Cholangiocarcinoma: principles and current trends.

BACKGROUND: Cholangiocarcinoma (CCA) is a lethal cancer of the biliary epithelium, originating from the liver (intrahepatic), at the confluence of the right and left hepatic ducts (hilar) or in the extrahepatic bile ducts. It is a rare malignancy associated with poor prognosis. DATA SOURCES: We searched the PubMed/MEDLINE database for relevant articles published from 1989 to 2008. The search terms used were related to "cholangiocarcinoma" and its "treatment". Although no language restrictions were imposed initially, for the full-text review and final analysis, our resources only permitted the review of articles published in English. This review deals with the treatment of cholangiocarcinoma, the principles and the current trends. RESULTS: The risks and prognostic factors, symptoms and differential diagnosis are thoroughly discussed. In addition, the tools of preoperative diagnosis such as endoscopic retrograde cholangiopancreatography, digital image analysis, fluorescence in situ hybridization and magnetic resonance cholangiopancreatography are reviewed. Moreover, the treatment of CCA is discussed. CONCLUSIONS: The only curative treatment available is surgical management. Unfortunately, many patients present with unresectable tumors, the majority of whom die within a year of diagnosis. Surgical treatment involves major resections of the liver, pancreas and bile duct, with considerable mortality and morbidity. However, in selected cases and where indicated, appropriate management with aggressive surgery may achieve a good outcome with a prolonged survival expectancy.

Laparoscopic resection of large adrenal tumors.

BACKGROUND: Laparoscopic adrenalectomy has rapidly replaced open adrenalectomy as the procedure of choice for benign adrenal tumors. It still remains to be clarified whether the laparoscopic resection of large (≥ 8 cm) or potentially malignant tumors is appropriate or not due to technical difficulties and concern about local recurrence. The aim of this study was to evaluate the short- and long-term outcome of 174 consecutive laparoscopic and open adrenalectomies performed in our surgical unit. METHODS: Our data come from a retrospective analysis of 174 consecutive adrenalectomies performed on 166 patients from May 1997 to December 2008. Fifteen patients with tumors ≥ 8 cm underwent laparoscopic adrenalectomy. Sixty-five patients were men and 101 were women, aged 16 years to 80 years. Nine patients underwent either synchronous or metachronous bilateral adrenalectomy. Tumor size ranged from 3.2 cm to 27 cm. The largest laparoscopically excised tumors were a ganglioneuroma with a mean diameter of 13 cm and a myelolipoma of 14 cm. RESULTS: In 135 patients, a laparoscopic procedure was completed successfully, whereas in 14 patients the laparoscopic procedure was converted to open. Seventeen patients were treated with an open approach from the start. There were no conversions in the group of patients with tumors > 8 cm. Operative time for laparoscopic adrenalectomies ranged from 65 minutes to 240 minutes. In the large adrenal tumor group, operative time for laparoscopic resection ranged from 150 minutes to 240 minutes. The postoperative hospital stay for laparoscopic adrenalectomy ranged from 1 day to 2 days (mean, 1.5) and from 5 days to 20 days for patients undergoing the open or converted procedure. The mean postoperative stay was 2 days for the group with large tumors resected by laparoscopy. CONCLUSION: Laparoscopic resection of large (≥ 8 cm) adrenal tumors is feasible and safe. Short- and long-term results did not differ in the 2 groups.

Radical resection of pancreatic cancer.

BACKGROUND: Pancreatic adenocarcinoma (PCa) is a disease with dismal prognosis, and the only possibility of cure, albeit small, is based on the combination of complete resection with negative histopathological margins (R0 resection) with adjuvant treatment. Therefore, a lot of effort has been made during the last decade to assess the role of extensive surgery in both local recurrence and survival of patients with PCa. DATA SOURCES: Medline search and manual cross-referencing were utilized to identify published evidence-based data for PCa surgery between 1973 and 2006, with emphasis to feasibility, efficacy, long-term survival, disease free survival, recurrence rates, pain relief and quality of life. RESULTS: Extended surgery is safe and feasible in high volume surgical centers with comparable short-term results. Organ preserving surgery is a main goal because of quality of life reasons and is performed whenever possible from the tumor extent. Concerning long-term survival major vein resection does not adversely affect outcome. To date, there are no changes in long-term survival attributed to the extended lymph node dissection. However, there is a benefit in locoregional control with fewer local recurrences and extended lymphadenectomy allows better staging for the disease. CONCLUSIONS: Extended PCa surgery is safe and feasible despite the inconclusive results in patient's survival benefit. In the future, appropriately powered randomized trials of standard vs. extended resections may show improved outcomes for PCa patients.

Open and laparoscopic approach in incisional hernia repair with ePTFE prosthesis.

BACKGROUND: The aim of this retrospective study was to analyze the results of incisional hernia laparoscopic and open surgery, focusing on the morbidity and postoperative implications. MATERIALS AND METHODS: A group of 106 (42 men, 64 women) patients suffering from incisional hernias were treated with either a laparoscopic (30) or an open (76) placement of a prosthetic mesh between January 1997 and December 2004. The age and gender of the patients, the size and type of the mesh, operation note, the length of postoperative hospital stay, and morbidity were recorded. RESULTS: An expanded polytetrafluoroethylene (ePTFE) mesh was used in 103 patients, whereas a polypropylene mesh was used in 3 patients. In the open technique, 3 patients with the ePTFE prosthetic material developed a mesh infection and required a mesh removal, which was easily performed under local anesthesia. Moreover, 2 patients from the same group developed a hernia recurrence. As for the laparoscopic approach, the only complication observed was one hernia recurrence. Finally, it should be mentioned that 1 patient with a polypropylene mesh developed a colocutaneous fistula. CONCLUSIONS: The benefits of the laparoscopic mesh technique, compared to the open technique, include a shorter hospital stay, less postoperative pain, and possibly, a reduction in wound and mesh complications. Regarding the recurrence rate, the two techniques show similar results.

Comparative analysis and evaluation of the effectiveness of demographic policies in EU countries (2009-2010).

PURPOSE: This article contains a comparative analysis and evaluation of the effectiveness of population policies in European Union (EU) countries, using multivariate analysis. DATA AND METHODS: To study these differences, it is primarily necessary to have the relevant data. The most recent database available was developed by the OECD in 2007 and currently covers OECD countries and most EU Member States. We used multivariate analysis to categorize the indicators into the following groups: (a) economic indicators, (b) indicators reconciling work and family life, and (c) demographic indicators. RESULTS: The results of measuring the degree of coherence of factors reveal that the four most important factors influencing the effectiveness of population policy are (i) the average maternal age at first childbirth, (ii) social protection expenditure, (iii) GDP, and (iv) public spending for benefits. Based on the data from the evaluation of the correlation matrix of variables and data, the classification of countries, according to the values of the coefficients of analysis, appears as follows: the Nordic countries (together with France and the United Kingdom), the Southern European countries and the Northern countries: Estonia, Latvia, Lithuania (by a very slight margin Romania), and Bulgaria, Poland, Slovakia (and, marginally, Malta). CONCLUSIONS: The key comparative findings from benchmarking best practices in the context of the European experience are the following: The EU is being demographically transformed as a direct result of an increase in average life expectancy and immigration and a decrease in fertility. Demographic factors are influenced by specific features, in contrast with economic factors which seem be less stable.

Laparoscopic resection of pheochromocytomas with delayed vein ligation.

OBJECTIVE: Laparoscopic adrenalectomy has been established as the surgical procedure of choice for benign adrenal diseases. Laparoscopic adrenalectomy for pheochromocytoma has been the subject of debate, due to potential systemic consequences of pneumoperitoneum in patients with catecholamine-secreting tumors and a perceived increased risk of malignancy for large-sized tumors. In this study we present our experience for laparoscopic resection of pheochromocytomas, and evaluate the safety of delayed adrenal vein ligation. METHODS: A total of 32 adrenalectomies for pheochromocytoma were performed between June 1997 and December 2009. Four paragangliomas, operated in the same period are not included in this series. All patients were investigated and operated on using an established departmental protocol. Preoperative diagnosis, operative details, complications, length of hospital stay, morbidity, and follow-up were documented from the hospital records of 200 patients who underwent 208 adrenalectomies for benign and malignant adrenal tumors in the same period. RESULTS: Thirty-two tumors were removed from 31 patients (17 men; mean age, 54 y; range, 19 to 72 y). One patient with MEN IIA underwent bilateral resection of pheochromocytomas in 2 stages. Tumor size in laparoscopic procedures ranged from 2.2 to 10.5 cm (mean, 4.97 cm). Operative time was from 55 to 210 minutes (mean, 110 min).Twenty-seven patients had sporadic disease (2 potentially malignant, 2 malignant), and 4 in the context of a familiar syndrome (2 MEN IIA syndrome, 1 Von Hippel Lindau syndrome and Recklinghausen disease, respectively). Twenty-four patients underwent laparoscopic adrenalectomy, 2 patients had open approach from the start for recurrent malignant pheochromocytoma and large benign tumor respectively, 1 patient had open approach due to inoperable malignant pheochromocytoma, and 4 patients had conversions from laparoscopic to open procedure. All patients with paragangliomas underwent open approach from the start. The mean hospital stay was 2 days (range, 1 to 3 d) for the laparoscopic procedures. All patients underwent late ligation of the main adrenal vein. Five patients received sodium nitroprusside intraoperatively to treat hypertension. One patient developed pulmonary embolism after the operation, and succumbed 1 month later. There were no recurrences for the benign tumors during the follow-up period. CONCLUSIONS: Laparoscopic adrenalectomy for pheochromocytoma although safe, should be converted to open for difficult dissection, to avoid tumor disruption, and recurrence. Hemodynamic instability can be prevented and is not influenced by early or late ligation of the adrenal vein. Delayed main adrenal vein ligation is a safe alternative to the "vein first" technique.