Occult hepatitis B virus infection predicts non-alcoholic steatohepatitis in severely obese individuals from Italy.

BACKGROUND & AIMS: Obesity is associated with non-alcoholic fatty liver (NAFL), which may progress towards non-alcoholic steatohepatitis (NASH), cirrhosis and hepatocellular carcinoma (HCC). Occult hepatitis B virus infection (OBI) may contribute to hepatic damage in patients with chronic liver disease of different aetiologies (eg HCV, alcohol). However, information on the prevalence and clinical impact of OBI in obese individuals is lacking. The aims of this study were to investigate NASH prevalence and risk factors in obese people who underwent bariatric surgery. METHODS: Two-hundred and twenty-six subjects (160 females; mean age 42.9 years ±10.8 SD) without evidence of any further cause of liver disease consecutively underwent bariatric surgery in two Italian liver centers. During surgery, all patients underwent liver biopsy for histological evaluation and molecular studies. Liver DNA extracts were tested for PNPLA3, TM6SF2, MBOAT7, IRGM polymorphisms and for OBI. Univariate and multivariate analyses were used to identify predictors of NASH. RESULTS: Histology showed NASH in 115 (50.9%) and NAFL in 111 cases (49.1%). Twenty-nine/226 (12.8%) cases had OBI, 24 (82.8%) of whom had NASH and 5 (17.2%) NAFL, whereas among the 197 OBI-negative cases, 91 (46.2%) had NASH and 106 (53.8%) NAFL (P = .0002). Multivariate analysis showed that older age (P = .03, OR 1.034), alanine aminotransferase values (P = .005, OR 1.023), insulin resistance/diabetes (P = .02, OR 2.257), TM6SF2 polymorphism (P = .04, OR 3.168) and OBI (P = .004, OR 5.503) were independent predictors of NASH. CONCLUSION: NASH is highly prevalent in obese individuals undergoing bariatric surgery. OBI is one of the strongest risk factors of NASH in these patients.

Multi-port versus single-port cholecystectomy: results of a multi-centre, randomised controlled trial (MUSIC trial).

BACKGROUND: Single-port laparoscopic surgery as an alternative to conventional laparoscopic cholecystectomy for benign disease has not yet been accepted as a standard procedure. The aim of the multi-port versus single-port cholecystectomy trial was to compare morbidity rates after single-access (SPC) and standard laparoscopy (MPC). METHODS: This non-inferiority phase 3 trial was conducted at 20 hospital surgical departments in six countries. At each centre, patients were randomly assigned to undergo either SPC or MPC. The primary outcome was overall morbidity within 60 days after surgery. Analysis was by intention to treat. The study was registered with ClinicalTrials.gov (NCT01104727). RESULTS: The study was conducted between April 2011 and May 2015. A total of 600 patients were randomly assigned to receive either SPC (n = 297) or MPC (n = 303) and were eligible for data analysis. Postsurgical complications within 60 days were recorded in 13 patients (4.7 %) in the SPC group and in 16 (6.1 %) in the MPC group (P = 0.468); however, single-access procedures took longer [70 min (range 25-265) vs. 55 min (range 22-185); P < 0.001]. There were no significant differences in hospital length of stay or pain VAS scores between the two groups. An incisional hernia developed within 1 year in six patients in the SPC group and in three in the MPC group (P = 0.331). Patients were more satisfied with aesthetic results after SPC, whereas surgeons rated the aesthetic results higher after MPC. No difference in quality of life scores, as measured by the gastrointestinal quality of life index at 60 days after surgery, was observed between the two groups. CONCLUSIONS: In selected patients undergoing cholecystectomy for benign gallbladder disease, SPC is non-inferior to MPC in terms of safety but it entails a longer operative time. Possible concerns about a higher risk of incisional hernia following SPC do not appear to be justified. Patient satisfaction with aesthetic results was greater after SPC than after MPC.

Fever of unknown origin due to intrahepatic wooden toothpick.

Ingestion of foreign bodies is a common clinical problem, but intrahepatic migration is an exceptional occurrence. Clinical history is not helpful. Abdominal ultrasonography and CT are fundamental to exclude surgical causes of fever of unknown origin. Laparoscopic segmental liver resection is recommendable to avoid generalized peritonitis.

[Laparoscopy in traumatic abdominal emergencies]. / La videolaparoscopia nelle urgenze addominali non traumatiche.

Over the past few years the laparoscopic technique has changed most of the concepts of traditional surgery and is today the standard approach in elective surgery for many pathologies requiring surgery. Unfortunately the same cannot be said for emergency surgery, though much progress has been made in this field, too. The Authors examine the most important abdominal diseases that can be diagnosed and, possibly, treated by the laparoscopic approach in the emergency setting, concluding that laparoscopic management of such conditions is a feasible proposition in many cases. Technological improvements and the development of new, more versatile surgical instruments will undoubtedly contribute to the increasingly widespread use of the laparoscopic approach also in emergency procedures.

[Role of ultrasonography in the non-operative management of liver traumas]. / iI ruolo dell'ultrasonografia nel trattamento non operatorio dei traumi epatici.

The technical progress in imaging methodology and intensive care over recent years has allowed a reduction in surgical operations for hepatic trauma. In the past, surgeons based their evaluations on clinical findings and patients in critical condition were submitted to surgery. The percentage of negative laparotomies was high (6% to 25%) due to non-haemorrhagic hepatic lesions at surgery. The introduction of ultrasonography and computed tomography offered two important tools for determining the origin and extent of traumatic lesions of the liver and other abdominal organs. These modern imaging techniques enable us to diagnose and monitor patients with hepatic trauma with a reduction in negative laparotomies and allow conservative treatment of numerous traumatic lesions of the liver. Despite the diagnostic superiority of computed tomography in the evaluation of patients with hepatic trauma, the risk of exposure to ionising radiation in several, consecutive examinations in patients undergoing conservative treatment has aroused considerable interest with regard to the use of ultrasonography for both the initial and later evaluation of such patients. We report on our experience with 28 patients with liver traumas, focusing on the role of ultrasonography in their non-operative management.

Three-Dimensional Versus Two-Dimensional Laparoscopic Cholecystectomy: Is Surgeon Experience Relevant?

BACKGROUND: A prospective randomized comparison of three-dimensional (3D) versus two-dimensional (2D) imaging during elective laparoscopic cholecystectomy (LC), both performed separately by an advanced laparoscopic surgeon and by a surgeon experienced in open surgical procedures but a novice at laparoscopic procedures, was designed to address the issue of whether 3D systems offer real operative time advantages to this laparoscopic procedure. PATIENTS AND METHODS: Eighty patients were randomized the day of surgery by random computer-generated allocation list to receive either a 3D or 2D high-definition imaging system LC by two surgeons with differing experience. After the insertion of the access ports the surgical procedure was divided in two component tasks. Operative times of the two component tasks and the entire procedure were recorded. RESULTS: The execution times for the two component tasks and the entire procedure were not significantly different between the 2D and 3D groups for the experienced laparoscopic surgeon. However, the execution times for the two component tasks and the entire procedure were significantly faster during 3D compared with 2D for the novice surgeon. Both surgeons experienced better depth perception with the 3D system and subjectively reported less strain using 3D rather than 2D vision. CONCLUSIONS: 3D imaging seems not to influence the performance time of LC by an experienced laparoscopic surgeon. Less experienced laparoscopic surgeons could benefit from shorter performance time with 3D imaging due to no need to adapt to 2D vision. Further comparative studies are necessary to verify on great numbers of cases whether 3D can reduce intraoperative complications such as biliary lesions.

Evaluation of CTNNB1 and TP53 variability in patients with hepatocellular carcinoma and occult hepatitis B virus infection.

Hepatitis B virus (HBV) infection plays a major role in hepatocellular carcinoma (HCC) development. Much evidence suggests that HBV also maintains its pro-oncogenic properties in cases of occult HBV infection (OBI). Mutations of the beta-catenin and p53 genes (CTNNB1 and TP53, respectively) may be associated with HCC occurrence in patients with overt HBV infection, whereas such genetic mutations have not been investigated in HCC patients with OBI thus far. We investigated the genetic heterogeneity of CTNNB1 exon 3 and all of the TP53 exons in tumor DNA extracts from a unique cohort of 61 HCC patients (all previously tested for HBV DNA and for its integration into the host's genome), including 34 OBI-positive, 20 HBV surface antigen (HBsAg)/OBI-negative, and 7 HBsAg-positive cases. No CTNNB1 exon 3 mutations or TP53 mutations were detected in any case. The homo- or heterozygous TP53 R72P polymorphism was found in 18 of 61 cases (29.5%), although no differences in its prevalence between OBI and non-OBI cases as well as between cases with and without viral integration were revealed. In conclusion, CTNNB1 and TP53 somatic mutations seem to be a rare event in patients with HCC in our area and in cases with either overt or occult HBV infection.

[Conservative treatment of hepatic trauma]. / Il trattamento conservativo dei traumi epatici.

Liver trauma has increased over the past few years. In haemodynamically stable patients with hepatic injuries a conservative approach is possible, mainly as a result of the reliability of the diagnostic tools available which allow accurate monitoring of the patients. Computed tomography (CT) of the abdomen is extremely useful for documenting the extent of the damage. Of 16 patients treated for blunt hepatic injury, 10 were managed non-operatively. In this group of patients there were no deaths or delayed laparotomies. Total hospital stay and transfusion requirements were lower. The advantages of non-operative therapy include a lower incidence of abdominal septic complications. All patients managed non-operatively were monitored until their CT scans showed complete resolution. The authors conclude that non-operative management of hepatic injury is a safe technique applicable to haemodynamically stable patients.

[Intrabiliary rupture of hepatic hydatid cyst]. / Rottura intrabiliare di cisti d'echinococco epatica.

Spontaneous hepatic hydatid cyst rupture into the biliary tract is unusual. The authors describe a case of a 62-year-old man with a hepatic hydatid cyst, showing that it is possible to confirm rupture into the biliary system with cholangiography-MRI. Surgical treatment remains the best form of management. Endoscopic management is a therapeutic possibility in all cases in which surgery is contraindicated. In the case observed endoscopic sphinctererotomy resolved the biliary obstruction, while the hydatid cyst was treated by transbiliary irrigation with scolicidal solutions and pharmacological therapy. The treatment permitted complete clinical resolution of the hepatic hydatosis.

[Diagnostic problems of choledochal cysts in the adult]. / Problematiche diagnostiche delle cisti del coledoco nell'adulto.

Choledochal cysts are rare malformations of the biliary tree, the precise pathogenesis of which remains unclear. The authors present the case of a 21-year-old man with a choledochal cyst and discuss the main issues regarding the diagnosis and treatment of this uncommon lesion. In particular, of all the diagnostic techniques available, magnetic resonance cholangiopancreatography (MRCP) could become the imaging technique of choice for defining the pancreatobiliary ductal anatomy with at least the same degree of accuracy as that of diagnostic ERCP, while avoiding the potential complications associated with the latter. The patient was treated by surgical operation and, after a 12 month follow-up, is disease-free. Surgical treatment is necessary owing to the possibility of malignant transformation.

Reversible bilio-pancreatic diversion with explorable excluded stomach-the Messina technique.

The authors propose a reversible bilio-pancreatic diversion with access to the bypassed stomach. In the Messina technique, bilio-pancreatic diversion is accomplished by transecting the stomach without gastric resection, as already described by Resa et al. In addition, a temporary gastrostomy is performed on the excluded stomach and allows direct postoperative exploration of the duodenum and the biliary tree. The Messina bilio-pancreatic diversion technique (MBPDT) seems to be safe and effective. The authors propose the MBPDT in a morbidly obese patient undergoing bariatric surgery when a malabsorptive operation is required, as it makes the original Scopinaro operation reversible, the bilio-pancreatic area explorable postoperatively, the operation shorter, and does not cause any significant increase in the postoperative complication rate. Larger numbers and longer follow-up, however, are needed to further confirm our data.

Single-incision versus three-port conventional laparoscopic right hemicolectomy: is there any real need to go single?

BACKGROUND: Preliminary results showed some benefits of single-incision laparoscopic surgery (SILS) over conventional laparoscopic colectomy, including better cosmesis, less postoperative pain, and faster recovery, but these results need further confirmation. In addition, the literature still lacks comparative studies between the two approaches to prove the above-mentioned advantages of SILS over conventional laparoscopy and, most importantly, its equivalent effectiveness in terms of initial oncological results. PATIENTS AND METHODS: Two consecutive series of 10 patients undergoing three-port conventional laparoscopic right hemicolectomy (3PCL-RH) and single-incision laparoscopic right hemicolectomy, respectively, were compared in their short-term surgical and oncological outcomes. RESULTS: Analysis of perioperative and postoperative outcomes revealed no significant differences between the two groups. In the SILS group an anastomotic leakage occurred, which was conservatively treated by continuous drainage, total parental nutrition, and antibiotic therapy. The analysis of oncological outcomes showed no differences in terms of length of distal tumor-free margin and harvest of lymph nodes. CONCLUSIONS: Despite its feasibility for right hemicolectomy and its equivalent short-term surgical and oncological outcome compared with conventional laparoscopy, SILS demonstrated no significant advantages in terms of surgical incision length and postoperative course compared with 3PCL-RH. We acknowledge that the small sample size and the nonrandomized design are a limit of the study. Thus, prospective randomized controlled trials are recommended to prove the superiority of single-incision laparoscopic right hemicolectomy.

SILS and NOTES cholecystectomy: a tailored approach.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS) have been proposed as different solutions to further minimize the invasiveness of laparoscopy. In this article, we present our experience with NOTES and SILS over the last few years, trying to focus on identifying which technique should be offered to which patients at the beginning of 2010. PATIENTS AND METHODS: Between January 2009 and January 2010, 100 patients were diagnosed with symptomatic cholelithiasis at our department. Considering our positive previous experiences with NOTES and SILS, we offered the hybrid NOTES approach to women over 40 years with no previous pelvic surgery or history of inflammatory pelvic disease and SILS to male patients and women excluded from the hybrid NOTES approach, with previous surgery in the upper right quadrant and gallbladder empyema being the main contraindications. RESULTS: Twenty-six patients accepted the SILS or NOTES approach instead of standard laparoscopic cholecystectomy (LC). Seventy-four patients underwent standard LC via four trocars. In the hybrid NOTES transvaginal cholecystectomy, there were no problems or complications related to the culdotomy, trocar, or stay suture placement. There were no conversions, and all the procedures were performed as planned without complications. In the SILS cholecystectomy, there were no problems or complications related to the trocar or stay sutures placement. All the procedure were completed without complications. CONCLUSIONS: NOTES and SILS are promising techniques that need new, dedicated instrumentations to reduce technical limitations. Randomized studies comparing SILS/NOTES and traditional laparoscopy are necessary to evaluate safety, efficacy, and potential benefits.