A Genetic Risk Score for the Estimation of Weight Loss After Bariatric Surgery.

BACKGROUND: Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are the most frequent bariatric surgery procedures worldwide. In this prospective study, we examined the association of a genetic risk score (GRS) with loss of excess weight after bariatric surgery. METHODS: A total of forty-seven morbidly obese Greek patients who underwent SG (81%) or RYGB were recruited, followed up for 2 years and genotyped. Weight loss after surgery was reported as the percentage of excess weight that was lost (%EWL) at 12 and 24 months after surgery. A GRS was constructed based on previously BMI- and WHR-related single nucleotide polymorphisms (SNPs) that were found significantly correlated with weight loss after bariatric surgery in our population. The level of post-surgery %EWL after 12 and 24 months was estimated through two multiple linear regression models that considered the effects of relevant genetic risk variants. RESULTS: The first proposed model suggested that the predictor variables of GRS, age, and BMI had a significant effect on %EWL12m. GRS was significantly associated with %EWL12m, indicating a 4.618% decrease of %EWL12m per score unit. The second model indicated a positive correlation between %EWL24m and %EWL12m, suggesting that while post-surgery weight loss increased during the first 12 months, an increase was expected in the next 12 months as well. GRS was also significantly associated with %EWL24m, indicating approximately 3% decrease of %EWL24m per score unit. CONCLUSION: GRS can be used in the future together with other preoperative parameters in order to predict the outcome of bariatric surgery.

The incidence of HPV infection in anal cancer patients in Greece.

BACKGROUND AND AIM OF THE STUDY: Although anal cancer represents a relatively uncommon malignancy, its incidence over the last five decades, has been reported as increased for both sexes, worldwide. Human papillomavirus (HPV) infection has been shown to be a major cause for its development. The aim of the present study is to report on clinical, epidemiological and virological data of squamous anal cancer in Greek patients. PATIENTS AND METHOD: Between January 2002 and December 2010, 11 Greek patients (6 females) who were diagnosed as suffering from squamous cell anal or perianal cancer, were treated in our Hospital. Formalin fixed paraffin embedded tissue samples, obtained at the time of the anal biopsy or surgery, were analyzed by PCR in order to identify the presence as well as the type of HPV infection. RESULTS: Overall, the presence of HPV DNA was detected in 6 out of the 11 patients (54.5%). The "high risk" HPV DNA was detected in 3 of them (2 women and 1 man), while the "low risk" HPV DNA was detected in the remaining three (2 women and 1 man). CONCLUSION: The incidence of HPV infection in squamous cell anal cancer Greek patients, is lower than other Western countries, probably reflecting differences in sexual habits in the Greek population.

Clinical implications of the histologically and immunohistochemically detected solitary lymph node metastases in gastric cancer.

BACKGROUND: Topographic correlation between the primary gastric tumor and the first peri- and extragastric lymphatic drain basin (solitary lymph node metastasis) on gastrectomy specimens, represents a reliable method to investigate and understand the exact pattern of lymphatic drainage from a gastric tumor. Analyzing that correlation, useful information regarding the extent of the appropriate oncological perigastric lymphadenectomy will be provided. We retrospectively evaluate the usefulness of a modified D2 lymphadenectomy in gastric cancer patients, based on the topographic correlation between the primary tumor and the location of the solitary lymph node metastases, as they were detected by histology and immunohistochemistry. MATERIALS AND METHOD: Between April 2003 and March 2010, 134 gastric cancer patients were submitted to a modified D2 lymphadenectomy. Postoperatively, the standard histological ex-amination by hematoxylin and eosin (HE) staining, disclosed metastatic infiltration of at least two lymph nodes in 90 patients, solitary lymph node metastases were histologically detected in 10 patients, while the remaining 34 patients were classified as pN0. All lymph nodes of the ten patients with histological solitary lymph node metastases, as well as the 34 patients who had been classified as pN0 by histology, were further submitted to immunohistochemistry for micrometastases detection. More than one micrometastases were detected in none of them, while in seven patients solitary micrometastases were detected either in the level I perigastric or in the level II extragastric lymph nodes stations (skip micrometastases). RESULTS: Solitary lymph node metastases were detected by histology in ten patients and by immunohistochemistry in additional seven (nine females and eight males). Solitary metastases were detected in the level I LN stations in seven patients (four by histology and three by immunohistochemistry) and in the level II LN stations in ten patients (six by histology and four by immunohistochemistry). In order of frequency, the solitary lymph node metastases were located in the no 7 (n = 6), no 6 (n = 4), no 9 (n = 2), no 5 (n = 2), no 4 (n = 1), no 8 (n = 1) and no 12 (n = 1) LN stations. Skip metastases encountered the 60% of the histologically detected, 57% of the immunohistochemically detected and 59% of all solitary lymph node metastases. 80% of solitary metastases in the level II LN stations, were mainly located in the nos 7-9 lymph node stations complex. Tumors of the lower and middle-third of the stomach were equally drained both to the level I and level II lymph node stations, while 67% of the tumors towards the lesser curvature, were mainly drained in the level II lymph node stations. CONCLUSION: D2 lymphadenectomy increases the number of true R0 resections. Thus, a modified D2 lymphadenectomy should be routinely performed in gastric cancer patients.

Clinical value of right hemicolectomy for appendiceal carcinoids using pathologic criteria.

BACKGROUND: Appendiceal carcinoids (AC) are usually adequately treated by appendectomy. The European Neuroendocrine Tumours Society (ENETS) has recently reconsidered the previous pathologic criteria to identify patients at high risk of extra-appendiceal disease, who are thought to require right hemicolectomy (RHC). AIM: The aim of this retrospective, observational study was to evaluate previous and currently introduced criteria, in identifying patients with AC in whom RHC is justified. SUBJECTS AND METHODS: Twelve patients who underwent RHC for AC were retrospectively identified. Demographic and follow-up data were collected and appendectomy specimens were reviewed for the presence of indications leading to RHC defined as: tumor diameter ≥2 cm, tumor location at the base, mesoappendiceal extension, mitotic index Ki-67≥2%. RHC specimens were examined to identify evidence of extra-appendiceal disease, remaining and/or metastatic disease. RESULTS: Four patients fulfilled two criteria and 8 one criterion for RHC. Two patients had tumors ≥2.0 cm, 5 located at the base, 8 invading the mesoappendix and periappendiceal fat; Ki-67 PI was 1% in all cases measured except one, in which it was 3%. Post-RHC, 3 patients (25%) had extra-appendiceal disease (no residual disease was identified in surgical margins); 1 had tumor at the colon specimen and 2 had lymph node metastasis. All 3 patients fulfilled only one pathologic criterion; 1 had tumor mesoappendiceal extension and 2 tumor location at the base of the appendix. CONCLUSIONS: Applying previous and currently introduced pathologic criteria, 25% of high-risk patients with AC had identifiable extra-appendiceal disease following RHC that might be not detected following the recently introduced ENETS criteria.

Abdominal scar endometriosis after caesarean section: report of five cases.

Scar endometriosis is an under-appreciated or misdiagnosed phenomenon in general surgery and may eventually be more common than reflected in the literature. We herein report five cases of scar endometriosis that were treated in our surgical department one to five years after Caesarean section. Scar endometriosis should be considered when the symptoms are present in a cyclic manner mostly after gynaecological operations and worsening during menstruation. Diagnosis is mainly based upon a high index ofsuspicion. The treatment of choice is surgical resection.

Laparoscopic sleeve gastrectomy for morbid obesity with intra-operative endoscopic guidance. Immediate peri-operative and 1-year results after 25 patients.

Laparoscopic sleeve gastrectomy (LSG) represents a promising alternative option for the surgical treatment of morbid obesity. Its standard technique includes the longitudinal division of the stomach along a bougie of varying diameter. We report in this retrospective study our experience with LSG being performed with the use of intra-operative endoscopy instead of the bougie. Twenty-five consecutive patients (18 women, seven men) with a mean age of 40.2 years and mean body weight of 152.1 kg were submitted to LSG with intra-operative endoscopy in our hospital. The mean preoperative BMI was 53.5 kg/m(2). There were no conversions. Mean operative time was 117.5 min. There was no morbidity or mortality. The mean loss of excess body weight (EBW) at 3 months post-op was 19 +/- 1.8 kg, at 6 months was 28.6 +/- 4.5 kg, and at 1 year post-op was 48.9 +/- 3.7 kg (min 11-max 92). In other words the patients had lost 30 +/- 5%, 45 +/- 7.7%, and 60.8 +/- 4.3% of their EBW, respectively. The mean excess body weight loss at the day of the last visit to our outpatient clinic was 52.3 +/- 4.3 kg which corresponded to 66.4 +/- 4.3% of the total excess weight. LSG with intra-operative endoscopic guidance is a safe and efficient alternative method to treat morbid obesity and is a viable option for surgical units familiar with endoscopic techniques.

Does Helicobacter pylori identification in the mucosa of the gallbladder correlate with cholesterol gallstone formation? / ¿Existe una correlación de la identificación de Helicobacter pylori en la mucosa de la vesícula biliar con la formación de cálculos biliares de colesterol?

OBJECTIVE: Helicobacter pylori (H pylori) represents a potential initiator of cholesterol crystallization and it has been proposed that it is related to gallstone formation. In this study, any possible association between the H pylori identification in the mucosa of gallbladder and cholesterol gallstone formation was evaluated. METHODS: Gallbladders containing pure or mixed cholesterol gallstones (cholelithiasis group, n = 89) and gallbladders without gallstones (control group, n = 42) were submitted to standard histopathological examination for H pylori detection, as well as to nested polymerase chain reaction amplification for H pylori DNA detection. RESULTS: Helicobacter pylori was identified in the gallbladder's epithelium in four patients with cholelithiasis and in two patients in the control group by histology. In all the cases which were found to be H pylori positive by histological examination, H pylori DNA were also detected. No correlation between gallstone formation and H pylori detection in the biliary epithelium was found. A higher incidence of acute inflammation in the cholelithiasis (22.5% vs 9.5%, p = not significant [ns]) and in the H pylori positive groups (33% vs 17.6%, p = ns) were histologically detected. A higher incidence (10% vs 0%), p = ns) of H pylori in gallbladders with gallstones and acute inflammation, compared to gallbladders with acute inflammation but without gallstones, was noticed. CONCLUSION: Helicobacter pylori is detectable in low frequency in the mucosa of the gallbladder and it does not seem to act as a lithogenic component for cholesterol gallstone formation. Its higher incidence in gallbladders with gallstones and acute inflammation, suggests a possible accessory role in a subset of patients with cholelithiasis.

OBJETIVO: Helicobacter pylori (H pylori) representa un iniciador potencial de la cristalización del colesterol, y se ha propuesto que guarda relación con la formación del cálculo biliar. En este estudio, se evaluó cualquier posible asociación entre la identificación de H pylori en la mucosa de la vesícula y la formación del cálculo biliar de colesterol. MÉTODOS: Las vesículas que contienen cálculos biliares de colesterol puros o mixtos (grupo de colelitiasis, n = 89) y vesículas sin cálculos biliares (grupo control, n = 42) fueron sometidos a un examen histopatológico estándar con el fin de detectar el H pylori descubrimiento, así como a la amplificación de la reacción en cadena de polimerasa para la detección de ADN H pilori. RESULTOS: El Helicobacter pylori fue identificado mediante histología en el epitelio de la vesícula en cuatro pacientes con el colelitiasis y en dos pacientes en el grupo de control. En todos los casos que resultaron ser H pylori positivo por el examen histológico, se halló también DNA H pylori. No se halló correlación ninguna entre la formación del cálculo biliar y la detección de H pylori en el epitelio biliar. Se detectó histológicamente una incidencia más alta de inflamación aguda en la colelitiasis (22.5% contra 9.5%, p = no significativo [ns]) y en los grupos H pylori positivos (33% contra 17.6%, p = ns). Se observó una incidencia más alta (10% contra 0%), p = ns) de H pylori en las vesículas con los cálculos biliares e inflamación aguda, en comparación con las vesículas con la inflamación aguda pero sin cálculos biliares. CONCLUSIÓN: Helicobacter pylori es detectable en baja frecuencia en la mucosa de la vesícula y no parece actuar como un componente litogénico en la formación del cálculo biliar de colesterol. Su mayor incidencia en las vesículas con cálculo biliar e inflamación aguda, hace pensar en un posible papel auxiliar en un subconjunto de pacientes con colelitiasis.

Retroperitoneal pararenal Castleman's disease.

A 51-year old male patient with a three-month history of constant and dull left flank pain was investigated by ultrasonography, computed tomography (CT) scan and magnetic resonance imaging (MRI) of the abdomen, which disclosed a 8 x 7 x 6 cm retroperitoneal pararenal mass with heterogeneous imaging characteristics and bright enhancement following intravenous contrast injection. Based on the hypervascularity of the mass and the lack of specific signs in the imaging investigation, lymphoma, sarcoma or vascular tumour were considered as probable, diagnoses and the patient underwent an exploratory laparotomy. The histologic examination of the surgically resected specimen disclosed "a hyaline type of Castleman's disease". Further evaluation of the patient with antibody testing for HIV 1 and 2, as well as viral load by PCR for Herpes Virus-8 (HHV-8) were negative. Bone marrow aspiration, biopsy and immunophenotypic study did not disclose any evidence of lymphoma. Molecular study of the bone marrow for immunoglobulin heavy chain rearrangement showed a polyclonal pattern; serum protein electrophoresis did not show any evidence of hypergammaglobulinaemia and serum immunofixation electrophoresis did not show any monoclonal protein. A diagnosis of localized-unicentric type of Castleman's disease was made. Castleman's Disease should be included in the differential diagnosis of any solitary, heterogeneous and hypervascular retroperitoneal mass. Discovery of Castleman's disease at any area of the body should be followed by a thorough imaging and laboratory work-up in order to exclude the multicentric type of the disease and the co-existence of lymphoma.

Retroperitoneal pararenal Castleman's disease / Enfermedad de Castleman de localización retroperitoneal pararenal

A 51-year old male patient with a three-month history of constant and dull left flank pain was investigated by ultrasonography, computed tomography (CT) scan and magnetic resonance imaging (MRI) of the abdomen, which disclosed a 8 x 7 x 6 cm retroperitoneal pararenal mass with heterogeneous imaging characteristics and bright enhancement following intravenous contrast injection. Based on the hypervascularity of the mass and the lack of specific signs in the imaging investigation, lymphoma, sarcoma or vascular tumour were considered as probable diagnoses and the patient underwent an exploratory laparotomy. The histologic examination of the surgically resected specimen disclosed "a hyaline type of Castleman's disease". Further evaluation of the patient with antibody testing for HIV 1 and 2, as well as viral load by PCR for Herpes Virus-8 (HHV-8) were negative. Bone marrow aspiration, biopsy and immunophenotypic study did not disclose any evidence of lymphoma. Molecular study of the bone marrow for immunoglobulin heavy chain rearrangement showed a polyclonal pattern; serum protein electrophoresis did not show any evidence of hypergamma-globulinaemia and serum immunofixation electrophoresis did not show any monoclonal protein. A diagnosis of localized - unicentric type of Castleman's disease was made. Castleman's Disease should be included in the differential diagnosis of any solitary, heterogeneous and hypervascular retroperitoneal mass. Discovery of Castleman's disease at any area of the body should be followed by a thorough imaging and laboratory work-up in order to exclude the multicentric type of the disease and the co-existence of lymphoma.

Un paciente varón de 51 años con una historia de tres meses de dolor constante y sordo en el costado izquierdo, fue sometido a investigación mediante ultrasonografía, tomografía axial computarizada (IAC) e imagen por resonancia magnética (IRM) del abdomen. La investigación reveló una masa retro-peritoneal pararenal de 8 x 7 x 6 cm, con imagen de características heterogéneas y aumento de la luminosidad tras la inyección intravenosa de contraste. Sobre la base de hipervascularidad de la masa y la falta de signos específicos en la investigación por imágenes, el linfoma, el sarcoma o el tumor vascular fueron considerados como diagnósticos probables y el paciente fue sometido a una laparotomía exploratoria. El examen histológico del espécimen resecado quirúrgicamente reveló "un tipo hialino de la enfermedad de Castleman." La evaluación ulterior del paciente con prueba de anticuerpos de VIH 1 y 2, así como la carga viral por PCR para la detección del virus herpes humano tipo 8, dio resultados negativos. La aspiración de médula ósea, la biopsia y el estudio inmunofenotípico no mostraron ninguna evidencia de linfoma. El estudio molecular de la médula ósea para el reordenamiento de la cadena pesada de inmunoglobulina mostró un patrón policlonal. La electro-foresis de la proteína en suero no mostró evidencia alguna de hipergammaglobulinemia y la electroforesis de inmunofijación sérica no mostró proteína monoclonal alguna. Se hizo un diagnóstico de tipo unicéntrico y localizado de la enfermedad de Castleman. La Enfermedad de Castleman debe incluirse en el diagnóstico diferencial de cualquier masa retroperitoneal solitaria, heterogénea e hipervascular. El descubrimiento de la enfermedad de Castleman en cualquier área del cuerpo debe ser seguido de un examen por imágenes completo y pruebas exhaustivas de laboratorio, a fin de eliminar la posibilidad de un tipo multicéntrico de la enfermedad y la co-existencia de un linfoma.

Does Helicobacter pylori identification in the mucosa of the gallbladder correlate with cholesterol gallstone formation?

OBJECTIVE: Helicobacter pylori (H pylori) represents a potential initiator of cholesterol crystallization and it has been proposed that it is related to gallstone formation. In this study, any possible association between the H pylori identification in the mucosa of gallbladder and cholesterol gallstone formation was evaluated METHODS: Gallbladders containing pure or mixed cholesterol gallstones (cholelithiasis group, n = 89) and gallbladders without gallstones (control group, n = 42) were submitted to standard histopathological examination for H pylori detection, as well as to nested polymerase chain reaction amplification for H pylori DNA detection. RESULTS: Helicobacter pylori was identified in the gallbladder's epithelium in four patients with cholelithiasis and in two patients in the control group by histology. In all the cases which were found to be H pylori positive by histological examination, H pylori DNA were also detected. No correlation between gallstone formation and H pylori detection in the biliary epithelium was found. A higher incidence of acute inflammation in the cholelithiasis (22.5% vs 9.5%, p = not significant [ns]) and in the H pylori positive groups (33% vs 17.6%, p = ns) were histologically detected. A higher incidence (10% vs 0%), p = ns) of H pylori in gallbladders with gallstones and acute inflammation, compared to gallbladders with acute inflammation but without gallstones, was noticed CONCLUSION: Helicobacter pylori is detectable in low frequency in the mucosa of the gallbladder and it does not seem to act as a lithogenic component for cholesterol gallstone formation. Its higher incidence in gallbladders with gallstones and acute inflammation, suggests a possible accessory role in a subset of patients with cholelithiasis.

Disappearance of recurrent intra-abdominal extrahepatic hydatid cyst following oral albendazole administration

A 44-year old male patient with a past medical history of a complete surgical excision of pelvic hydatid cyst two years previously presented with constant pelvic floor pain and plasma IgG anti-echinococcal antibody titres of 14.27 U/mL. Based on that and the imaging findings of abdominal ultrasound (US), Computed Tomography (CT) and Magnetic Resonance (MR) the diagnosis of a recurrent retrorectal pelvic hydatid cyst was made. Three courses of oral albendazole treatment were administered and sixteen weeks later, the patient was admitted for a planned elective operation. At that time, a new CT scan revealed disappearance of the cyst, while the serological tests showed a decrease in the IgG anti-echinococcal antibody titres to 0. 71 U/mL. Four different species of the Echinococcus tapeworm can produce infection in humans. E granulosus and E multilocularis are the most common, causing cystic and alveolar echinococcosis respectively, while E vogeli and E oligarthrus, have only rarely been associated with human infection. Although surgical resection remains the treatment of choice for hydatid disease, the present case could suggest that especially in cases of recurrent intraabdominal extrahepatic hydatid cyst, treatment with albendazole may lead to disappearance of the recurrent cyst therefore, should constitute a first line therapeutic option prior to any planned reoperation.

[Restoration of the continuity of the colon with preservation of an existing colostomy]. / Erhaltung einer vorbestehenden Kolostomie bei Re-Operation des Dickdarms - Ein technischer Hinweis.

A new technique for the restoration of the continuity of the colon with preservation of an existing colostomy is described here. A 75-year-old male with a three-year history of abdominal-perineal resection and a well functioning end colostomy was admitted to our department for a second primary cancer of the descending colon. At operation the colon was divided close to the abdominal wall; the colostomy was left in situ while the descending colon and mesocolon were radically resected. The viability of the colostomy was being continuously inspected. An EEA stapler was then inserted through the colostomy and an anastomosis was created. Shortening the length of the operation and avoiding the possible complications that follow the creation of a new stoma are the major benefits of the technique. Still, the viability of the colostomy after its separation of the rest of the colon and mesocolon has to be ensured before proceeding.

Disappearance of recurrent intra-abdominal extrahepatic hydatid cyst following oral albendazole administration.

A 44-year old male patient with a past medical history of a complete surgical excision of pelvic hydatid cyst two years previously presented with constant pelvic floor pain and plasma IgG anti-echinococcal antibody titres of 14.27 U/mL. Based on that and the imaging findings of abdominal ultrasound (US), Computed Tomography (CT) and Magnetic Resonance (MR) the diagnosis of a recurrent retrorectal pelvic hydatid cyst was made. Three courses of oral albendazole treatment were administered and sixteen weeks later, the patient was admitted for a planned elective operation. At that time, a new CT scan revealed disappearance of the cyst, while the serological tests showed a decrease in the IgG anti-echinococcal antibody titres to 0. 71 U/mL. Four different species of the Echinococcus tapeworm can produce infection in humans. E granulosus and E multilocularis are the most common, causing cystic and alveolar echinococcosis respectively, while E vogeli and E oligarthrus, have only rarely been associated with human infection. Although surgical resection remains the treatment of choice for hydatid disease, the present case could suggest that especially in cases of recurrent intraabdominal extrahepatic hydatid cyst, treatment with albendazole may lead to disappearance of the recurrent cyst therefore, should constitute a first line therapeutic option prior to any planned reoperation.

Surgical treatment of carotid body tumors without embolization.

AIM: Carotid body (CB) paragangliomas are rare neoplasms, usually benign. This study deals with our 10-year experience in their surgical treatment and the evaluation of its effectiveness, without preoperative embolization. METHODS: During a 10-year period, from 1995 to 2004, we studied the medical records of 11 patients with CB tumors, 8 males and 3 females, whom only one had bilateral tumors. Their age ranged from 23 to 65 years (mean 35 years) and all had a palpable neck mass. Only two of the patients were asymptomatic on admission to our department. Twelve tumors were surgically resected and no patient underwent preoperative selective embolism of his tumor. Two patients had carotid endarterectomies with venous patch angioplasty. No one of the patients underwent radiotherapy or chemotherapy. RESULTS: Perioperative mortality was zero. No stroke or any other cerebral event was observed. One patient, with a grade III tumor, had an injury of the internal carotid artery that was repaired with a vein patch. Three patients had temporal cranial nerve lesions that resolved within 3 months. No malignancy was found even in a 10-year follow-up. CONCLUSIONS: Early surgical treatment is strongly recommended in almost all patients. Their resection is a very challenging operation with good postoperative results. Preoperative embolism of the tumor does not need to be a routine procedure. To exclude malignancy, long term follow-up is necessary.

Phase II study of gemcitabine plus 5-fluorouracil biologically modulated by folinic acid plus long-acting formulation of octreotide (LAR) in patients with advanced pancreatic cancer.

PURPOSE: To investigate the efficacy and toxicity of gemcitabine, in combination with 5-fluorouracil (5-FU) biologically modulated by folinic acid (FA) plus a somatostatin analogue (octreotide acetate-long acting formulation-LAR) that can both inhibit the action of several growth factors and angiogenesis, in patients with advanced pancreatic cancer. PATIENTS AND METHODS: Thirty-two patients with advanced symptomatic pancreatic cancer with measurable disease and median age 64 years (range 50-72) received the following combination: 5-FU, given at 350 mg/m(2) i.v. bolus, biologically modulated by FA 350 mg/m(2) on days 1, 2, 8 and 9; and gemcitabine, given by short i.v. infusion at 1000 mg/m(2) on days 1 and 8. The regimen was administered every 3 weeks. LAR 30 mg was given intramuscularly every 4 weeks. RESULTS: Objective tumor response was documented in 7 out of 32 evaluable patients (all partial responses-PR), yielding a 22% response rate (RR) (95% CI 10.5-35). Sixteen (50%) patients (95% CI 31.4-60.8) remained with stable disease (SD), while 9 (28%) patients (95% CI 20.4-48.4) progressed while on chemotherapy. The median response duration (RD) was 7 months (range 4-18). The median time to tumor progression (TTP) was 7 months (range 2-20), while the median survival was 7 months (range 4-29). The probability of surviving beyond 12 months was 20%. Of the 32 patients with tumor-related symptoms who were considered evaluable for clinical benefit response, 25 (78%) had pain improvement, while 14 (44%) experienced weight gain during treatment. In general, performance status improved in 16 (50%) patients during treatment. Serum concentrations of Ca 19-9 were decreased by more than 50% in 14 (44%) of the 32 assessable patients. Chemotherapy was well tolerated with mild myelotoxicity. Gastrointestinal toxicity was moderate with mild mucositis. CONCLUSION: The combination of gemcitabine and 5-FU/FA plus LAR 30 was well tolerated and showed a moderate antitumor activity and a significant palliative effect on tumor-related symptoms. It would be interesting to evaluate in a randomized study the impact of octreotide administration on the palliative effect of the regimen.

Liver resection in cases of isolated hepatic actinomycosis: case report and review of the literature.

Hepatic actinomycosis is an uncommon entity that forms communicating abscesses and fistulae. We report a 53-y-old immunocompetent male patient with hepatic actinomycosis. Symptoms included intermittent fever, abdominal pain, right upper quadrant tenderness and jaundice. A hepatic tumour mass was found on abdominal sonography and computerized tomography. Two preoperative percutaneous core biopsies of the mass were not diagnostic. The above findings were highly suggestive for liver abscess or purulent primary liver neoplasm. Treatment with intravenous antibiotics was continued for 20 d, but both symptoms and liver ultrasound findings remained unchanged. The patient underwent exploratory laparotomy and right posterior segmentectomy of the liver. Pathological examination of the surgically removed specimen disclosed hepatic actinomycosis. Following operation the patient remains in excellent condition without evidence of recurrence.

Advantages of laparoscopic stented choledochorrhaphy over T-tube placement.

BACKGROUND: Postoperative complications after laparoscopic choledochotomy are mainly related to the T tube. Both laparoscopic endobiliary stent placement with primary closure of the common bile duct (CBD) and primary closure of the CBD without drainage have been proposed as safe and effective alternatives to T tube placement. METHODS: This was a retrospective analysis of data collected prospectively on 53 consecutive patients suffering from proven choledocholithiasis who underwent laparoscopic CBD exploration through a choledochotomy between January 1999 and January 2003. In the early period a T tube was placed at the end of the procedure (n = 32). Biliary stent placement and primary CBD closure was performed from June 2001 (n = 21). RESULTS: There were no significant differences in epidemiological characteristics, preoperative factors or intraoperative findings between the groups. Seven patients developed complications, six in the T tube group and one in the stent group. Univariate analysis revealed a significantly lower morbidity rate and shorter postoperative hospital stay in the stent group. CONCLUSION: Placement of a biliary endoprosthesis after laparoscopic choledochotomy achieves biliary decompression, and avoids the complications of a T tube, leading to a shorter postoperative hospital stay. The method is a safe and effective alternative method of CBD drainage after laparoscopic choledochotomy.

The significance of perioperative anemia in patients with resectable gastrointestinal tract tumors.

Cancer-related anemia occurs in more than 50% of patients with malignancies and constitutes a common finding in patients with gastrointestinal tract tumors. In the present article we present the possible pathogenetic mechanisms as well as the appropriate clinical and laboratory investigations for the anemia, which is associated with gastrointestinal tract malignancies. Moreover, we conducted a MEDLINE database search between 1992- 2003, focusing on the currently available methods for perioperative correction and treatment of anemia. The currently available evidence suggests that perioperative allogenic blood transfusion is associated with increased rates of postoperative infections and constitutes an independent adverse prognostic factor in gastrointestinal malignancies; autologous blood transfusions are of no clinical benefit compared to allogenic transfusions, as autologous blood is not immunologically neutral; and the shortterm results of erythropoietin (EPO) use remain controversial, while its long-term results remain unknown. Correction of anemia in every patient with resectable gastrointestinal malignancy is mandatory, because it improves surgical stress response, wound healing process and quality of life. Although EPO administration constitutes the treatment of choice for patients receiving chemotherapy and/ or radiotherapy, the best perioperative method for anemia correction remains unknown and further prospective randomized studies are required. From the surgical point of view, any effort for "bloodless surgery" should be attempted.