Maternal Serum B Cell activating factor in hypertensive and normotensive pregnancies.

OBJECTIVES: The objective of this study was the analysis of B-Cell Activating Factor (BAFF) levels in pregnancies affected by PE, and in pregnancies affected by fetal growth restriction without Hypertensive disorders and its possible correlation with pulse wave velocity and cardiac output. STUDY DESIGN: Prospective study of 69 women at 24-40 weeks gestation. Haemodynamic function was assessed in those with Pre-eclampsia (PE, n = 19), fetal growth restriction (FGR, n = 10) and healthy pregnancies (n = 40). Maternal venous BAFF levels at recruitment were measured using ELISA. We analysed the relationship between BAFF and cardiac output (CO), and BAFF and PWV (pulse wave velocity); the gold standard for assessing arterial stiffness. PWV was measured with an oscillometric device and CO using inert gas rebreathing technique. PWV and CO were converted to gestation adjusted indices (z scores). MAIN OUTCOME MEASURES: The association between BAFF levels in PE and FGR, and the relationship of BAFF with PWV and CO. RESULTS: BAFF was higher in PE (p = 0.03) but not in FGR (p = 0.83) when compared to healthy pregnancies. There was a positive correlation between BAFF levels and z score PWV (r = 0.25, p = 0.04), but not CO (r = -0.01, p = 0.91). BAFF levels did not change with gestational age. (r = 0.012, p = 0.925). CONCLUSIONS: These findings provide evidence of a possible contribution of BAFF to both maternal inflammation and arterial dysfunction associated with PE. Though no relationship was found with another disorder of placentation: normotensive FGR, this condition is not thought to be associated with maternal inflammation.

Reticulon1-C modulates protein disulphide isomerase function.

Endoplasmic reticulum (ER) is the primary site for the synthesis and folding of secreted and membrane-bound proteins. Accumulation of unfolded and misfolded proteins in ER underlies a wide range of human neurodegenerative disorders. Hence, molecules regulating the ER stress response represent potential candidates as drug targets for tackling these diseases. Protein disulphide isomerase (PDI) is a chaperone involved in ER stress pathway, its activity being an important cellular defense against protein misfolding. Here, we demonstrate that human neuroblastoma SH-SY5Y cells overexpressing the reticulon protein 1-C (RTN1-C) reticulon family member show a PDI punctuate subcellular distribution identified as ER vesicles. This represents an event associated with a significant increase of PDI enzymatic activity. We provide evidence that the modulation of PDI localization and activity does not only rely upon ER stress induction or upregulation of its synthesis, but tightly correlates to an alteration in its nitrosylation status. By using different RTN1-C mutants, we demonstrate that the observed effects depend on RTN1-C N-terminal region and on the integrity of the microtubule network. Overall, our results indicate that RTN1-C induces PDI redistribution in ER vesicles, and concomitantly modulates its activity by decreasing the levels of its S-nitrosylated form. Thus RTN1-C represents a promising candidate to modulate PDI function.

Outcomes and survival after laparoscopic gastrectomy for adenocarcinoma. Analysis on 65 patients operated on by conventional or robot-assisted minimal access procedures.

AIMS: Despite laparoscopic surgery for gastric cancer has gained worldwide acceptance, long term results and survival are seldom reported. This study was designed to assess long term outcomes after laparoscopic gastrectomy with D2 dissection. The short term results of conventional and robot-assisted minimally invasive procedures were also examined. PATIENTS AND METHODS: The charts of 65 patients who underwent laparoscopic surgery for non-metastatic adenocarcinoma were reviewed retrospectively. This series included 35 patients with early gastric cancer (EGC) and 30 with advanced gastric cancer (AGC). A 4/5 laparoscopic subtotal gastrectomy (LSG) with D2 nodal clearance was the procedure of choice for distal cancers. Laparoscopic total gastrectomy (LTG) with modified D1 lymphadenectomy was performed for mid-proximal EGC. RESULTS: Sixty gastrectomies were carried out laparoscopically, 56 LSG and 4 LTG. Conversion to laparotomy was required in 5 patients with distal cancer. No intraoperative complication was registered. Morbidity included 2 duodenal leaks that healed conservatively. Two postoperative deaths were registered. An average number 31.3+/-8.8 lymph nodes were collected. The mean hospital stay was 10 days (range 7-24). The mean follow up was 30 months (range 2-86) and the cumulative overall 5 year survival rate was 78%. Survival at 5 years for EGC was 94% and survival at 4 years for AGC was 53% (57% for non-converted patients). CONCLUSIONS: Laparoscopic gastrectomy for cancer represents a valid alternative to open surgery with minimal morbidity and acceptable long term survival. Considering the risk of preoperative under diagnoses a D2 lymphadenectomy is suggested also for EGC. This study validated the effectiveness of minimally invasive technique in the management of gastric cancer.

Laparoscopic resection for rectal adenocarcinoma.

AIMS: Laparoscopic surgery for rectal cancer is still under discussion, but there is evidence that minimal access surgery can be feasible and safe also in this field. The aim of this study was to confirm that laparoscopic resection for rectal cancer can afford good results in terms of recurrence rate and survival. PATIENTS AND METHODS: Since June 1998 through December 2007 as many as 252 patients underwent laparoscopic resection for rectal cancer. Laparoscopic anterior resection (LAR) was performed in 209 and laparoscopic abdominoperineal resection (LAPR) in 43. Neoadjuvant radiochemotherapy (nCRT) was administered in 48 patients with mid-low rectal cancer stage II and III with evidence of nodal involvement in preoperative work up. RESULTS: Patients who received nCRT showed a significant longer duration of surgery compared to patients who did not (p=0.004). Conversion to laparotomy was needed in 24 cases, (21 LAR and three LAPR) but no patient receiving nCRT needed conversion. Postoperative surgical complications occurred in 38 patients, 20 of which were represented by anastomotic leak after LAR. Six patients died postoperatively, in half the cases for surgery related causes. Downstaging after nCRT was seen in 40 patients, and complete histological response was observed in six cases. The mean number of lymph nodes harvested was 12, also in patients receiving nCRT. The mean follow-up was 48+/-33 months (range 0.1-120.4), and 10 patients experienced local recurrence. Cumulative 5 year survival was 73.7%. CONCLUSION: Laparoscopic resection for rectal cancer is feasible and safe, with morbidity and long-term results quite acceptable also in patients receiving neoadjuvant treatment.

Robot-assisted laparoscopic gastrectomy with D2 dissection for adenocarcinoma: initial experience with 17 patients.

Robot-assisted gastrectomy has been practised so far in very few centres in the world. The aims of this study were to assess the feasibility of robot-assisted gastrectomy for adenocarcinoma with D2 lymph nodal dissection and to analyze our preliminary results. Between January 2006 and August 2008, as many as 17 patients (11 females, 6 males) underwent laparoscopic robot-assisted surgery for non-metastatic adenocarcinoma of the stomach by a 3-armed da Vinci(®) Robotic Surgical System. The mean age of patients was 65.9 years. This series included eight patients with early gastric cancer (EGC) and nine with advanced gastric cancer (AGC). A 4/5 laparoscopic subtotal gastrectomy (LSG) with D2 nodal clearance was the procedure of choice for 16 distal cancers. Laparoscopic total gastrectomy (LTG) with D2 lymphadenectomy was performed for one AGC of the middle third of the stomach. No intraoperative complication was registered. Conversion to laparotomy was required in two patients with distal cancer. The mean operating time (excluding converted patients) was 352 min (348 for LSG). Morbidity consisted in one pancreatic leak that healed conservatively. One death occurred postoperatively for haemorragic stroke. On average, 25.5 ± 4 lymph nodes were collected (range 10-40). The resection margin was 6.4 ± 0.6 cm (range 4.2-8), and the margin was tumour free in all the specimens. The mean hospital stay of totally laparoscopic subtotal gastrectomy was 10 ± 1.2 days (range 8-13). The mean follow-up was 14 months (range 1-29) and three patients with AGC showed recurrence after LSG and died of disease. Robotics in gastrectomy for cancer is a feasible and safe procedure, yielding adequate D2 nodal clearance with respect of oncologic principles. Robotic techniques can represent a remarkable tool to improve laparoscopic surgeon's ability and precision in small surgical fields, i.e. during D2 dissection. This study demonstrated the feasibility of robot-assisted gastrectomy for cancer although further studies are required to validate our preliminary results, especially as far as patients' benefits are concerned.

Total and subtotal laparoscopic gastrectomy for adenocarcinoma.

BACKGROUND: Laparoscopic gastrectomies are currently performed in many centers, but compliance with oncologic requirements still represents a subject open to debate. The aim of this work was to compare the short-term and oncologic outcomes after laparoscopic and open surgery in gastric adenocarcinoma. METHODS: From June 2000 through June 2005, 147 patients in our institution underwent gastrectomy by open or mininvasive approach for adenocarcinoma. The laparoscopy group included 48 patients, 29 with early gastric cancer (EGC) and 19 with antral advanced gastric cancer (AGC). The short-term results and oncologic data were compared to those obtained in 99 patients who underwent open surgery. Survival in the laparoscopy group was analyzed. RESULTS: In the laparoscopy group no intraoperative complications were observed, and conversion was needed in only one patient with a large advanced tumor. Overall, 32 lymph nodes were collected by D2 dissection, 30 for EGC, 34 for advanced cancers. The resection margin was 6.7 cm (range: 4-8 cm). The mean operating time was 240 min (range: 150-360 min), with a blood loss of 150 ml on average (range: 70-250 ml). Morbidity included two duodenal leaks that healed without reoperation; after enclosing or reinforcing the staple line, no further leaking was noted. There was one death from massive bleeding in a cirrhotic patient. Ambulation and oral feeding started significantly earlier than in open surgery. The mean hospital stay was 10 days (range: 7-24 days), significantly shorter than the stay of 18 days after open surgery (p < 0.05). All patients treated laparoscopically were alive without recurrence at the end of this study. CONCLUSIONS: Short-term results with laparoscopic gastrectomy were better than with open surgery in this study. Oncologic radicality was a major concern, but in the authors' experience the extent of lymphadenectomy was the same as in open surgery. This study suggests that laparoscopic gastrectomy in malignancies is a reliable tool and oncologic requirements can be warranted.

Outcomes of laparoscopic Miles' operation in very low rectal adenocarcinoma. Analysis of 32 cases.

AIMS: Minivasive techniques for excision of low rectal tumours have spread worldwide with good results, but their employment is still under discussion. The purpose of this study is to assess short term results and survival of laparoscopic abdominoperineal resection (LAPR) in very low rectal cancers. METHODS: The charts of 32 patients undergoing LAPR for very low rectal adenocarcinoma (0-2cm from dentata line) were reviewed retrospectively. Outcomes were evaluated considering surgical procedure, short and long-term results and survival. RESULTS: A thorough LAPR was performed in 31 patients and conversion to laparotomy was required in 1 patient. Mean operating time was 244min. The length of hospital stay (LOS) was 13,3days. The mean number of nodes collected was 12 and the distal margin was 3,6cm on average. There was 1 post-operative death. In the follow up no pelvic recurrence was observed, while metachronous metastases were observed in 5 patients and peritoneal carcinosis in 2 patients. No port site metastasis was registered. Cumulative 5year survival probability was 0,50. CONCLUSIONS: The outcomes of this study suggest that LAPR in very low rectal cancer is a reliable procedure, operating time and LOS were acceptable. Oncologic principles were respected: length of specimen, distal margin and number of nodes retrieved were quite acceptable. Pelvic recurrence frequency was nil. Long term results were comparable with those of other series.

Laparoscopic splenectomy: A retrospective review of 75 cases.

Laparoscopic splenectomy (LS) is considered a safe procedure for spleens of normal size as well as for larger spleens. Seventy-five consecutive patients underwent LS. Splenomegaly was defined by diameter >15 cm and by weight >400 g. Thirty patients had splenomegaly. The outcomes with spleens <15 cm and spleens >15 cm were compared. LS was successfully completed in 73 cases (97.4%). Spleens >15 cm required longer operating time and were associated with greater blood loss (P < 0.001), longer hospital stay, and more complications. Two patients needed blood transfusion. No overwhelming postsplenectomy infection was registered, and operative mortality was zero.

[Criteria for training in laparoscopic gastric surgery: guidelines and experience of 30 cases]. / Criteri di apprendimento nella chirurgia laparoscopia delle lesioni gastriche. Proposta di linee guida es esperienzxa di 30 casi.

AIM: Although many studies on laparoscopic surgery of the stomach have been conducted so far, yet they have not provided surgeons with criteria for gradual and safe training with this technique. The results of gastric surgery with 30 patients operated on by laparoscopic approach are hereby described. The aim of this issue is to provide surgeons with guide lines for progressive training, respectful to patients, complying with oncologic criteria and useful to reduce conversion rate or drawbacks at the start of the experience. METHODS: The Authors made a retrospective analysis on 30 patients affected by gastric lesions, 5 benign chronic ulcers and 25 neoplasms of the stomach. Our guide lines suggest that the training begin with the treatment of benign lesions, followed by early gastric cancer (EGC) and by advanced gastric cancer (AGC) of the antrum. Our experience started with 4 laparoscopic subtotal distal gastrectomies (LSGs) for benign ulcer; independent of the guidelines hereby proposed 1 laparoscopic total gastrectomy (LTG) was done after the intraoperative finding of a benign ulcer of the lesser curve penetrating into the left hepatic lobe. The beginning of training included also 1 LSG for distal stromal tumor (GIST). Subsequently 13 early gastric cancers (EGC) were operated on: echoendoscopy could demonstrate 12 T1 m and 1 T1 sm and no evidence of nodal involvement. The diameter of EGCs was 1,3 cm on average ( range 0,7-4 cm), all were marked by Indian ink to allow performance of 10 LSGs and 3 LTGs. Moreover, 8 LSGs for advanced gastric carcinoma (AGC) of the antrum were carried out. The training in malignancies progressed with LTG for 2 non-Hodgkin gastric lymphomas; 1 lymphoma required conversion to laparotomy due to infiltration of the diaphragmatic crus. A D2 lymphadenectomy was associated to gastrectomy in adenocarcinomas. RESULTS: The feasibility of laparoscopic gastric surgery was confirmed by this study, with operating time of 240 minutes (range 150-360), intraoperative blood loss was 180 ml (range 100-250), and only 1 patient required blood transfusion for postoperative bleeding. The specific morbidity rate was 10% owing to duodenal leakage in 3 cases in the early phase of this study (3/30): 1 required laparotomy. The mortality rate was 3% due to 1 serious postoperative bleeding and acute hepatic failure in a patient with post-alcoholic cirrhosis. The conversion rate was 3% (1/30). The nasogastric tube was removed on the 4(th) postoperative day, and the oral intake started on the 6(th) postoperative day after a barium follow-through examination. The mean postoperative hospital stay was 16 days (range 10-25). The number of nodes retrieved was 18 on average and it improved with the experience: from the minimum of 9 nodes in benign ulcers, it grew to 20 in EGCs and to 25 in AGCs, so that this data confirmed the guide lines proposed in this issue . The histologic examination of EGC confirmed the data of echoendoscopy about nodal status. CONCLUSIONS: Laparoscopic surgery is a safe and feasible procedure both for benign and for malignant lesions of the stomach. The results analysed hereby suggest that at the start of training be treated patients affected by benign lesions, followed by patients with EGC and then by patients with AGC. For gastric cancers, the average number of 18 nodes harvested from each patient was adequate, complying with the requirements suggested by the latest TNM classification. This choice of progressive selection of patients for training represents a good means to get an optimal performance level, especially in view of the oncologic requirements, and can prevent surgeons from elevated conversion rates and disappointing outcomes at the beginning of experience.

Laparoscopic treatment of sigmoid diverticulitis: a retrospective review of 103 cases.

BACKGROUND: Laparoscopic treatment of sigmoid diverticulitis is commonly accepted in Hinchey cases I and II, whereas it is debated in the case of purulent peritonitis, and not indicated for fecal peritonitis. METHODS: A single-center experience of 103 patients treated for Hinchey I-III sigmoid diverticulitis was reviewed. One-stage laparoscopic resection and primary anastomosis constituted the planned procedure. Abscesses in patients with Hinchey IIa were drained percutaneously before surgery. Patients with Hinchey III underwent surgery in emergency. A four-trocar approach with left iliac fossa minilaparotomy was used. Fistulas were treated laparoscopically with Harmonic Scalpel dissection. RESULTS: Laparoscopic treatment was successfully completed for 100 patients. Intraoperative complications occurred in 2.9% of the cases. Postoperative procedure-related morbidity was 8%, occurring mainly in Hinchey I patients. A longer hospital stay was recorded among Hinchey IIb patients treated for colovescical fistula. No mortality was observed. CONCLUSIONS: Laparoscopic surgery for sigmoid diverticulitis in experienced hands can be a safe and effective gold standard procedure also for patients with fistula or purulent peritonitis.

Impact of insecurity, the AIDS epidemic, and poverty on population health: disease patterns and trends in Northern Uganda.

A retrospective analysis of the discharge records of 186,131 inpatients admitted to six Ugandan hospitals during 1992-1998 was performed to describe the disease patterns and trends among the population of Northern Uganda. In all hospitals, malaria was the leading cause of admission and the frequency of admissions for malaria showed the greatest increase. Other conditions, such as malnutrition and injuries, mainly increased in the sites affected by civil conflict and massive population displacement. Tuberculosis accounted for the highest burden on hospital services (approximately one-fourth of the total bed-days), though it showed a stable trend over time. A stable trend was also observed for acquired immunodeficiency syndrome (AIDS), which is in contrast to the hypothesis that AIDS patients have displaced other patients in recent years. In conclusion, preventable and/or treatable communicable diseases, mainly those related to poverty and poor hygiene, represent the leading causes of admission and death, reflecting the socioeconomic disruption in Northern Uganda.

[Superparamagnetic iron oxide in the differential diagnosis of focal hepatic lesions using a 0.5-tesla magnetic resonance apparatus]. / Ossido di ferro superparamagnetico nella diagnosi differenziale delle lesioni focali epatiche con apparecchio di risonanza magnetica da 0.5 tesla.

INTRODUCTION: We investigated the efficacy of superparamagnetic iron oxide (SPIO) in the characterization of focal liver lesions on MR images by means of quantitative and qualitative analysis. MATERIAL AND METHODS: We examined 60 patients with at least one focal liver lesion on US images. Conventional T1-weighted spin echo (CSE), proton density and T2-weighted MR images were acquired before and after the injection of a SPIO agent (Endorem, slow infusion, 15 micromoles Fe/kg body weight). A qualitative and a quantitative analysis were performed calculating the contrast enhancement rate in different kinds of lesions; the differences were related to the type of sequence statistically using Student's t-test for coupled samples. RESULTS: Excellent correlation was found with biopsy findings in all but two patients who were false positive for hepatocellular carcinoma (scar on cirrhotic liver). T1-weighted sequences after AMI-25 injection were the most specific ones in hemangioma characterization; PD were the most sensitive sequences in the detection and characterization of liver metastases. T2-weighted sequences were helpful only in the detection of focal liver lesions but they were not specific. CONCLUSIONS: In conclusion, SPIO-enhanced MRI is an excellent imaging tool for the differential diagnosis of focal liver lesions, with a good specificity for the differential diagnosis of hemangioma and metastasis. It is also helpful to distinguish benign from malignant lesions.

[Gastric adenocarcinoma: magnetic resonance versus surgical staging]. / Adenocarcinoma gastrico: Risonanza Magnetica versus staging chirurgico.

Preoperative MR staging in 34 patients with gastric adenocarcinoma was compared with postoperative histologic findings to evaluate MR sensitivity, specificity and accuracy. MR exams were carried out with an 0.5-T superconductive magnet, with SE T1- and T2-weighted sequences on axial and sagittal planes, 10-mm slice thickness and 3-mm interval. The stomach was distended with a watery solution of Gd-DTPA. MRI showed the tumors only in their advanced stage. MR sensitivity was high in detecting hepatic metastases, but peritoneal carcinomatosis was difficult to demonstrate because of inherent technical MR limitations, such as motion and respiratory artifacts. MRI had 40.6% sensitivity, 93.87% specificity and 42.08% accuracy in demonstrating lymph node involvement. Hepatoduodenal lymph nodes were particularly difficult to study, as were those in the splenic hilum and artery. No correlation was found between tumor invasion and lymph node size. MRI exhibits many limitations in gastric carcinoma staging because of motion and respiratory artifacts and of the long acquisition times needed for gastric studies. However, MR sensitivity and specificity are similar to those of CT, as reported in the literature.

MRI postoperative monitoring in patients surgically treated for aortic dissection.

In most cases, surgery of aortic dissections repairs only the ascending portion of the aorta, leaving a residual dissection in the arch and descending aorta. We studied 17 patients operated upon for type A aortic dissection. A total of 42 magnetic resonance imaging (MRI) examinations were performed, with two to five studies per patient (mean 2.47). The studies were done between 5 weeks and 47 months (mean 17.5 months) after surgery. The patients were evaluated by MRI using gated spin-echo and gradient-echo sequences on axial and oblique sagittal views, and in selected cases, coronal views. A high incidence of abnormalities was observed. Pericardial hematoma was observed in 11% of cases, aortic and branch involvement in 41%, abdominal aortic branch involvement in 47%, dilatation of native aorta in 58%, and extension of dissection in 10%. New complications were detected during follow-up in 53% of patients. MRI was helpful in the follow-up of patients operated upon for aortic dissections, owing to its noninvasiveness and multiplanarity. By means of this technique, it was possible to obtain information about the natural history of the disease, as well as information useful for subsequent treatment.

[Urethral parameatal cysts. Report of two cases and review of the literature]. / Cisti uretrali parameatali. Descrizione di due casi e revisione della letteratura.

Two cases of parameatal urethral cysts in the male are reported. These round cysts don't interfere with sexual function but can determinate an alteration of the urinary flow (biforcation of the flow). The aetiology of these cysts is not completely understood, while the treatment is univoque and simple: complete excision but no aspiration or marsupialization.

[One-stage curative treatment of neoplastic colonic obstruction: long-term results, comparison with elective surgery and therapeutic implications]. / Il trattamento curativo in un tempo dell'occlusione colica neoplastica: risultati a lungo termine, confronto con l'elezione e implicazioni terapeutiche.

Over a period of ten years (1980-1989) 528 patients with colon cancer were treated at one institution. One hundred seventy nine (33.9%) were obstructed (O) and underwent emergency surgery, while 349 received elective (E) treatment; of these 363 had one-stage curative treatment. Operative mortality was 10.3% (O) and 3.5% (E) respectively (p < .0.5). Three hundred forty three patients survived surgery and entered follow-up: 96 were O (M:F, 54:42) and 247 E (M:F, 119:128, p = N.S.). Their mean age was 69.5 and 64.4 (p < .001), respectively. Dukes' stage and histological grading were evenly distributed within the two groups, but sites of the primary were not (p < .001). During the follow-up local recurrence occurred in 40 patients (13 O, 27 E, p = N.S.) and metastatic disease in 78 (28 O, 50 E, p < .05, Life Table Analysis) including liver recurrence in 17 O and 30 E (p = .063). Five year crude survival (51%) was significantly worse in obstructed patients. Multivariate analysis showed that Dukes' stage and obstruction were the only prognostic factors of recurrent disease, while survival was affected by the same variables and age over 70. When recurrent disease was introduced in the model survival depended on Dukes' stage, site of the primary and age over 70 and the variable obstruction disappeared as prognostic factor. Right sided tumours showed a better and those at the splenic flexure a worse prognosis. Despite one-stage curative treatment obstruction carries a significantly higher risk of developing metastatic disease, suggesting that obstruction enhances cancer cell dissemination. These patients might benefit from per-operative intra-portal and post-operative systemic adjuvant chemotherapy.

Ureterouterine fistula as a complication of cesarean section.

A rare case of ureterouterine fistula caused by a complication of cesarean section after a normal pregnancy is reported. The patient presented with a urinous seeping into the vagina, and the fistula was diagnosed preoperatively on urography and computerized tomography. Treatment consisted of a 2-stage surgical approach, including percutaneous nephrostomy and subsequent ureteral reimplantation.