Somatostatinoma of the Ampulla of Vater: A Systematic Review.

BACKGROUND AND AIMS: Somatostatinoma of the ampulla of Vater (SAV) is a rare neuroendocrine tumor that usually appears with atypical clinical manifestations and is associated with Von Recklinghausen's disease. The aims of this study were to systematically review the literature regarding SAV and to highlight the clinicopathological characteristics and optimal therapeutic management of this rare entity. METHODS: A systematic search of the literature in PubMed/Medline and Scopus databases was performed by two independent investigators, including all case reports and case series concerning SAVs from 1980 until September 2021. RESULTS: In total, 37 articles were retrieved, including 43 patients, with a male to female ratio of 1.8:1 and a mean age of 46.8 ± 11.3 years (mean, SD). For 23 out of 43 patients (53.5%), Von Recklinghausen's disease was proved. The main clinical manifestations were abdominal pain (41.9%), jaundice (27.9%), weight loss (20.9%) and bowel disorders (20.9%). Typical histological findings included psammoma bodies, nests or clusters of epithelial cells with eosinophilic cytoplasm, while somatostatin staining was positive in 35 patients (81.4%), chromogranin-A in 21 patients (48.8%) and synaptophysin in 18 patients (41.9%). Surgery was the initial therapeutic approach in 34 patients (79.1%), whereas Whipple's procedure was the preferred surgical approach in 23 patients (53.4%). The longest survival among included patients was 13 years and only two postoperative deaths (4.7%) were reported. CONCLUSIONS: Somatostatinomas of the ampulla of Vater are rare malignancies that require increased physicians' suspicion and accurate surgical approach in order to achieve optimal therapeutic results.

The impact of surgery delay on survival of resectable pancreatic cancer: A systematic review of observational studies.

BACKGROUND: Pancreatic cancer is considered a lethal disease and the only potentially curative option is R0 excision. The aim of this study was to investigate whether the waiting time interval from diagnosis to surgical treatment affects overall survival in patients who undergo curative-intent surgery for pancreatic cancer. METHODS: Search in Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar databases was conducted from inception until April 2022. RESULTS: Overall, 10 studies were included that enrolled 181,344 patients. The dominating cut-off time point was 4 weeks in studies which utilized a biphasic waiting time pattern. In addition, prolonged waiting time interval was associated with decreased overall survival in 3 studies, whereas it demonstrated a favorable effect on overall survival in 2 studies and no impact on survival in 5 studies. CONCLUSION: The great diversity that was observed regarding the impact of surgery delay on survival underlines the lack of knowledge about biologic pathways of pancreatic cancer. Novel imaging studies and molecular "fingerprints" in combination to time-to-treatment standardization in the design of future randomized trials could lead to the recognition of patients that could benefit from a timely resection.

A rare combination of tibial artery aneurysm and traumatic arteriovenous fistula: a case report.

Aneurysms of the tibial arteries are rare, and they most commonly occur due to trauma of the lower extremities. Acquired arteriovenous fistulas of the tibial arteries are a recognized complication of trauma of the lower extremity and they are related to the mechanism of the injury. Although the natural history of stable arteriovenous fistula is relatively benign, the aneurysms of the tibial arteries should be repaired with autologous vein bypass grafts, if there is distal ischemia. Endovascular repair has been reported as an effective alternative treatment for traumatic tibial artery aneurysms. The case of a 60-year-old male with the rare combination of a tibial artery aneurysm and traumatic arteriovenous fistula of the left lower extremity is reported in view of its rarity and the modern holistic endovascular approach used for treatment. A covered stent graft in the anterior tibial artery was used for the treatment of both the aneurysm and the arteriovenous fistula. The patient was discharged under dual antiplatelet treatment for three months, continued by clopidogrel as monotherapy. At the six-month follow-up, the patient has restored palpable peripheral pulses and no sign of recurrence or complication was recognized. A total endovascular approach can be an effective treatment for these complicated traumatic aneurysms.

Preoperative embolization of hypervascular Castleman's disease of the mediastinum.

We report the case of a 31-year-old woman with mediastinal Castleman's disease of the hyaline vascular type. This large tumor was safely resected after arterial embolization. We describe the steps of this interventional procedure and discuss related necessary precautions.

BCL-2 and BAX expression and cell proliferation, after partial hepatectomy with and without ischemia, on cholestatic liver in rats: an experimental study.

BACKGROUND: Liver regeneration after partial hepatectomy (PHx) is regulated by several factors that activate or inhibit hepatocyte proliferation. Apoptosis seems to play an important role in cellular proliferation and liver regeneration. This study investigates the expression apoptosis-associated genes bcl-2 and bax, and the presence of apoptosis and cell proliferation after PHx, in normal and jaundiced rats with or without superimposed ischemia. MATERIALS AND METHODS: The study included 50 male Wistar rats assigned into; five groups (10 rats each). On day 0, rats of groups II, IV, and V underwent common bile duct ligation (BDL). On day 10, total liver ischemia (TLI) (occlusion of hepatic artery and portal vein-TLI) for 30 min was performed on animals of group V. When TLI was completed, all 30 animals (of groups I, IV, and V) underwent PHx (68%). Animals of group III underwent only TLI for 30 min. Rats of groups I, IV, and V were sacrificed 24 and 48 h after PHx was completed. Rats of group II were sacrificed 10, 11, and 12 days after BDL. Rats of group III were sacrificed immediately, 24 and 48 h after TLI completion. Liver tissue was obtained and pathologic examination included: (a) H&E stain, (b) in situ hybridization (detection of bcl-2 and bax mRNA) in paraffin sections, (c) Western blot analysis for the evaluation of bcl-2 and bax protein levels, (d) in situ hybridization (TUNEL) for the detection of apoptotic bodies, and (e) immunohistochemical stains (streptavidin-biotin method) in paraffin sections to detect cells that (i) express bcl-2 and bax proteins and (ii) undergo proliferation (Ki67+ cells). Results were expressed following morphometric analysis. RESULTS: Before hepatectomy, bcl-2 (protein or mRNA) levels were higher in jaundiced rats vs controls. Furthermore, bax (protein or mRNA) levels and apoptotic body index (ABI) were higher in cholestatic livers. After hepatectomy, there was an early decrease in the protein and mRNA levels of antiapoptotic gene bcl-2 and a late increase of proapoptotic gene bax and the ABI, compared to controls. Cell proliferation of hepatocytes was lower in group V (BDL + TLI) compared to that of groups II and IV (BDL). CONCLUSIONS: This study shows that apoptosis takes place in cholestatic livers with or without superimposed ischemia and may contribute in the impaired regenerative response observed in livers of jaundiced rats after partial hepatectomy.

The effect of ischemia on the regeneration of the cholestatic liver. An experimental study.

BACKGROUND/AIMS: Cholestatic liver is known to be more susceptible to ischemia than normal liver. In this study we assessed the histopathologic features of hepatic ischemic damage and liver regeneration in rats with experimental obstructive jaundice. METHODOLOGY: The study comprised 90 male Wistar rats. These were assigned randomly to 4 groups according to the surgical procedure they underwent: I (n = 10) controls (non-operated), II (n = 10) sham-operated, III (n = 30) occlusion of hepatic artery and portal vein (total liver ischemia), and IV (n = 40) ligation and division of the common bile duct ligation. Rats of group III were sacrificed 15 (IIIa), 30 (IIIb) and 60 min (IIIc) after total liver ischemia was done. Ten days after bile duct ligation, 10 rats of group IV underwent euthanasia, whereas the remaining 30, underwent total liver ischemia and were sacrificed after 15 min (IVb), 30 min (IVc), and 60 min (IVd). Liver wedge biopsies (left anterior lobe) were obtained and histologic examination included hematoxylin and eosin, and immunohistochemical stains for cytokeratin AE1, HEPPAR (hepatocyte paraffin antigen), and antigen Ki67. Immunohistochemical results for Ki67 were expressed following morphometric analysis. RESULTS: Liver sections from category IVa showed large duct obstruction features, and those from group III, ischemic chages including centrilobular hepatocellular swelling and necrosis, hepatocanalicular cholestasis, and mild portal mononuclear/mixed inflammation. Sections from groups IVB, IVc, IVd displayed together changes of large duct obstruction and ischemia, and in categories IVc (bile duct ligation +30 min total liver ischemia), and IVd (bile duct ligation +60 min total liver ischemia) necrosis of the large bile ducts was present. The total liver parenchymal area affected (% necrosis) was higher in categories IVd, and IVc compared to categories IVb (P < 0.05), and IIIc, IIIb, IIIa (P < 0.01). All 60 total liver ischemia-liver biopsies, developed features of liver regeneration that originated from zone 2, extended to zone 1 and occasionally to zone 3. Immunohistochemical stains revealed cells positive to AE1 and cells positive to HEPPAR. Proliferation rate (% Ki67+ cells) was higher in category IIIa compared to categories IIIb, IIIc, IVb, IVc, and IVd (P < 0.05). CONCLUSIONS: Our study shows that liver ischemia induces more severe hepatocyte damage in livers with obstructive cholangiopathy compared to normal ones. Liver regenerative process is mediated mainly by proliferation of non-necrotic cells that express hepatocellular or ductular epithelial features. Proliferation rate of hepatocytes is lower when liver ischemia and obstructive jaundice coexist.