rates. CONCLUSION: DL collection procedure proved to be rapid as well as acceptable by the women studied. It retains the advantage over other methods of nipple aspirate fluid in that it is easy to perform, thereby removing most clinician variability. It also helped low risk women to discriminate those with breast disorders that require additional investigation, further follow-up or administration of preventive medication.

Prophylactic total gastrectomy for hereditary diffuse gastric cancer. Review of the literature.

Hereditary diffuse gastric cancer (HDGC) is characterized as an autosomal dominant cancer susceptibility syndrome largely attributable to germline mutations and deletions in the gene encoding E-cadherin, CDH1. Mutation carriers have a more than 70% lifetime risk of developing DGC and an elevated probability of lobular breast cancer. The aim of this review was to evaluate the results of surgical treatment for HDGC with special reference to the extent of its histological spread and to analyze the recent literature in order to provide an update on the current concepts of prophylactic gastrectomy for disease prevention. Nevertheless, it is not clear that our current knowledge of molecular and genetic diagnostics calls for the addition of HDGC to the roster of malignant familial syndromes in which early counseling and preventive surgical intervention should become the standard of care. Endoscopic screening cannot be recommended because the stomach appears normal and biopsies often fail to demonstrate signet ring cell adenocarcinoma. Prophylactic gastrectomy has provided many members of affected families with relief from GC with minimal implications.