Percutaneous cholecystostomy in the treatment of acute cholecystitis: is there still a role? A 20-year literature review.

OBJECTIVE: Percutaneous cholecystostomy (PC) is used for the treatment of acute cholecystitis in patients with high surgical risk due to the severity of cholecystitis and/or the underlying acute or chronic medical comorbidities. The evidence for this strategy is unclear. MATERIALS AND METHODS: We searched PubMed and the Cochrane databases for English-language studies published from January 1979 through December 31, 2019, for randomized clinical trials (RCTs), meta-analyses, systematic reviews, and observational studies. RESULTS: The two randomized studies that have compared PC with cholecystectomy (CCY) or conservative treatment have shown that the clinical outcomes did not differ significantly between the groups. Similar results have been found in the large majority of retrospective cohorts or single-center studies that have compared PC with CCY. CONCLUSIONS: PC does not seem to offer any benefit compared with CCY in the treatment of acute cholecystitis in patients with high surgical risk due to the severity of cholecystitis and/or the underlying acute or chronic medical comorbidities. A large, prospective, randomized study that compares percutaneous PC and CCY in patients with high surgical risk and/or moderate to severe cholecystitis is warranted.

Meckel's diverticulum findings on Tc-99m red blood cell scintigraphy in a bleeding leukemic patient confirmed by Tc-99m pertechnetate scintigraphy.

A 25-year-old Caucasian woman with a medical history of acute promyelocytic leukemia presented to the emergency department with massive gastrointestinal bleeding. A bone marrow biopsy excluded hemorrhagic leukemia. Esophagogastroduodenoscopy, colonoscopy, emergency abdominal angiography, abdominal CT scan, and wireless capsule endoscopy were performed but no source of bleeding could be detected. Tc-99m RBC scintigraphy was consistent with a small bowel bleeding focus. The persistent and focal images in the right abdomen were suggestive of Tc-99m RBC trapping in the lumen of a Meckel diverticulum (MD). In accordance with this suspicion, successive Tc-99m pertechnetate scintigraphy was performed after 3 days, consistent with the diagnostic hypothesis. Due to the persisting severe bleeding (with a drop in baseline hemoglobin from 10.4 to 7.1 g/dL), despite 8 units of blood transfusion, emergency surgery was performed. Through a minilaparotomy a segmental small bowel resection, including Meckel diverticulum, was performed. The postoperative course was uneventful.

A novel microdeletion syndrome with loss of the MSH2 locus and hereditary non-polyposis colorectal cancer.

Constitutional chromosome deletions can predispose to the development of cancer with the phenotypic characteristics of inherited cancer syndromes, when the deleted region encompasses a tumour suppressor gene. Examples of such conditions are represented by the cytogenetic deletions associated with retinoblastoma, Wilms tumour and familial adenomatous polyposis. So far, no constitutional deletions involving the genes implicated in hereditary non-polyposis colorectal cancer (HNPCC) have been identified. This may be at least partially because of the lack of distinctive phenotypic manifestations in HNPCC. We describe the first case of a constitutional microdeletion associated with HNPCC. Suspicion of a microdeletion was prompted by the association of mental retardation, postnatal growth deficiency, minor congenital anomalies and early onset (37 years) sporadic colon cancer. The patient was found to harbour a microdeletion within chromosome 2p16-p21, including the MSH2 gene. Since there are very few reports of deletions of the 2p16-p21 region, our observation sets the grounds for the definition of a novel multiple congenital anomaly/mental retardation/cancer microdeletion syndrome.

[Thermal ablation by radiofrequency of hepatic metastasis of colorectal cancer: short-term results]. / Termoablazione mediante radiofrequenza di metastasi epatiche da cancro colorettale: risultati a breve termine.

Radiofrequency (RF) was used to ablate 42 colorectal liver metastases in 20 patients (10 males and 10 females) in a four years period. Median age was 62.2 years, 36 lesions (75%) had 3 cm diameter or less. An open surgical approach was adopted in 13 patients, whereas a percutaneous one in 14. On 27 surgical sessions, RFA was used in 49 procedures for a total of 81 needle applications. Morbidity was 6.0% (3 cases), one patient died on third po day for myocardial infarction. No differences in terms of complete ablation rate was observed in the two approach's groups. Overall survival was 65% with a median follow-up of 18.5 months.

[Evaluation of prognostic factors in gastrointestinal stromal tumors]. / Valutazione dei fattori prognostici nei tumori stromali gastrointestinali.

Gastrointestinal stromal tumors are relatively rare but have been recently widely investigated; the study analyses the role of different prognostic factors on disease-free survival after complete resection of tumor.

Radiofrequency thermal ablation (RFA) of liver tumors: open surgical or percutaneous approach?

RFA was used to ablate 81 liver lesions: 61 liver metastases and 20 hepatomas. An open surgical approach was adopted in 19 instances (27.5%), 12 of which were simultaneously treated for associated diseases, and percutaneous treatment was adopted in 50 instances (72.5%). The CT liver control at 6 months showed a complete necrosis in 50 lesions (66.3%). The advantages of the percutaneous approach include less invasiveness, reduced postoperative pain, shorter hospitalization, reduced costs and less discomfort in repeating the procedure. In conclusion, radiofrequency liver nodule ablation could be considered, today, as one of the promising and versatile techniques for loco-regional liver cancer control.

[Effect of preoperative biliary drainage on the immediate and long-term results after duodeno-cephalo-pancreatectomy for peri-ampullar neoplasia]. / Effetti del drenaggio biliare preoperatorio sui risultati immediati e a distanza dopo duodenocefalopancreasectomia per neoplasia periampollare.

Pancreaticoduodenectomy has a primary role in the treatment of patients with periampullary carcinoma. Several series have reported encouraging operative mortality and survival after resection. Controversies exist regarding the impact of preoperative biliary drainage on immediate and long-term results.

[Radiofrequency thermal ablation of hepatic nodules: selection criteria for percutaneous treatment]. / Termoablazione con radiofrequenza di noduli epatici: criteri di scelta del trattamento percutaneo.

Radiofrequency thermal ablation (RFA) of liver tumor is done by percutaneous, laparoscopic and open surgical approach. Selection criteria for percutaneous or open surgical ablation of 54 hepatic lesions are here evaluated in 30 consecutive patients. Open surgical approach was performed in 9 cases only, 5 of them due to concomitant treatment of associated diseases. Number and size of the lesions did not interfere with surgical approach. Postoperative CT control showed no differences in terms of complete ablation of the tumor in between the two groups of patients. Percutaneous approach of RFA is gone to be in the future the modality of choice in these patients.

Diagnostic laparoscopy in a HIV positive patient with disseminated non-Hodgkin's lymphoma.

We report a case of massive peritoneal involvement in AIDS-related non-Hodgkin's lymphoma (NHL). Abdominal CT scan showed a retroperitoneal lymphoadenopaty and a wide thickening of omental peritoneum. At laparoscopy a diffuse massive involvement of peritoneum mimicking carcinomatosis was demonstrated and an omentum biopsy revealed a diffuse infiltration of large cell NHL.

Radiofrequency thermal ablation (RFA) of liver tumors: percutaneous and open surgical approaches.

Radiofrequency Thermal Ablation (RFA) of liver tumors is done by percutaneous, laparoscopic and open surgical approach. Selection criteria for percutaneous or open surgical ablation of 65 hepatic lesions are here evaluated in 45 patients treated in a two-years period. Twenty-five patients were males and 20 females, ages ranged from 35 to 80 years (mean 63 years). RFA was performed in 57 procedures, ablating 14 hepatomas and 51 liver metastases. In 10 cases the treatment was repeated twice. Tumor size ranged from 0.5 cm to 8 cm, with a mean of 2.4 cm. Open surgical approach was performed in 14 cases (24.6%), seven of which were simultaneously treated for associated diseases. Percutaneous treatment was adopted in 43 cases (75.4%). A laparoscopic approach was not tempted in any case. Morbidity was 8.8%, mostly in open surgery (4 cases or 28.6%) but in one patient (2.3%) with percutaneous approach. Difference in between the two groups was statistically significant (p=0.013). Overall mortality was 2.2%: one patients deceased for myocardial infarction. The mean length of hospital stay was of 4.1 days for the percutaneous treatment group and 7.6 days for the open surgery approach. Number of the lesions did not interfere with surgical approach. Postoperative CT control showed no differences, in terms of complete ablation of the tumor, between the two groups of patients. Advantages of percutaneous approach include less invasiveness, reduced postoperative pain, shorter hospitalization, reduced costs and lower discomfort in repeating the procedure. In addition, open surgical RFA allows better cancer staging, avoidance of adjacent organ injury, accessibility to all liver areas and gives the chance to performe simultaneous organ resection. These results are encouraging in making the percutaneous approach of RFA the method of choice in these patients.

Prognostic factors after surgical resection for pancreatic carcinoma.

BACKGROUND AND OBJECTIVES: Surgical resection offers the only potential cure for pancreatic carcinoma. Several recent series have reported an encouraging increase in 5-year survival rate exceeding 20% and have emphasized the importance of patient selection based on reproducible prognostic factors. The impact on survival of demographic, intraoperative, and histopatologic factors are investigated in this study. METHODS: Seventy-three patients with adenocarcinoma of the pancreas, treated at the Department of Surgery of the Catholic University of Rome during 1988-1998, were retrospectively analyzed. Survival data were reviewed, and potential prognostic factors were compared statistically by univariate and multivariate analyses. RESULTS: There was no operative mortality, and the morbidity rate was 37%. Actuarial overall and disease-specific survival rates for all 73 patients were, respectively, 27% and 31% at 3 years and 13% and 21% at 5 years, with a median survival time of 16 months. T stage and nodal status significantly affected survival according to univariate analysis (P = 0.0017 and 0.04). An impact on survival, even if not of statistical significance, was shown for other pathologic or intraoperative factors. CONCLUSIONS: T and nodal stage are the strongest independent predictors of survival. Limited intraoperative transfusion, reduced operative time, and clear margins also may play a role, which requires further confirmation in a larger series.

Long-term treatment of spontaneously hypertensive rats with losartan and electrophysiological remodeling of cardiac myocytes.

OBJECTIVE: Cardiac hypertrophy due to pressure overload is associated with several cellular electrophysiological alterations such as prolongation of action potential duration (APD), decrease in transient outward current (Ito) and occurrence of the pacemaker current I(f). These alterations may play a role in sudden arrhythmic death, which is a major risk factor in myocardial hypertrophy and failure. Since angiotensin II is a key signal for myocyte hypertrophy, we tested if an 8-week treatment of old spontaneously hypertensive rats (SHR) with the antagonist of type-1 angiotensin II receptor (AT1), losartan (10 mg/kg/day), was able to influence the cellular electrophysiologic remodeling associated with cardiac hypertrophy. METHODS: Left ventricular myocytes were isolated from control (CTR) or losartan-treated (LOS) 18-month old SHR. Patch-clamped LVM were superfused with a normal Tyrode's solution (to measure action potential) or appropriately modified Tyrode's solution (to measure Ito and I(f)). RESULTS: Heart weight to body weight ratio (HW/BW) was significantly smaller in LOS (5.69 +/- 0.25 mg/g) than in CTR rats (6.67 +/- 0.37 mg/g; P < 0.05). Membrane capacitance, an index of cell size, was significantly reduced in LOS (342 +/- 12, n = 92) vs. CTR (422 +/- 14 pF, n = 96, P < 0.001). APD was significantly shorter in LOS than in CTR (at -60 mV: 197 +/- 23 vs. 277 +/- 19 ms, n = 28, P < 0.001); this effect was paralleled by a larger maximum Ito density in the LOS group (LOS: 15.1 +/- 1.4 pA/pF, CTR: 10.0 +/- 0.8 pA/pF) (n = 27, P < 0.02). I(f), elicited by hyperpolarizing steps (range: -60 to -130 mV), was consistently recorded in SHR cells; however, its maximal specific conductance was significantly lower in LOS than in CTR rats (28.6 +/- 3.6 vs. 54.2 +/- 8.0 pS/pF, n = 55, P < 0.001). Voltage of half-maximal activation (V1/2) of both Ito and I(f) was unchanged by the treatment. CONCLUSIONS: AT1 receptor blockade with losartan prevents the development of myocyte hypertrophy and associated electrophysiological alterations in old SHR.

Use of antihypertensive drugs in the Italian hospitals. GIFA group. Gruppo Italiano di Farmacoepidemiologia nell'Anziano.

Calcium channel blockers and ACE-inhibitors are among the most common drugs prescribed for the initial treatment of hypertension. While their ability to control surrogate outcomes, such as blood pressure and left ventricular hypertrophy, is proven, there is limited evidence of their prevention of major cardiovascular events, including mortality. The aim of our work was to assess the use of these drugs in Italy in comparison with beta-blockers and diuretics. We examined the consumption of the four main antihypertensive classes of drugs (beta-blockers, diuretics, calcium channel blockers and ACE- inhibitors). In-hospitalization data from the GIFA (Gruppo Italiano di Farmacoepidemiologia nell'Anziano) database were used. During the period from 1988 to 1995, the most frequently prescribed antihypertensive drugs were calcium channel blockers (47%) followed by diuretics (37%), ACE-inhibitors (33%) and beta-blockers (5.5%). Changes over time in the use of these drugs were analysed: ACE-inhibitors had the greatest increase in use over time. Calcium channel blockers, ACE-inhibitors and beta-blockers were usually prescribed to the youngest patients (aged <65 years), while diuretics to the oldest. Calcium channel blockers were prescribed to 60% of patients with myocardial infarction and to 55% of those with congestive heart failure. In conclusion, our study demonstrates that the Italian physicians very often prescribe drugs like calcium channel blockers and ACE-inhibitors. Among these pharmacological agents, enalapril (twice per day) and slow release calcium channel blockers are the most frequently prescribed drugs.

Ampullary carcinoma: prognostic significance of ploidy, cell-cycle analysis and proliferating cell nuclear antigen (PCNA).

BACKGROUND/AIMS: The aim of the present study is to assess the nuclear DNA ploidy patterns, the fraction of cells in the various phases of the cell cycle as determined by flow cytometry and to evaluate Proliferative cell-nuclear antigen (PCNA) expression in order to examine the relationships between phase-two molecular factors, clinicopathological aspects and outcome of patients with cancers of the ampulla of Vater. METHODOLOGY: Paraffin-embedded specimens from 18 cases of cancers of ampulla of Vater radically resected between 1985 and 1995 were analyzed by flow-cytometry and immunohistochemical staining with monoclonal antibody to the PCNA. The relationships between cell-proliferation kinetics, PCNA-positive cancer cells, clinicopathological findings and the clinical course were evaluated. RESULTS: Pathologist reports documented 17 papillary adenocarcinomas and one case of mucinous carcinoma. According to the TNM classification, 4 patients were in stage I, 7 in stage II and 7 in stage III. Locally advanced ampullary tumors (T3-T4) had a significantly worse prognosis (p = 0.01); survival at 3 and 5 years for stage I-II patients (11 cases) was 90% and 79% as compared to 42% and 42% for patients with stage III (8 cases), respectively (p = n.s.). Thirteen cancers (72%) were diploid and 5 (28%) aneuploid. Patients with aneuploid tumors were younger (mean age: 59 years) than patients with diploid tumors (mean age: 66 years; p = 0.04). No significant correlation was found between size of the tumor (T), lymphnodal status (N), grading (G) or aneuploidy. Difference in terms of survival between aneuploid and diploid patients was relevant (16 vs. 121 months) but, due to the small number of cases, was not statistically significant (p = n.s). The mean value of S-phase fraction (SPF) was 14.8%. PCNA positive rate significantly correlates with size of the tumor (T1-T2 vs. T3-T4; p = 0.03). Actuarial overall survival resulted in 70%, 63% and 31% at 1, 5 and 10 years, respectively. The high rate of diploidy (72%) supports the relative benign behavior of ampullary cancers. CONCLUSIONS: PCNA positive rate significantly correlates with size of the disease. Aneuploidy, although without significant prognostic value, correlates well with survival. Because of the wide range of all variables, more data are needed to establish the relationships between pathological factors, DNA ploidy and PCNA rate and their significance as molecular predictors of prognosis in ampulla of Vater cancers.

[Surgical resection of pancreatic cancer]. / Il trattamento chirurgico resettivo del carcinoma pancreatico.

AIMS AND BACKGROUND: Surgical resection offers the only potential cure for pancreatic carcinoma. Although the overall prognosis remains a dismal, several recent series have reported an encouraging increase in 5-year survival after resection, exceeding 20%. As the reasons for this improvement are not clearly understood, numerous clinico-pathological parameters (demographic, intraoperative and histopathologic factors) have been investigated to evaluate their role in predicting long term survival. In this single-institution study, immediate and long-term outcome after pancreatic resection in patients with pancreatic adenocarcinoma was retrospectively evaluated, focusing attention on the possible impact of different clinico-pathologic factors on long-term survival. METHODS: Sixty-six patients with a confirmed histologic diagnosis of adenocarcinoma of the pancreas, treated by pancreatic resection at the Department of Surgery of the Catholic University of Rome in the years 1988-1997, were retrospectively analyzed. Morbidity and survival data were reviewed and potential prognostic factors were compared statistically by univariate analysis. RESULTS: There was no postoperative mortality. Twenty-five patients (38%) developed major operative complications. Pancreatic fistula was the most common complication, and occurred in 7 patients (11%). The actuarial overall and disease-specific survival for all 66 patients were respectively 58% and 59% at 1 year, 27% and 31% at 3 years, and 13% and 20% at 5 years, with a median survival time of 13.4 months. Nodal status was the only single factor significantly affecting survival by univariate analysis. The 3-and 5-year survival rates were respectively 35% and 19% for node-negative patients and 7% and 0% for node-positive patients (P = .04). A positive correlation with improved survival, even if not of statistical significance, was shown for other pathologic or intraoperative factors. Among the former, 5-year survival rates were better for patients with negative resection margins as compared to patients with positive margins (12% vs 7%, P = ns). Among the latter, a better actuarial 5-year survival rate was shown for patients with shorter operative time (< 4 hours, 21% survival vs > 4 hours 5%, P = ns) and for patients that received fewer transfusions (0-2 blood units, 14% survival vs 3 or more blood units, 0%; P = ns). Age, gender, tumor diameter and tumor grading showed no influence on survival in this series. CONCLUSIONS: Our series confirmed that nodal status is the strongest independent predictor of survival. Limited intraoperative transfusion, reduced operative time and clear margins could also yeald a prognostic significance, and require further confirmation in larger series.

Systemic manifestations and liver disease in patients with chronic hepatitis C and type II or III mixed cryoglobulinaemia.

The aim of this study was to evaluate the prevalence of cryoglobulins in patients with chronic hepatitis B and C virus infection and to investigate the association of type II and type III mixed cryoglobulinaemia with systemic manifestations and liver disease stage and outcome in hepatitis C virus (HCV)-positive patients. We analysed the prevalence of cryoglobulinaemia in a cohort of patients with chronic liver disease and compared the systemic manifestations and liver involvement in HCV-positive patients with type II or type III mixed cryoglobulinaemia. The prevalence of serum cryoglobulins was significantly higher in HCV-positive patients than in hepatitis B surface antigen (HBsAg)-positive patients (55.4 vs 20.6%). In HCV-positive patients, stage of liver disease correlated with the prevalence of cryoglobulinaemia. Patients with type II cryoglobulins showed a significantly higher risk of cirrhosis and of extrahepatic manifestations while patients with type III cryoglobulins had a significantly higher prevalence of hepatocellular carcinoma. During follow-up the former had an odds ratio of 11.9 of death from extrahepatic complications while the latter had an odds ratio of 3.4 of dying from hepatic disease. Our study confirms the high frequency of mixed cryoglobulinaemia in patients with chronic hepatitis C virus infection. The presence and type of cryoglobulins seem to be associated with different clinical manifestations and outcome.

Pancreatic resection for periampullary cancer in elderly patients.

BACKGROUND/AIMS: Major abdominal surgery in elderly patients has traditionally been thought to carry a high operative risk. Recent data, however, have suggested that with proper selection, elderly patients can withstand pancreatic resection. METHODOLOGY: The medical records of 102 patients who underwent pancreatic resection for pancreatic or periampullary tumors were retrospectively reviewed. Twenty-nine patients were aged 70 years or older (mean age: 74 years) and 73 patients were younger (mean age: 56 years). Concomitant comorbid conditions were evaluated in the patients of both groups, and no significant differences were identified. A pancreaticoduodenectomy was performed in 81 cases and a total pancreatectomy in 21. RESULTS: The operative mortality rate was 0% in the older patients and 6.8% in the younger patients. Major complications occurred in 28% of the patients. There were no significant differences in morbidity among the two age groups. The overall actuarial survival curves showed similar trends in both groups. CONCLUSIONS: With appropriate preoperative selection, pancreatic resection can be performed with low operative risk in elderly patients. Chronological age alone should not be considered an absolute contraindication for pancreatic resection.