Ultrasound-guided liver resection: Early experience in a district general hospital.

INTRODUCTION: Intraoperative ultrasonography (IOUS) is the gold standard for tumor staging and operative decision making in liver surgery. Providing dynamic information on tumor-vessel relationships and distribution of intrahepatic veins, IOUS is also an important support for guiding the resection. Few authors report an extensive use of IOUS-guidance as a safe and effective approach. The aim of this study is to investigate the short-term results of an early experience of ultrasound (US) guided liver resection. METHODS: From December 2005 to December 2007 an extensive use of IOUS-guided resection was applied in 11 consecutive patients (8 males and 3 females; median age 74 years). Perioperative data were collected prospectively to assess the influence of this approach on mortality, morbidity and early recurrence. RESULTS: Four patients had hepatocellular carcinoma, 4 liver metastases, 1 peripheral cholangiocarcinoma, 1 hemangioma and 1 inflammatory pseudotumor. A median of 1 (range: 1-4) nodule per patient was resected. Median lesion size was 44 mm. Liver procedures included: 3 wedge resections, 3 subsegmentectomies, 4 segmentectomies and 3 bisegmentectomies. Median blood loss was 235 ml. Median surgical margin in cancer patients was 5 mm (range: 1-12). An average of 1 unit of blood transfusion was administered in 5 patients. Median postoperative hospital stay was 9 days. There was no mortality. Major complications occurred in 1 patient and minor complications in 5 patients. During a median follow-up of 14 months no recurrences were observed. CONCLUSIONS: In this study, use of IOUS-guided liver resection performed in a district general hospital proved to be a safe and effective approach in terms of short-term outcome.

[Laparoscopic or open appendectomy. Critical review of the literature and personal experience]. / Appendicectomia laparoscopica o a cielo aperto. Revisione critica della letteratura ed esperienza personale.

UNLABELLED: In the era of video-laparoscopic surgery there are a lot of surgeons that still continue to perform open appendectomy. This choice is the consequence of the good results of open appendectomy (clinical, cosmetic, hospital stays and hospital costs). Published trials on laparoscopic appendectomy don't show that it is superior to the open approach. The aim of this study is to critically review the literature on laparoscopic and traditional appendectomies and to report a clinical experience on 86 consecutive patients that underwent open appendectomy. PATIENTS AND METHODS: From September 2000 to March 2001, in the Department of Emergency Surgery of Villa Scassi Hospital in Genoa, 86 patients underwent open appendectomy (32 men; mean age 29.8 years; range 15-54 years/54 women; mean age 22.4 years; range 13-80 years). All the patients underwent blood examinations, abdomino-pelvic ultrasonographys and the women gynecological evaluation. The Authors used, almost always, the Stropeni way of access (cutaneous Mac Burney and right para-rectal incision of the muscles). Discharge has been done as soon as possible. Removed appendices were submitted to histological examination and were classified as normal or pathologic according to the severity of the lesion. Review of articles has been done on Medline. RESULTS: Suspected appendicitis have been confirmed by histological examination that documented 1 normal appendix, 7 chronic appendicitis, 45 acute catharralis, 22 acute suppurative and 11 gangrenous or perforated appendicitis. The specificity of open appendectomy has been 97.6% (100% for men). Post-operative complications were: 2 wound infections and 1 recurrence of an abscess (2.58%). Open appendectomy did carry an hospital bill of 2,500,000 IT liras (1,200 USA dollars) for non complicated appendicitis and 2,000 USA dollars for perforated appendicitis. The early discharge allowed us to spend 119 millions IT liras less in 7 months (99,600 USA dollars in a year). DISCUSSION: The role of laparoscopic appendectomy isn't still established. After a critical review of the literature we can suggest that: 1) laparoscopic appendectomy increase operative time (63 vs 43 minutes: p < 0.0001); 2) laparoscopic approach can reduce the length of post-operative stay in hospital; 3) hospital bill is strongly reduced by open appendectomy (4,274 vs 7,923 USA dollars). On our experience the cost of the hospital for uncomplicated appendicitis is 2,500,000 IT liras (1,200 USA dollars). Otherwise it has been suggested that laparoscopic appendectomy has a better diagnostic accuracy respect to open appendectomy. Some Authors report a percentage of "negative" appendices of 16-50%. In Authors experience the percentage of "negative" appendices is 1.3% and so the diagnostic accuracy is 96% in women and 100% in men, probably because we systematically performed a preoperative abdomino-pelvic ultrasonography and, for the women, a gynecological evaluation. In conclusion, laparoscopic appendectomy should be done in case of suspected appendicitis in women. In the other cases, when there is a strong clinical suspect of appendicitis and, in particular, in case of suppurative appendicitis, the Authors recommend to perform an open appendectomy using the Stropeni approach. In case of perforated appendicitis with abdominal abscess they recommend to perform an open appendectomy using the right para-rectal approach or the median umbilical-pubis approach.

Disruption of PML subnuclear domains by the acidic IE1 protein of human cytomegalovirus is mediated through interaction with PML and may modulate a RING finger-dependent cryptic transactivator function of PML.

Both of the major immediate-early (IE) proteins IE1 and IE2 of human cytomegalovirus (HCMV) as well as input viral DNA and sites of viral IE transcription colocalize with or adjacent to punctate PML domains (PML oncogenic domains [PODs] or nuclear domain 10) in the nucleus within the first few hours after infection of permissive human fibroblasts. However, colocalization of IE1 and PML in PODs is only transient, with both proteins subsequently redistributing into a nuclear diffuse form. These processes are believed to promote efficient viral IE transcription and initiation of DNA synthesis especially at low multiplicities of infection. To examine the mechanism of PML displacement by IE1, we carried out indirect immunofluorescence assay experiments with plasmids expressing intact or deleted forms of PML and IE1 in DNA-transfected cells. The results demonstrated that deletion of the C-terminal acidic region of IE1 uncouples the requirements for displacement of both endogenous and coexpressed PML from those needed to target to the PODs. Mutant PML proteins containing either a Cys point mutation within the N-terminal RING finger domain or a small deletion (of positions 281 to 304) within the coiled-coil region did not localize to the PODs but instead gave a nuclear diffuse distribution, similar to that produced by intact PML in the presence of IE1. Endogenous PML also colocalized with IE1 in metaphase chromosomes in HCMV or recombinant adenovirus type 5-IE1-infected HF cells undergoing mitosis, implying that there may be a direct physical interaction between IE1 and PML. Indeed, a specific interaction between IE1 and PML was observed in a yeast two-hybrid assay, and the strength of this interaction was comparable to that of IE2 with the retinoblastoma protein. The RING finger mutant form of PML showed a threefold-lower interaction with IE1 in the yeast system, and deletion of the N-terminal RING finger domain of PML abolished the interaction. Consistent with the IFA results, a mutant IE1 protein that lacks the C-terminal acidic region was sufficient for interaction with PML in the yeast system. The two-hybrid interaction assay also showed that both the N-terminal RING finger domain and the intact coiled-coil region of PML are required cooperatively for efficient self-interactions involving dimerization or oligomerization. Furthermore, truncated or deleted GAL4/PML fusion proteins that retained the RING finger domain but lacked the intact coiled-coil region displayed an unmasked cryptic transactivator function in both yeast and mammalian cells, and the RING finger mutation abolished this transactivation property of PML. Therefore, we suggest that a direct interaction between IE1 and the N-terminal RING finger domain of PML may inhibit oligomerization and protein-protein complex formation by PML, leading to displacement of PML and IE1 from the PODs, and that this interaction may also modulate a putative conditional transactivator function of PML.

[Adhesive peritonitis caused by a foreign body. A case report]. / Peritoniti plastiche da corpo estraneo. Caso clinico.

After investigation of the international literature on this subject, the authors describe a case report of adhesive-stenotic and retractile peritonitis, very likely caused bt a foreign body reaction (surgical stitches, gloves, rice powder, etc.?). This case-report is interesting both to remember the existence of this pathology and to limit its iatrogenic development. In conclusion, it is advisable to wash surgical gloves with sterile solutions and to limit enlarged bowel resections mostly in young people.

[Prognostic significance of cell-mediated immune response in patients with colorectal carcinoma. Preliminary results]. / Significato prognostico della risposta immunitaria cellulo-mediata in pazienti affetti da carcinoma colo-rettale. Risultati preliminari.

Pre-operative skin test response has been evaluated in 50 cases of colorectal carcinoma. Cellular defense's depression was correlated with tumoral staging (p = < 0.001). In B2 and C groups, a higher incidence of metastatic and local recurrences was registered in subjects with low response. These last are suitable for a randomized trial including immunotherapy.

[Idiopathic and torsion-induced omental infarct: case reports and a review of the literature]. / Infarto omentale idiopatico e da torsione: contributo casistico e revisione della letteratura.

The authors review nosologic problems related to the infarction of the greater omentum on the ground of two cases (one idiopathic, the other by torsion) recently observed. Omental infarction, far from being a real diagnostic or surgical problem, is an unusual cause of acute abdomen; resection of the affected omentum is curative in 100% of cases.

[Evaluation of blood flow using a reservoir flowmeter of several types of arteriovenous fistulas in chronic hemodialysis treatment]. / Valutazione del flusso ematico di alcuni tipi di fistole artero venose per il trattamento emodialitico cronico mediante "flussi metria a pozzetto".

Blood flow of nine end to end and eight side to side arteriovenous fistulas (AVF) at distal forearm for maintenance hemodialysis, was measured by blood flowmeter inserted in the arterial line between the pump and the dialyzer. The mean flow of the end to end and the side to side fistulas was 386.6 +/- 69.6 ml/min and 345 +/- 45 ml/min (p 0.01) respectively. Since, in addition, the end to end flow seems to be better than the side to side flow as regards local and general effects, we advocate the use of end to end fistulas.

[Behavior of plasma insulin and GIP in obese patients subjected to biliopancreatic bypass]. / Comportamento dell'insulina e del gip plasmatici in soggeti obesi sottoposti a bypass biliopancretico.

Biliopancreatic bypass for obesity entails a 2/3 distal gastrectomy with Roux-en-Y reconstruction, being the small bowel transected at its midpoint and the enteroenteroanastomosis placed 50 cm proximal to the ileocecal valve. Insulin and GIP fasting and meal-stimulated plasma concentrations were determined in 13 nonobese healthy volunteers, in 13 nonoperated obese patients, in 11 subjects within two months, in 12 subjects four to twelve months, and in 7 subjects fifteen to twenty months after operation. Insulin in the obese patients was significantly higher than in the control group. Postoperatively these patients showed a sharp reduction in basal and postprandial values. Plasma insulin levels, both basally and following the test meal, were very similar in the 15-20 month and the control group. Plasma GIP fasting level, meal-stimulated peak and integrated response in the obese group were higher than in control group. Due to the extreme variability among subjects in the obese group, the difference was significant only for the mean peak response. All values were greatly reduced after surgery. The mean fasting level in the 15-20 month group was very similar to that in the control group, and both peak and integrated responses were significantly lower than in the preoperative and control groups.

[Behavior of plasma pancreatic polypeptides and motilin in obese patients subjected to biliopancreatic bypass]. / Comportamento del polipeptide pancreatico e della motilina plasmatici in soggetti obesi sottoposti a bypass biliopancreatico.

Biliopancreatic bypass for obesity entails a 2/3 distal gastrectomy with Roux-en-y reconstruction, being the small bowel transected at its midpoint and the enteroenteroanastomosis placed 50 cm proximal to the ileocecal value. Pancreatic polypeptide (PP) and motilin fasting and meal-stimulated plasma concentrations were determined in 13 nonobese healthy volunteers, in 13 nonoperated obese patients, in 9 subjects within two months, in 12 subjects four to twelve months, and in 7 subjects fifteen to twenty months after operation. There were no significant differences in PP fasting levels between either the obese and control groups or between the postoperative groups and the preoperative group. Both meal-stimulated peak and integrated response values were similar in the obese and control groups, and were strikingly and progressively reduced postoperatively, with statistically significant difference between all postoperative groups and preoperative group. Mean plasma motilin fasting and peak values were higher in the obese group than in the control group, and significantly reduced in the 4-12 and 15-20 month group. Despite the huge variability among data, the integrated response in the 0-2 month group was significantly decreased in comparison with the preoperative group, while a subsequent progressive increase was shown by the 4-12 and 15-20 month groups.

[Behavior of plasma gastrin in obese subjects subjected to biliopancreatic bypass]. / Comportamento della gastrina plasmatica in soggetti obesi sottoposti a bypass biliopancreatico.

Biliopancreatic bypass for obesity entails a 2/3 distal gastrectomy with Roux-en-Y reconstruction, small bowel being transected at its midpoint and the enteroenterostomy placed 50 cm proximal to the ileocecal valve. Plasma fasting and meal-stimulated gastrin concentrations were measured by radioimmunoassay in 13 nonobese healthy volunteers, 13 pre-surgery obese patients, 11 patients within two months, 12 patients between four and twelve months and 7 patients between fifteen and twenty months after operation. There were no significant differences in fasting and meal-stimulated peak plasma gastrin levels between obese group and the control group and between any of the postoperative groups and the preoperative group. The 15-20 month post-surgery group mean fasting value was lower than in the other groups, whilst the mean peak value was unchanged. Integrated gastrin response was significantly higher in this group than in the preoperative group.

[Intestinal transit time in bilio-pancreatic bypass]. / Il tempo di transito intestinale nel bypass bilio-pancreatico.

Transit times were evaluated in 23 obese subjects before and 1,4 and 12 months after biliopancreatic by-pass. A modified version of the method of Hinton et al. was used to determine emptying of the stomach and partial and total transit times. Emptying of the stomach was normal preoperatively. After surgery, it was almost immediate, except in two subjects with stomitis. Both transit times were virtually unchanged. Since the segment between the stomach and the ileocaecal valve is only half as long as in the normal subject, the results show that the by-pass leads to a slowing of transit that concerns the small intestine only, is quickly established, and does not change in the course of time. Evaluation of the altered anatomical and functional situation, and the absence of a correlation between the long-term behaviour of transit times on one hand and of lipid malabsorption and weight loss on the other-hand, suggest that a slower transit time must not be regarded as a compensation mechanism, except insofar as it restricts the degree of malabsorption set up immediately after surgery. Preliminary studies of enterohormonal changes following the by-pass indicate that increased glucagon and decreased motiline values are mainly responsible for slower transit times.