Incisional hernia in hepatobiliary and pancreatic surgery: incidence and risk factors.

PURPOSE: The occurrence of incisional hernia (IH) is one of the main complications after open abdominal surgery. However, its incidence in hepatobiliary and pancreatic surgery is not known. Studies on hepatectomy and necrotizing pancreatitis show that the incidence can reach up to 42%. This study aims at evaluating the incidence of IH and its risk factors. METHODS: Patients submitted to open hepatobiliary and pancreatic surgery at our centre between 2010 and 2016 were selected. IH was defined as discontinuity in the abdominal fascia reported during physical examination or on computed tomography. Variables analysed range from individual characteristics and medical history to surgical and postoperative aspects. RESULTS: The cumulative incidence of IH was 21.6% at 72 months. In pancreatic surgery, this incidence was 11.6%, while hepatobiliary patients presented an incidence of 27.0%. Cox regression showed that height (p = 0.028), subcutaneous fat (p = 0.037), wound dehiscence (p = 0.001) and superficial surgical site infection (p = 0.001) correlate positively with IH in pancreatic surgery patients. BMI (p = 0.037) and perirenal fat (p = 0.043) associated independently with IH in hepatobiliary surgery. CONCLUSIONS: Height, obesity and wound complications are risk factors for IH in patients submitted to pancreatic surgery, whereas obesity presents as risk factor in hepatobiliary surgery patients. The incidence of IH goes up to 12% in patients submitted to pancreatic surgery, while this risk is higher in the hepatobiliary group (27%). It is suggested the adoption of strategies in the clinical practice prevents this high incidence, namely in high-risk patients.

Validation of a Difficulty Grading Score in Laparoscopic Splenectomy.

INTRODUCTION: Laparoscopic splenectomy (LS) is the gold standard for the treatment of many spleen-related disorders. However, in the presence of splenomegaly, the rate of conversion to open surgery can be as high as 33.9% and is associated with longer operative times and higher costs. In an attempt to improve risk stratification and patient selection for LS, a score that includes four preoperative parameters (age, gender, diagnosis, and spleen size) has been developed. The aim was the validation of a difficulty grading score, in predicting conversion and poorer outcomes. METHODS: Retrospective analysis of 153 consecutive patients subjected to LS from January 2006 through December 2016 was performed. Several parameters were reviewed and correlation with evaluated outcomes was analyzed. RESULTS: Conversion to open surgery occurred in 13 (8.50%) patients and was highly associated with serious intraoperative complications. Spearman correlation showed a significant association between the score and risk of conversion, operative time, and postoperative complications, but not with intraoperative bleeding. DISCUSSION: Patient and disease features, incorporated in a difficulty grading score, can reliably determine the difficulty of LS and predict risk of conversion, intraoperative, and postoperative complications. This simple and reproducible score improves risk stratification for LS and could be practical in daily clinical activities.

Meckel's diverticulum perforation by a fish bone: A case report.

INTRODUCTION: Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract. The perforation of a Meckel's diverticulum by a foreign body is a very rare complication. CASE PRESENTATION: A 61-year-old male presented to the Emergency Department with complaints with abdominal pain and fever, and abdominal rebound tenderness on physical examination. An intestinal perforation by a foreign body was diagnosed by CT scan. The patient was submitted to a diagnostic laparoscopy and a perforation of a Meckel's diverticulum by a foreign body was identified. The foreign body was removed and a stapled diverticulectomy was performed. DISCUSSION: Meckel's diverticulum is asymptomatic in most of the affected individuals, with a 4.2-16.9% probability of symptomatic presentations. The clinical presentation ranges from intestinal obstruction, to bleeding, inflammation and perforation. While children with Meckel's diverticulum present more often with gastrointestinal bleeding, intestinal obstruction is the most common presentation in adults. Foreign body perforation of a Meckel's diverticulum is an extremely rare event. There is general agreement that a symptomatic Meckel's diverticulum should be resected. Laparoscopy is a safe diagnostic and therapeutic tool that can decrease diagnostic time and theoretically avoids the morbidity and mortality of a delayed diagnosis. CONCLUSION: The perforation of a Meckel diverticulum by a foreign body is an extremely rare event and may have a bad prognosis in case of a delayed diagnosis.

Gastrointestinal stromal tumor of the stomach and hepatocellular carcinoma: An unusual association.

INTRODUCTION: Gastrointestinal stromal tumors (GIST) are uncommon, potentially malignant tumors, that arise in the wall of the gastrointestinal tract. Up to 50% can develop metastasis, mainly in the liver, but the occurrence of synchronous primary liver tumors is a rare event in these patients. PRESENTATION OF CASE: The authors report a case of the association of gastric GIST and hepatocellular carcinoma (HCC) in a non-cirrhotic liver in a 76 year-old patient. DISCUSSION: The appearance of an hepatic lesion in a GIST patient does not necessarily imply its secondary nature. CONCLUSION: In diagnosed GIST patients, all efforts should be pursued to characterize synchronous hepatic lesions, in order to plan a correct and tailored treatment of the patients.

Gastric stump cancer: more than just another proximal gastric cancer and demanding a more suitable TNM staging system.

BACKGROUND: Considerable controversy persists about the biological behavior of gastric stump cancer (GSC). The aim of this study is to clarify if this cancer is just another proximal gastric cancer or if it emerges as a distinctive clinicopathologic entity. METHODS: This review of a prospectively collected gastric cancer database identified 73 patients with GSC in a single institution between January 1980 and June 2012 and compared them with 328 patients with proximal gastric cancer (PGC) and 291 patients with esophagogastric junction cancer (EGJC). RESULTS: Patients with GSC were predominantly males. Eighty-three percent of GSC penetrated the subserosal or the serosal layers. The median number of lymph nodes retrieved in GSC patients was significantly lower than in PGC patients or in EGJC patients. Cumulative survival curves were not different between GSC, PGC, or EGJC patients. Unlike that observed in PGC and in EGJC, no significant differences in cumulative survival according to the TNM staging system were observed in GSC cases. CONCLUSIONS: The outcome of patients with GSC displayed significant differences when compared to those with other proximal gastric cancers concerning the lack of survival association with the TNM staging system. Therefore a more suitable staging system should be designed for these unique cancers.

Multiple hepatic inflammatory pseudotumours diagnosed after laparoscopic excisional biopsy.

Inflammatory pseudotumours (IPTs) may occur in almost every organ of the human body, the liver being the second most frequent organ which is affected. Inflammatory pseudotumours of the liver are rare benign lesions of unknown aetiology, which usually present as solitary liver masses of variable sizes. The differential diagnoses of malignant liver tumours are challenging and they usually require biopsies and histologic examinations. We are presenting the case of a patient with multiple hepatic lesions which mimicked liver metastases. Two percutaneous biopsies were inconclusive. The definitive diagnosis of multiple hepatic inflammatory pseudotumours was made after a laparoscopic exploration with an excisional biopsy of liver lesions and their pathologic evaluation. All lesions disappeared after several months, without any further treatments.

Methodological assessment of HCC literature.

Despite the fact that the hepatocellular carcinoma (HCC) represents a major health problem, very few interventions are available for this disease, and only sorafenib is approved for the treatment of advanced disease. Of note, only very few interventions have been thoroughly evaluated over time for HCC patients compared with several hundreds in other, equally highly lethal, tumours. Additionally, clinical trials in HCC have often been questioned for poor design and methodological issues. As a consequence, a gap between what is measured in clinical trials and what clinicians have to face in daily practice often occurs. As a result of this scenario, even the most recent guidelines for treatment of HCC patients use low strength evidence to make recommendations. In this review, we will discuss some of the potential methodological issues hindering a rational development of new treatments for HCC patients.

Adenoma-carcinoma sequence in intrahepatic cholangiocarcinoma.

INTRODUCTION: Cholangiocarcinoma is a rare tumor but recent data report a worldwide increase in incidence and mortality. There are several risk factors associated with cholangiocarcinoma, and chronic inflammation of billiary tree seems to be implied in the cholangiocarcinogenesis, but little is known about this process. PRESENTATION OF CASE: We present a 56-year-old female with a bile duct adenoma incidentally discovered in the follow up of breast cancer that 18 months later progress to intrahepatic cholangiocarcinoma. DISCUSSION: This is a rare presentation of intrahepatic cholangiocarcinoma that suggests the classic adenoma-carcinoma sequence in cholangiocarcinogenesis. Furthermore this case gives rise to some questions about the possible common ground on intrahepatic cholangiocarcinoma and breast cancer. CONCLUSION: Cholangiocarcinogenesis is a complex multi-step mechanism and further investigations are needed to fully understand this process.

Petersen's space hernia: A rare but expanding diagnosis.

BACKGROUND: Petersen's space hernia is caused by the herniation of intestinal loops through the defect between the small bowel limbs, the transverse mesocolon and the retroperitoneum, after any type of gastrojejunostomy. The laparoscopic approach facilitates the occurrence of this type of hernia, due to the lack of post-operative adhesions which prevent bowel motility and hence, herniation. CASE REPORT: We report the case of a 46 year-old male submitted to an open antrectomy and vagotomy with a Roux-en-Y reconstruction six-years before, for the treatment of bleeding gastric ulcer.He presented with epigastric abdominal pain radiating to the back and alimentary vomiting with a 3 days evolution, with an episode of hematemesis 2 h before admission. His abdomen was bloated and tender at the epigastric region. The laboratory exams revealed mild leucocytosis and CRP elevation with normal pancreatic tests. The abdominal CT scan revealed an intestinal occlusion. An exploratory laparotomy was performed, disclosing an incarcerated Petersen space hernia of the common limb, with obstruction and dilatation of the biliary limb. CONCLUSION: The knowledge of this anatomic post-operative defect and a low threshold for diagnosis are crucial to its management, since its nonspecific clinical and laboratory findings. Early operative intervention is warranted in order to avoid the severe complications of bowel necrosis.

[Transcatheter arterial chemoembolization with doxorubicin eluting beads in the treatment of hepatocellular carcinoma]. / Quimioembolização transarterial com partículas carregadas com doxorrubicina no tratamento do carcinoma hepatocelular.

Retrospective study to evaluate local tumor control and survival data after transcatheter arterial chemoembolization with doxorubicin eluting beads in the treatment of hepatocellular carcinoma. Between April 2007 and November 2008, a total of 47 patients (mean age 61,7 years; range 42-84 years) with hepatocellular carcinoma were treated with transcatheter arterial chemoembolization. In total 73 chemoembolization procedures were performed in superselective manner with microcatheter (mean 1,57 procedures per patient). The local chemoembolization protocol consisted of doxorubicin eluting beads mainly 300-500 micra but also 500-700 micra and 700-900 micra, to a maximum dose per session of 150 mg doxorubicin. Tumor response was evaluated with CT imaging. Change in tumor size was calculated and response was evaluated according to the European Association for the Study of the Liver (EASL) criteria. Survival from first chemoembolization was calculated in the subgroup treated between April 2007 and January 2008 (24 patients). Follow-up imaging was performed until January 2009 or patient death. Evaluation of tumor response resulted in complete response in 13 patients (27,7%), partial response in 15 patients (31,9%), stable disease in 9 patients (19,1%) and progressive disease in 10 patients (21,3%). The one year survival rate after chemoembolization in the 24-patient subgroup was 54%. Chemoembolization with doxorubicin eluting beads is a minimally invasive, safe and effective therapy option for palliative treatment of hepatocellular carcinoma.

Brunner's gland hyperplasia: an unusual cause of hemorrhagic shock.

Brunner's gland hyperplasia is a very rare lesion of the duodenum, which is usually asymptomatic and diagnosed incidentally during upper gastrointestinal endoscopy. It can cause gastrointestinal bleeding but hemorrhagic shock is a rare clinical presentation of Brunner's gland hyperplasia. The authors present a case of a patient with hemorrhagic shock due to a bleeding Brunner's gland hyperplasia, treated by urgent laparotomy and polypectomy.

Escisión laparoscópica de quiste mesotelial hepático / Laparoscopic excision of a hepatic mesothelial cyst

Los quistes mesoteliales son lesiones congénitas extremadamente raras que tienen origen en restos celómicos. Los autores describen el caso de un niño de tres años de edad. Presenta como hallazgo casual imagen quística hepática en ecografía abdominal, en el contexto de estudio de dolor abdominal. El examen objetivo y el estudio analítico no demostraron ninguna alteración. La RMN confirmó la presencia de lesión quística, sugiriendo como hipótesis diagnóstica tratarse de un cistadenoma quístico. El enfermo fue sometido a quistectomía por laparoscopia, con alta al 2º día. El estudio de anatomía patológica concluye que se trata de un quiste mesotelial hepático. Los quistes mesoteliales hepáticos son lesiones muy raras, de difícil diagnóstico preoperatorio. Su escisión laparoscópica es un procedimiento exequible y seguro (AU)

Over the past few years there has been an increase in application of minimally invasive techniques in pediatric surgery, especially in the approach of liver lesions. The mesothelial cysts are extremely rare congenital lesions that arise from celomic remnants. The authors present the clinical case of a three year old child, referred to our institution after an incidental finding of a liver cystic lesion in abdominal ultrasound. The physical examination and blood study were irrelevant. The MRI confirmed the presence of the cystic lesion and pointed, as a possible etiology, a cystic cyst adenoma of the liver. The child was submitted to laparoscopic cyst resection. There peri and postoperative periods were uneventful. He was discharged 48h after surgery. The anatomo-pathological and immunohistochemical studies concluded it was a mesotelial cyst of the liver. The mesothelial cysts of the liver are very rare lesions, with difficult preoperative diagnosis. The laparoscopic excision is a feasible and safe (AU)

[Laparoscopic excision of a hepatic mesothelial cyst]. / Escisión laparoscópica de quiste mesotelial hepático.

Over the past few years there has been an increase in application of minimally invasive techniques in pediatric surgery, especially in the approach of liver lesions. The mesothelial cysts are extremely rare congenital lesions that arise from celomic remnants. The authors present the clinical case of a three year old child, referred to our institution after an incidental finding of a liver cystic lesion in abdominal ultrasound. The physical examination and blood study were irrelevant. The MRI confirmed the presence of the cystic lesion and pointed, as a possible etiology, a cystic cyst adenoma of the liver. The child was submitted to laparoscopic cyst resection. There peri and postoperative periods were uneventful. He was discharged 48h after surgery. The anatomo-pathological and immunohistochemical studies concluded it was a mesotelial cyst of the liver. The mesothelial cysts of the liver are very rare lesions, with difficult preoperative diagnosis. The laparoscopic excision is a feasible and safe.

Searching for the role of protein phosphatases in eukaryotic microorganisms.

Preference for specific protein substrates together with differential sensitivity to activators and inhibitors has allowed classification of serine/threonine protein phosphatases (PPs) into four major types designated types 1, 2A, 2B and 2C (PP1, PP2A, PP2B and PP2C, respectively). Comparison of sequences within their catalytic domains has indicated that PP1, PP2A and PP2B are members of the same gene family named PPP. On the other hand, the type 2C enzyme does not share sequence homology with the PPP members and thus represents another gene family, known as PPM. In this report we briefly summarize some of our studies about the role of serine/threonine phosphatases in growth and differentiation of three different eukaryotic models: Blastocladiella emersonii, Neurospora crassa and Dictyostelium discoideum. Our observations suggest that PP2C is the major phosphatase responsible for dephosphorylation of amidotransferase, an enzyme that controls cell wall synthesis during Blastocladiella emersonii zoospore germination. We also report the existence of a novel acid- and thermo-stable protein purified from Neurospora crassa mycelia, which specifically inhibits the PP1 activity of this fungus and mammals. Finally, we comment on our recent results demonstrating that Dictyostelium discoideum expresses a gene that codes for PP1, although this activity has never been demonstrated biochemically in this organism.

Searching for the role of protein phosphatases in eukaryotic microorganisms

Preference for specific protein substrates together with differential sensitivity to activators and inhibitors has allowed classification of serine/threonine protein phosphatases (PPs) into four major types designated types 1, 2A, 2B and 2C (PP1, PP2A, PP2B and PP2C, respectively). Comparison of sequences within their catalytic domains has indicated that PP1, PP2A and PP2B are members of the same gene family named PPP. On the other hand, the type 2C enzyme does not share sequence homology with the PPP members and thus represents another gene family, known as PPM. In this report we briefly summarize some of our studies about the role of serine/threonine phosphatases in growth and differentiation of three different eukaryotic models: Blastocladiella emersonii, Neurospora crassa and Dictyostelium discoideum. Our observations suggest that PP2C is the major phosphatase responsible for dephosphorylation of amidotransferase, an enzyme that controls cell wall synthesis during Blastocladiella emersonii zoospore germination. We also report the existence of a novel acid- and thermo-stable protein purified from Neurospora crassa mycelia, which specifically inhibits the PP1 activity of this fungus and mammals. Finally, we comment on our recent results demonstrating that Dictyostelium discoideum expresses a gene that codes for PP1, although this activity has never been demonstrated biochemically in this organism