A Translational Approach to Standardization of Machine Perfusion Adoption in Ex Vivo Liver Resection.

BACKGROUND: Hepatic resection represents the best treatment for primary and metastatic liver tumors but is not always feasible. In early 1980, Piclmayr described a complex liver resection technique, termed "ex vivo liver resection," for the treatment of locally advanced tumors not conventionally resectable. The authors approached this technique with translational research in a preclinical setting and then similarly reproduced it in human patients. METHODS: In the swine median xyphopubic laparotomy, the liver was mobilized to expose the vena cava. A temporary porto-caval shunt was previously prepared on the back table using a segment of thoracic aorta, and a vascular anastomosis between the supra-hepatic vena cava and a caval graft was quickly performed. The liver was placed in a machine perfusion system and continuously perfused for 2 h for its final implantation orthotopically in the same animal. The anastomoses were performed as usual. Based on this experience, the intervention was reproduced in the human model of a 39-year-old woman affected by large intrahepatic cholangiocarcinoma considered unresectable.' RESULTS: All animals survived the procedure. The peak aspartate aminotransferase level (460 ± 87 U/L) was recorded 60 min after reperfusion. Lactate levels flared up for 120 min (3.6 ± 0.2 mmol/L). In the clinical case, the postoperative period was uneventful, and the patient was discharged on day 22. CONCLUSIONS: The described procedure is feasible only for surgeons with a transplantation background. The study showed that this translational approach enhances the surgeon's ability to perform the intervention systematically in a shorter time and with a good outcome.

Prognostic role of BAP-1 and PBRM-1 expression in intrahepatic cholangiocarcinoma.

Intrahepatic cholangiocarcinoma (ICC) has universally poor outcome, mainly due to its late clinical presentation. Identification of specific biomarkers and development of effective treatment are still urgently required. Mutations in PBRM-1 and BAP-1 genes, and the expression of S100P have been related to survival in ICC. miR-31 seems also to play important regulatory functions in ICC and it directly regulates BAP-1 expression in lung cancer. In this study, tissue expression of BAP-1, PBRM-1, S100P, and miR-31 was investigated in ICC and correlated with clinical-pathological features. Sixty-one consecutive patients who underwent curative hepatic resection for ICC were enrolled. None received any therapy prior to surgery. Immunostaining for BAP-1, PBRM-1, and S100P, and in situ hybridization for miR-31 were performed, using tissue microarray slides. A strong retained expression of BAP-1 and PBRM-1 was associated with a reduced overall (p = 0.04 and p = 0.002, respectively) and disease-free survival (p = 0.05 and p = 0.02, respectively). An overexpression of S100P was related to a reduced overall survival (p = 0.005). The multivariate analyses identified the presence of perineural invasion and the retained PBRM-1 expression as independent predictors of worse overall [p = 0.02, hazard ratio (HR) = 2.25 (1.16-4.39) and p = 0.001, HR = 3.13 (1.56-6.28), respectively] and disease-free survivals [p = 0.03, HR = 2.43 (1.09-5.4) and p = 0.03, HR = 2.51 (1.11-5.67), respectively]. An overexpression of S100P was predictive of a worse overall survival [p = 0.02, HR = 1.66 (1.08-2.55)]. High levels of miR-31 were significantly associated to a low expression of BAP-1 protein (p = 0.03). In ICC, a retained expression of BAP-1 and PBRM-1, and an overexpression of S100P are related to a poor prognosis.

Salvage liver transplantation after laparoscopic resection for hepatocellular carcinoma: a multicenter experience.

Liver transplantation is the ideal treatment for patients affected by early stage hepatocellular carcinoma and chronic liver disease. Considering organs shortage, alternative treatments have to be adopted to minimize the waitlist drop-out, and in case of recurrence within the accepted criteria, salvage transplantation can be considered. Surgical resection is one of the most effective treatments, with the possibility of oncological radicality and pathological analysis of the specimen. Although these theoretical advantages, surgical strategy cannot be applied to all patients because of the impaired liver function as well as the amount of parenchyma to be resected does not allow a sufficient future liver remnant. Furthermore, resection by laparotomy may lead to strong intra-abdominal adhesions in a contest of portal hypertension and, as potential consequence, increase transplantation difficulty raising morbidity. Laparoscopic liver resection is now performed as a routine procedure in tertiary referral centers, with increasing evidence of long-term results comparable to traditional surgery together with the advantages of a minimally invasive approach. In addition, with a salvage transplantation strategy that has been shown to be comparable to primary transplantation, the patient can live with his native liver avoiding an invasive procedure and long-term immunosuppression, allowing the use of liver grafts for the community. We present the results of an Italian multicenter experience of salvage liver transplantation following the recurrence of HCC initially treated by laparoscopic resection in 31 patients, performed by four referral centers. Mean operative transplantation time was 450 min, morbidity was 41.9%, 90-days mortality was 3.2%, and median post-operative length of stay was 17.9 days. Salvage liver transplantation after laparoscopic liver resection for HCC is comparable to open surgery in terms of operative time, oncologic radicality, morbidity and mortality, with the advantages of laparoscopic surgery.

[Treatment of microcarcinoma and papillary carcinoma of the thyroid]. / Trattamento del microcarcinoma e del carcinoma papillifero della tiroide.

AIM OF THE STUDY: Of our is to demonstrate that total thyroidectomy with lymphadenectomy of the six level is effective in papillary thyroid carcinomas than for microcarcinoma, according to recent acquisitions on the biological behavior of some microcarcinoma. MATERIALS AND METHODS: Ours is a retrospective study based on analysis of the process of therapy in 2849 patients undergoing total thyroidectomy, performed from January 1985 to January 2008 by our group at the U.O. Clinica Chirurgica Ospedale "Vittorio Emanuele" of Catania, Italy. RESULTS: Of all the interventions of total thyroidectomy, 75% performed for benign disease and 25% for malignant disease (PTMC 356 cases, 291 PTC cases, 56 cases of follicular carcinoma, 5 cases of medullary carcinoma, anaplastic carcinoma, 2 cases). 40% of PTMC underwent TT and subsequent follow up, because the diagnosis was placed postoperatively and in 60% diagnosis was placed during surgery with indication for TT and lymphadenectomy of the sixth level and subsequent follow-up showed no evidence of residual disease or relapse. PTC of 40% underwent a TT with lymphadenectomy of the sixth level. 60% of patients with PTC underwent a TT with lymphadenectomy of the sixth level and lateral cervical lymphadenectomy was performed only in 3 cases with a TT level VI lymphadenectomy of the bilateral lateral cervical lymphadenectomy. All patients in the follow-up post-operatively does not show in the following years, signs of residual disease or relapse. CONCLUDING REMARKS: From the results we can confirm that a total thyroidectomy with lymphadenectomy of the sixth level, the more lateral lymphadenectomy of the neck when needed, ensures a good prognosis and few complications, if ever performed in expert hands. This applies to papillary carcinomas than for microcarcinoma whose surgical treatment (total thyroidectomy, lobectomy, subtotal thyroidectomy or near-total) is still debated.

[Total thyroidectomy vs subtotal thyroidectomy for plurinodular goiter. Analysis 1517 cases]. / L'efficacia della tiroidectomia totale nel gozzo plurinodulare. Un'esperienza di 1517 casi.

AIM OF THE STUDY: The surgical treatment of benign thyroid diseases is still controversial, as there is a tendency by some Authors toward a more conservative treatments and wider treatments by others. OBJECTIVE: To claim and demonstrate that total thyroidectomy is the best and effective surgical therapy in benign thyroid diseases. MATERIALS AND METHODS: Retrospective study based on an analysis of 2136 patients with benign thyroid diseases of the thyroid, observed from January 1985 to July 2008 in the Operative Unit of Surgical Clinic of the Ospedale Vittorio Emanuele of Catania. Patients with certain or suspected diagnosis of thyroid cancer have been drawn out from the study. RESULTS: 71% of the patient (that is 1517) were treated for a goiter, 5.9% with preoperative diagnosis of recurrent goiter; 105 cases of primary and non recurrent goiter (6.9%) were found to have foci of microcarcinoma (PTMC) at final histologic examination. All cases of recurrent goiter were selected as non responders patients to suppressive therapy. Total thyroidectomy was performed on 1183 cases (78%), including 89 that required the totalizations for recurrent goiter. The remaining 334 cases with a diagnosis of multinodular goiter were treated with lobectomies or near-total and subtotal thyroidectomy because the remaining parenchima showed macro- and microscopically free of disease. In 1094 cases a total thyroidectomy was performed because extemporary histological examination showed architectural and cytological abnormalities considered as indicative of the formation of new nodules. CONCLUDING REMARKS: The histological examination carried out on portions of macroscopically healthy thyroid showed almost ubiquitous spread of the disease in the gland, with marks of presumable evolutive disease. Moreover has been also documented the not negligible possibility that residual parenchyma may undergo malignant degeneration. These two last observations justify our inclination toward a radical treatment also of benign thyroid diseases.

[Parathyroid cyst. Case report]. / Cisti paratiroidea. Caso clinico.

Parathyroid cysts (PCS) are rare, and less than 300 cases have been reported in literature till now. They occur in most cases as a swelling at the lower third of the neck or are identified by means of diagnostic tests performed for other neck diseases. They are rarely symptomatic. They are often confused with thyroid nodules. Rarely give compressive symptoms. PCS are divided into functional (causing hyperparathyroidism, hypercalcemia and hypophosphatemia) and not functional PCS that represent about 10% of PCS. The non functional PCS are considereted true PCS because their wall is lined by secretory epithelium, instead of the functioning ones that are cystic degeneration of parathyroid gland adenomas. The histopathological data suggest the origin of two different variants of PCS. Their diagnosis requires knowledge of the disease and an high suspicion for it. Ultrasound associated with FNA is the first instance investigation. The ultrasound study allows to verify the nature of the cystic lesion and its peripheral vasculature, whereas FNA can observe the macroscopic characteristics of the liquid sample (clear liquid called "water from rocks") and to dose the levels of PTH and C-terminal/mid-region of PTH itself. The dose of intracystc PTH is the universally accepted method for diagnosis of PCS. The first treatment is the aspiration FNA, which can be curative, but recurrences can be treated surgically. Here is a case of PCS, which we observed in June 2009.

[New trends in the treatment of venous leg ulcer. Personal experience]. / Recenti acquisizioni sul trattamento delle ulcere flebostatiche degli arti inferiori. Nostra esperienza.

Venous leg ulcer is the most frequent cause of trophic lesions of the limbs in patients with chronic venous insufficiency. Appropriate management of cutaneous vascular lesions is based on systemic, vascular and local assessment. The Authors used a protease-modulating matrix in 126 patients suffering from venous leg ulcers with wound granulation: 81 (64.2%) patients with primary chronic reflux disorder and varicose veins and 45 (35.8%) post-thrombotic; in addition 30 patients (23.8%) had peripheral arteriopaty and 41 (32.5%) peripheral arteriopaty and diabetes. One hundred sixteen patients showed complete healing, 2 were refractory to every treatment and 8, with arteriopathy and diabetes, are on the mend. According to the literature we achieved reduction of the healing time and increased healing rate. All patients were treated in outpatient settings. In conclusion the Authors suggest protease-modulating matrix is a really effective treatment of venous leg ulcers with wound granulation. Their treatment is also feasible in outpatient treatment with a reduction in health spending and reduced absence from work.

[Pelvic splenomegaly. Ptosic, migrant or accessory spleen?]. / Splenomegalia in sede pelvica. Milza ptosica, migrante o accessoria?

A wandering or ectopic spleen is a rare condition in which the spleen is not located in the left upper quadrant but is found lower in the abdomen or in the pelvic region caused by improper fixation of the ligamentous attachments. Laxity of the peritoneal attachments of the spleen results in splenic hyper mobility, known as wandering spleen. Congenital and acquired causes have been advocated to explain its onset. However, the precise aetiology is not completely understood. Many patients with wandering spleen are asymptomatic and therefore, the real incidence is unknown. Symptomatic patients may have intermittent abdominal pain because of splenic congestion with intermittent torsion of the splenic pedicle and its spontaneous detorsion, or may present acutely with pedicle torsion with subsequent infarction. Pain and dangerous potential evolution recommend surgery, splenoplexy or splenectomy. The Authors report the case of a 48-year-old man with painful abdominal mass suspected for wandering splenomegaly after diagnostic imaging (abdominal Ultrasonography and TC). Laparotomy evidenced a large spleen (DL 22 cm.) with a long (1 mt) and tortuous vascular pedicle, both removed. Histopathologic examination showed partial infarction of the spleen. The postoperative course was uneventful.

[The use of laparoscopy for diagnosis and stadiation of the lymphomas]. / La laparoscopia nella diagnosi e stadiazione dei linfomi.

AIM: To evaluate feasibility, safety and effectiveness of laparoscopic biopsies in the diagnosis and stadiation of intraabdominal lymphadenopathy. MATERIAL OF STUDY: From January 2005 to December 2006 12 patients (5 males, 7 females, age 31-54, average 43) with intra-abdominal lymphadenopathy were admitted to our institution (V Chirurgia Generale Ospedale Ferrarotto Catania) to perform laparoscopic biopsies. Indication to treatment was primary diagnosis in ten patients and restaging in two cases. Laparoscopic procedure was performed with a three-trocars technique also using an ultrasound laparoscopic probe. RESULTS: All cases were completed laparoscopically (conversion rate nil). Mean operation time: 35 min. All patients were discharged from hospital the day after the procedure. There were no complications. In all cases laparoscopic biopsies provided adequate tissue for correct diagnosis and complete immune-histochemical assessment (11 Lymphoma H, 1 Lymphoma NH). DISCUSSION: Today surgery has a new important role in the diagnosis and stadiation of intraabdominal lymphadenopathy. Imaging such as TC-RM and Surgery Radiology Techniques (fine needle aspiration and core needle biopsy) are frequently inadequate to diagnosis and show a worse diagnostic accuracy than laparoscopic biopsies. Our limited experience in accordance with major literature reports demonstrate laparoscopic procedure is really effective and safe. CONCLUSION: Laparoscopic lymph node biopsy safely provides adequate tissue for full histological evaluation in patients with intra-abdominal lymphadenopathy adding the advantages of "miniinvasive" techniques.