Favorable Management of Low Colorectal Anastomotic Leakage with Transanal Conventional and Endoscopic Drainage (GelPOINT® Path Transanal Access Platform).

OBJECTIVE: We describe our experience with transanal-laparoscopic treatment of anastomotic leakage. SUMMARY OF BACKGROUND DATA: Anastomotic leakage leads to high mortality rates, morbidity, a complicated post-operative course and increased cost. The management of low anastomotic leakage after anterior resection of rectal cancer is not standardized. METHODS: This was a retrospective cohort study based on prospectively collected data. Among patients who underwent anterior resection for rectal cancer in our division between January 2014 and October 2017, 14 developed colorectal or colo-anal anastomotic leakage and underwent reoperation with a transanal approach. Data regarding patient demographics, reoperative outcomes, morbidity, length of hospital stay, mortality, leak closure and long-term outcomes are presented. RESULTS: In all patients, anastomotic healing was confirmed by radiology. No perioperative complications were detected. One patient presented anastomotic stricture after 20 months, which was successfully treated with dilatation. CONCLUSIONS: There is little information available on the management of anastomotic leakage after anterior resection for rectal cancer. Although more studies are needed to standardize patient selection criteria and evaluate the long-term outcome of these procedures, minimally invasive transanal conventional and laparoscopic anastomotic leak repair is a feasible and safe surgical option that can often avoid the need for anastomotic takedown and stoma formation.

Hepatitis B virus (HBV) DNA integration in patients with occult HBV infection and hepatocellular carcinoma.

BACKGROUND & AIMS: Hepatitis B virus (HBV) DNA integration in the host genome is a major mechanism responsible for the etiopathogenetic role exerted by HBV in hepatocellular carcinoma (HCC) development. Extensive analyses evaluating viral integration in HBV surface antigen (HBsAg) negative patients with occult HBV infection (OBI) have not yet been performed. The aim of this study was to investigate and characterize HBV DNA integration in HCC tissues from OBI patients. METHODS: Tumour DNA extracts from 69 HCC patients (49 HBsAg-negative with occult infection diagnosed by HBV DNA detection in tumour tissues; 10 HBsAg-positive and 10 HBsAg-negative/OBI-negative as control groups) were examined by Alu-PCR technique to reveal HBV DNA integration into the host genome. The molecular characterization of the virus-genome junctions was performed by cloning and sequencing analyses. RESULTS: Integrated HBV DNA was detected in 37/49 (75.5%) OBI-positive HCC samples, in 8/10 (80%) HBsAg-positive and in 0/10 OBI-negative HCC samples. Nine of 37 (24.3%) integrated viral sequences from OBI-positive cases were inside human genome coding regions and in the remaining cases the localization at intergenic level was frequently adjacent to coding genes. Concerning viral integrants in OBI cases, X gene sequences were found in 14 cases, preS/S sequences in 13, Core sequences in 7, and Polymerase gene sequences in three cases. CONCLUSIONS: In analogy to what occurs in HBsAg-positive cases, HBV DNA integration is highly prevalent in OBI-related HCCs, it mainly involves X and preS/S viral genomic regions and it frequently occurs at the level of regulatory and functional genes.

Rate of hepatocellular carcinoma diagnosis in cirrhotic patients with ultrasound-detected liver nodules.

Ultrasound (US) detection of liver nodules in cirrhotic patients requires further radiological examinations and often a follow-up with repeated short-term evaluations to verify the presence of hepatocellular carcinoma (HCC). Aims of the study were to assess the rate of HCC diagnosis and to identify HCC predictors in a cohort of cirrhotics followed-up after US detection of the liver nodule(s). One-hundred-eighty-eight consecutive cirrhotic patients (124 males, mean age 64.2 years) with liver nodule(s) detected by US were enrolled. All patients underwent second-level imaging [computed tomography (TC) or magnetic resonance (MR)], and those without a definite diagnosis of HCC were followed-up with TC and/or RM repeated every 3-6 months up to 18 months if HCC was not diagnosed. After 18 months, non-HCC patients came back to routine US surveillance. HCC was diagnosed in 73/188 cases (38.8%). In 66/73 patients (90.4%) HCC was identified at first radiological evaluation after US, while in the remaining seven subjects it was diagnosed at the subsequent imaging examination. Age (p = 0.001) and nodule dimension (p = 0.0001) were independent predictors of HCC at multivariate analysis. Fourty-nine/188 patients were lost at follow up after 18 months. Twenty/139 remaining patients developed HCC and 3/139 cholangiocarcinoma; 77 died between 3 and 110 months from the beginning of the study (61 for end-stage liver disease, 8 for extrahepatic causes, eight for unknown causes). Patients who developed liver cancer earlier during the follow up had the shortest overall survival. US-detected liver nodules are not neoplastic in more than half of cirrhotic patients. A definite diagnosis may be obtained at the time of the first radiologic evaluation after US in the vast majority of the cases. Patients in whom nodules are found not to be tumoral may return to the US surveillance program routinely applied to all cirrhotics.

Gastric Histopathologic Findings in South Italian Morbidly Obese Patients Undergoing Laparoscopic Sleeve Gastrectomy: Is Histopathologic Examination of All Resected Gastric Specimens Necessary?

BACKGROUND: The value of the routine histopathologic examination of resected gastric remnants following laparoscopic sleeve gastrectomy (LSG) remains to be controversial. This study aimed to determine whether the routine histopathologic examination of gastric specimens is necessary for all patients undergoing LSG if upper gastrointestinal endoscopy (UGIE) plus multiple biopsies are performed routinely during the preoperative work-up. MATERIALS AND METHODS: Clinicopathologic data of 474 patients who underwent LSG were analysed. Types of histopathologic findings in LSG specimens and the prevalence of these and Helicobacter pylori (HP) infection were estimated. Comparisons were conducted to assess the association of risk factors with the most frequent abnormal and premalignant histopathologic findings. RESULTS: Chronic gastritis was the most common gastric pathology (63.5%) and premalignant lesions were present in 7.8% of the specimens. The prevalence of HP infection was 36.9%. A statistically significant association was observed between HP infection and chronic gastritis (P = .000), and premalignant lesions (P = .000). Similarly, a statistically significant association was noted between age and premalignant gastric lesions (P = .000). CONCLUSION: Histopathologic examination of LSG specimens may not be routinely needed and can be performed on selected patients. While we recommend routine preoperative UGIE in all LSG-treated patients, we suggest that histopathologic assessment of the LSG specimens should be mandatory when UGIE biopsies demonstrate HP infection and/or premalignant lesions, in all patients older than 42 years, and in cases of intraoperative detection of incidental tumours or suspicious lesions.

Ultrasound-guided radiofrequency-assisted segmental liver resection: a new technique.

Segmental hepatectomy is appealing for several reasons including preservation of liver parenchyma, reduction of intraoperative blood loss, and blood replacement by dividing tissues along the anatomic planes. A simple technique guided by intraoperative ultrasound is described here using radio-frequency energy to create coagulative desiccation of segmental or subsegmental arterial and portal vessels. Thirty patients underwent a segmental resection using this technique without mortality and with minor morbidity. This technique has a major advantage of being easy and safe to apply. We believe it has a potentially important role in both open and laparoscopic liver surgery.

Voluminous paraumbilical hernia containing the pancreas - An unusual cause of acute pancreatitis: A case report.

INTRODUCTION: The paraumbilical hernia sac often contains the omentum, the small bowel, and less commonly the colon. The herniation of the pancreas through a paraumbilical hernia is extremely rare and has been reported only by two cases in the literature; moreover, acute pancreatitis secondary to this condition is a particularly unusual event. CASE REPORT: We present a very unusual case of a 67-year-old female patient with a voluminous paraumbilical hernia containing the pancreas, complicated by acute pancreatitis. Laboratory data revealed an elevation of the pancreatic enzymes. An intravenous contrast-enhanced computed tomography (CT) scan of the abdomen demonstrated a large hernia sac containing multiple viscera, including the pancreas. The patient underwent emergency laparotomy with a diagnosis of intestinal obstruction. CONCLUSION: The clinicians should consider this rare condition in the differential diagnosis of patients presenting with large paraumbilical hernias associated with classical symptoms of acute pancreatitis, particularly in the absence of typical risk factors for pancreatitis. An intravenous contrast-enhanced abdominal CT scan should be performed immediately in these patients. We recommend the patients and the surgeons to consider prompt surgical repair for paraumbilical hernias to avoid further complications and the higher incidence of morbidity and mortality associated with emergency surgeries.

Free episomal and integrated HBV DNA in HBsAg-negative patients with intrahepatic cholangiocarcinoma.

There is evidence that chronic hepatitis B virus (HBV) infection is associated with an increased risk of intrahepatic cholangiocarcinoma (ICC) development, and it has been hypothesized an etiological role of HBV in the development of this tumor. Very little is known about occult HBV infection (OBI) in ICC. Aims of the study were to investigate the OBI prevalence and to characterize the HBV molecular status at intrahepatic level in OBI-positive cases with ICC. Frozen liver tumor specimens from 47 HBV surface-antigen-negative patients with ICC and 41 paired non-tumor liver tissues were tested for OBI by 4 different HBV-specific nested PCR. Covalently closed circular HBV DNA (HBV cccDNA) and viral integrations were investigated in OBI-positive cases. HBV DNA was detected in tumor and/or non-tumor specimens from 29/47 (61.7%) ICC patients. HBV cccDNA was found in tissues from 5/17 (34.5%) cases examined. HBV integration was detected in 4/10 (40%) tumor tissues tested and involved HBx and HBV-core gene sequences in 3 and 1 cases, respectively. Viral integration occurred: (a) 9,367 nucleotides upstream of the cat-eye-syndrome critical region protein-5-isoform coding sequence; (b) within the cystinosin isoform-1-precursor gene; (c) within the thromboxane-A-synthase-1 gene; (d) within the ATPase phospholipid transporting 9B gene. Occult HBV infection is highly prevalent in patients with ICC. Both free viral genomes and integrated HBV DNA can be present in these cases. These results suggest an involvement of HBV in the carcinogenic process leading to ICC development even in cases with occult infection.

miRNA expression profiling regulates necroptotic cell death in hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is one of the most aggressive types of cancer and is among the leading causes of cancer-related mortality worldwide. Although the dysregulation of microRNAs (miRNAs or miRs) has often been reported in HCC, the precise molecular mechanisms by which miRNAs modulate the process of tumorigenesis and the behavior of cancer cells are not yet clearly understood. In this study, we identified a novel three­miRNA signature, including miR­371-5p, miR­373 and miR­543, that appears to orchestrate programmed cell necrosis in HCC by directly targeting the caspase­8 gene (Casp­8). Our results demonstrated that miR­371-5p, miR­373 and miR­543 were overexpressed in HCC tissues compared with paired adjacent normal tissues. The upregulation of these miRNAs specifically and markedly downregulated the expression of Casp­8, as well as significantly enhanced the Z-VAD/TNF­α-induced necroptosis of HCC cells. By contrast, the selective knockdown of miRNA expression led to a significant increase in Casp­8 levels and a marked reduction in programmed cell necrosis. Intriguingly, the sustained overexpression of Casp­8 reversed the pro­necroptotic effects exerted by miRNA mimics. Finally, a strong inverse association between the level of miR­223 and the expression levels of nucleotide-binding oligomerization domain-like receptor family, pyrin domain-containing-3 inflammasome was observed in our HCC specimens. On the whole, the present study revealed a molecular link between the three­miRNA signature, comprising miR­371-5p, miR­373 and miR­543, and the negative necroptotic regulator Casp­8, and presents evidence for its employment as a novel potential diagnostic, prognostic and therapeutic target in HCC.