Laparoscopic cholecystectomy can be performed safely with only three ports in the majority of cases.

Reducing the number of ports used to perform laparoscopic cholecystectomy (LC) is indicated as means of further minimising postoperative pain, allowing a rapid return to activity and work, and obtaining patient satisfaction and better cosmetic results. It is still debatable whether the three-port technique is comparably safe. Since 2001, 374 consecutive patients underwent laparoscopic cholecystectomy in elective and emergency surgery. Three ports were routinely positioned and the need for a fourth cannula was evaluated during the surgical procedure. Of the 374 consecutive cholecystectomies performed, 204 were completed with three ports and 161 needed a fourth port to be completed, while 9 required conversion to laparotomy. Patients who were operated on with just three ports were significantly younger and mostly female. Complications of procedures completed with three ports were negligible and those of procedures completed with four ports were in line with the recent literature. Our experience shows that the three-port technique is always a good initial option when performing laparoscopic cholecystectomy. It is safe and requires conversion to four-port placement in only a minority of cases overall.

Hydatid cyst of the liver: spontaneous rupture with peritoneal and thoracic involvement. Report of a case.

Hydatidosis due to Echinococcus granulosus is an endemic parasitic disease in Mediterranean countries. The most frequent anatomical locations are the liver and lung and the most significant complication of liver hydatidosis is rupture into the biliary tract. Spontaneous rupture into the free peritoneal cavity associated with thoracic involvement is an unusual complication accompanied by a high mortality rate. An isolated abdominal approach is necessary when peritoneal cavity drainage is required and may be sufficient in cases of contamination of the pleural cavity by scolices without suppurative involvement. An unusual case of spontaneous rupture of a hydatid cyst of the liver into the free peritoneal cavity associated with diaphragmatic and pleural involvement is reported. This complication requires immediate surgical treatment consisting in a combined thoracic and abdominal approach. The isolated abdominal approach not requiring thoracotomy may be satisfactory if there is no intrathoracic damage due to the chronic presence of scolices. Intrabdominal and intrathoracic cyst rupture still remains a serious complication because of the complexity of the lesions which are often difficult to treat in a one-stage operation. The mortality remains high in various series.

Treatment of liver metastases from uveal melanoma.

BACKGROUND: Uveal melanoma patients with liver metastases have a poor prognosis. The effect of screening and multimodality treatment (including surgery) should be evaluated. METHODS: A total of 602 patients treated for uveal melanoma during a 14-year period had abdominal ultrasonography screening every 6 months. Sixty-three developed liver metastases as the first extraocular metastatic site. When possible, liver surgery and intra-arterial catheter implantation were performed. The influence on survival of demographics, uveal tumor characteristics, liver metastasis presentation, and treatment was studied. RESULTS: The median time to liver metastasis was 29 months. Twenty-eight patients (44%) were operated on: 14 (22%) had R0 liver surgery, and 14 with diffuse liver involvement had R2 liver surgery (there were no significant surgical complications). Thirty-five patients with diffuse liver involvement received systemic chemotherapy or best supportive care only. The median overall survival was 15 months (range, 3-110 months): 25 months for the 14 patients with R0 surgery, 16 months for the 14 with R2 surgery, and 11 months for the 35 with chemotherapy or supportive care. By univariate analysis, age (< or =70 years), number of metastases (< or =10), and quality of operation (R0) were predictive of a better prognosis. CONCLUSIONS: In the case of liver metastases from uveal melanoma, aggressive treatment permitting tumor eradication seems to offer a chance of long-term survival to selected patients. Nevertheless, neither ultrasound screening nor quality of operation had an effect on the outcome of most patients (78%). Better screening tests and more effective multimodality treatments are required to improve survival in uveal melanoma patients with hepatic metastases.

Pemetrexed in gastric cancer.

Gastric cancer is a major clinical challenge, with poor overall prognosis and limited life expectancy for patients with advanced disease. Even with surgery and other modalities, palliation is often difficult. Improvement of response rates has evolved with the development of standard regimens and those incorporating newer chemotherapy agents, such as oral fluoropyrimidines, the taxanes, camptothecins, novel platinums (eg, oxaliplatin [Eloxatin]), and antifolates (eg, pemetrexed [Alimta]). Ongoing trials with these regimens aim toward improving survival, as well as improving the safety profile. It is hoped that in conjunction with molecular research in the pathogenesis of gastric cancer and development of targeted therapies in this disease, these trial data might lead to the evolution of treatment strategies that could prove effective.