Survival prognostic factors of gastro-enteric-pancreatic neuroendocrine tumors after primary tumor resection in a single tertiary center: Comparison of gastro-enteric and pancreatic locations.

AIM: This study aimed to evaluated prognostic factors of patients with GEP-NETs after primary tumor resection comparing pancreatic and gastro-enteric locations. METHODS: Patients undergone surgery for primary GEP-NETs between 01/2000 and 03/2012 were considered. All specimens were reclassified according to the WHO 2010 scheme. RESULTS: A total of 83 patients were considered: 37 pancreatic NETs (pNET) and 46 gastroenteric NETs (GE-NET). The two groups were similar in terms of age, sex and tumors size. A higher rate of patients with pNETs had Ki67 score ≥3 (64.8% vs. 39%, p = 0.027) while the rates of Mitotic Index ≥2x10HPF (62% pNET vs. 50% GE-NET, p = 0.374) and diagnosis of neuroendocrine carcinoma NEC (16.2% pNET vs. 17.3% GE-NET, p = 0.100) were similar. The rates of distant metastases (GE-NETs 30.4% vs. p-NETs 29.7%, p = 0.944) and liver metastases (19.5% GE-NET vs. 27% pNET, p = 0.421) were comparable. Radical resection was achieved in a similar proportion in both groups [33 patients (89.1%) pNET vs. 36 (78.2%) GE-NET, p = 0.393]. After a median follow-up of 47.1 months overall 3, 5 and 10-years survival rates of whole patients were 88.1%, 81.2% and 76.7%. There was not difference on 5-years overall survival between pNET (81.4%) and GE-NET (81%, p = 0.901). At multivariate analysis age ≥70 [OR 4.177 (CI 95% 1.26-13.8), p = 0.019] and NEC [OR 5.932 (CI 95% 1.81-19.40), p < 0.001] were negative prognostic factors of survival. CONCLUSION: Overall survival of GEP-NET after resection of primary tumors seems to be correlated to patient's age and WHO 2010 staging system but not to primary tumor site.

Impact of perioperative symbiotic therapy on infectious morbidity after Hpb Surgery in jaundiced patients: a randomized controlled trial.

This study aimed at evaluating whether the administration of symbiotic therapy in jaundiced patients could reduce their postoperative infectious complications. The study was conducted between November 2008 and February 2011. Jaundiced patients scheduled for elective extrahepatic bile duct resection without liver cirrhosis, intestinal malabsorption or intolerance to symbiotic therapy were randomly assigned to receive [Group A] or not [Group B] symbiotics perioperatively. The primary endpoint was the infectious morbidity rate. Forty patients were included in the analysis (20 in each group). The patients in Group B presented a higher overall morbidity (70 vs 50%) and infectious morbidity rate (50 vs 25%), but the differences were not significant. Eleven patients in Group A (Group ndA) and 13 in Group B (Group ndB) did not receive preoperative biliary drainage. The results of the two groups were comparable. Infectious complications were higher in Group B [5 (34%) vs 0, p = 0.030], while the prevalence of natural killer (NK) cells was higher in Group ndA the day before surgery (17% ± 5.1 vs 10% ± 5.3, p < 0.01) and on post-operative day (POD) 7 (13.1% ± 4.1 vs 7.7% ± 3.4, p < 0.01). The rates of lymph node colonization were similar. The symbiotic therapy failed to reduce the rate of infectious morbidity in jaundiced patients. Further studies investigating the place of symbiotic in no-drainage patients are required.

Safety and outcome of combined liver and pancreatic resections.

BACKGROUND: In Western countries, combined liver and pancreatic resections (CLPR) are performed rarely because of the perceived high morbidity and mortality rates. This study evaluated the safety and outcomes of CLPR at a tertiary European centre for hepatopancreatobiliary surgery. METHODS: A review of two prospectively maintained databases for pancreatic and liver resections was undertaken to identify patients undergoing CLPR between January 1994 and January 2012. Clinicopathological and surgical outcomes were analysed. Univariable and multivariable analyses for postoperative morbidity were performed. RESULTS: Fifty consecutive patients with a median age of 58 (range 20-81) years underwent CLPR. Indications for surgery were neuroendocrine carcinoma (16 patients), biliary cancer (15), colonic cancer (5), duodenal cancer (1) and others (13). The type of pancreatic resection included pancreaticoduodenectomy (30), distal pancreatectomy (17), spleen-preserving distal pancreatectomy (2) and total pancreatectomy (1). Twenty-three patients had associated major hepatectomies, 27 underwent minor liver resections and 11 had associated vascular resections. Mortality and morbidity rates were 4 and 46 per cent respectively. Univariable and multivariable analysis showed no differences in postoperative morbidity in relation to extent of liver resection or type of pancreatic resection. Use of preoperative chemotherapy was the only independent risk factor associated with postoperative morbidity (P = 0.021). CONCLUSION: CLPR can be performed with fairly low morbidity and mortality rates. Postoperative outcomes were not affected by the extent of liver resection or the type of pancreatic resection. Patients receiving chemotherapy should be evaluated carefully before surgery is considered.

Locally advanced gallbladder cancer: which patients benefit from resection?

OBJECTIVES: Patients with T3-4 gallbladder cancers (GBCs) often require extended surgical procedures, and up to 30% of patients have N2 metastases. This study investigated which patients with T3-4 GBC benefit from resection. METHODS: Consecutive patients (n = 78) with T3-4 GBC who underwent resection between 1990 and 2011 were analysed (38 before 2003, 40 in 2003-2011). Forty patients required common bile duct (CBD) resection, 10 pancreatoduodenectomy, 4 right colectomy and 2 gastric resection. Fifty-two (67%) patients had LN metastases, including 22 with N2 metastases. RESULTS: The in-hospital mortality rate was 8%, 11% before 2003 vs. 5% in 2003-2011. The morbidity rate (47%) remained stable during the study. Undergoing liver and pancreatic resection did not increase severe morbidity (0%) or mortality (10%). Sixty-seven (86%) patients had R0 resection. The 5-year survival rate was 17% (median follow-up, 65 months). Survival improved after 2002 (26% vs. 9%, p = 0.04). R1 patients had poor 3-year survival (0% vs. 32%, p = 0.001). N+ patients also had low survival (5-year survival, 10% vs. 32% in N0, p = 0.019), but N1 and N2 patients had similar outcomes. CBD resection and major hepatectomy did not worsen prognosis. Patients requiring pancreatoduodenectomy, gastric or colonic resection had 0% 3-year survival (p = 0.036 in multivariate analysis). CONCLUSIONS: Resection of T3-4 GBC is worthwhile only if R0 surgery is achievable. Outcomes improved in most recent years. N2 metastases should not preclude surgery. Good results are possible even with CBD resection or major hepatectomy, while benefits from surgery are doubtful if pancreatoduodenectomy or other organ resection is needed.

An unusual cause of cardiogenic shock: tricuspid regurgitation and right ventricular perforation due to vena cava filter migration.

Dislocation and migration of the inferior vena cava filter to the right heart is an uncommon but serious complication, requiring prompt diagnosis and appropriate therapy. We report the case of a seventy-year old man, who had previously undergone vena cava filter implantation and who was admitted to the Intensive Care Unit due to acute respiratory distress with the suspect of pneumonia-related sepsis. Due to the worsening of hemodynamics and the development of cardiogenic shock, the patient underwent bedside echocardiography, which on the contrary revealed dislocation of the filter and the entrapment of the device within the tricuspid valve and chordae tendineae. This evidence was confirmed also by the chest-abdominal X-ray. The patient underwent tricuspid valve surgical replacement and successfully recovered. The transthoracic and transesophageal echocardiographies performed in the intensive care unit were able to first orient the diagnostic efforts toward the correct cause.

Laparoscopic versus open liver resection for hepatocellular carcinoma in patients with histologically proven cirrhosis: short- and middle-term results.

BACKGROUND: Liver surgery, especially for cirrhotic patients, is one of the last areas of resistance to progress in laparoscopic surgery. This study compares the postoperative results and the 2-year patient outcomes between laparoscopic and open resection for hepatocellular carcinoma in patients with histologically proven cirrhosis. METHODS: From May 2000 to October 2004, 23 consecutive cirrhotic patients who underwent laparoscopic hepatectomy (LH) for HCC were compared in a retrospective analysis with a historic group of 23 patients who underwent open hepatectomy (OH). The two groups were well matched for age, gender, American Society of Anesthesiology (ASA) class, tumor location and size, type of liver resection, and severity of cirrhosis. The selection criteria for both groups specified a small (size < 5 cm), exophytic, or subcapsular tumor located in the left or peripheral right segments of the liver (II-VI segments, Couinaud); a well-compensated cirrhosis (Child-Pugh A); and an ASA score lower than 3. In the LH group, 15 subsegmentectomies, 3 segmentectomies, and 5 left lateral sectionectomies were performed, as compared with 12 subsegmentectomies, 5 segmentectomies, and 6 left lateral sectionectomies in the OH group. RESULTS: One patient in the LH group (4.3%) underwent conversion to laparotomy for inadequate exposition. The mean operative time was statistically longer for the LH group (LH, 148 min; OH, 125 min; p = 0.016), whereas blood transfusions (LH, 0%; OH, 17.3%; p = 0.036), Pringle maneuver (LH, 0%; OH, 21.73%; p = 0.017), mean hospital stay (LH, 8.3 days; OH, 12 days; p = 0.047), and postoperative complications (LH, 13%; OH, 47.8%; p = 0.010) were significantly greater in OH group. There was no statistically significant difference in mortality and 2-year survival rates between the two groups. CONCLUSION: This study shows that LH for HCC in properly selected cirrhotic patients results in fewer early postoperative complications and a shorter hospital stay than the traditional OH. The 2-year survival rate was the same for LH and OH.

[Cardiovascular adaptation during cycloergometric exercise test in insulin-dependent diabetics with or without autonomic cardiopathy]. / Adattamenti cardiovascolari durante test da sforzo al cicloergometro in diabetici insulino-dipendenti con e senza cardiopatia autonomica.

Sixty patients with type I diabetes mellitus underwent an ergometric stress test (EST) to evaluate the relationship between cardiac autonomic neuropathy (CAN) and hemodynamic changes during EST. All patients were divided into 2 groups: in the Group A were included 26 patients (mean age 43 +/- 9 years) with impairment of 2 or more autonomic tests according to Ewing (patients with CAN) and in the Group B were included 34 patients (mean age 38 +/- 13 years) without CAN. The EST was symptom-limited and performed with load increases of 25 W every 3 min. No positive EST were observed in both groups. Heart rate (HR) at rest and systolic blood pressure (SBP) at maximum common workload were significantly higher in Group A than in Group B. Moreover, a significant linear correlation was found between a CAN score and SBP x HR product at rest and at maximal workload. These findings are correlated with increased sympathetic activity due to a parasympathetic impairment. The data show the relationship between hemodynamic changes during EST and the Ewing test used in the diagnosis of CAN.

[Behavior of systolic blood pressure during recovery phase after bicycle ergometric test. Its value in the diagnosis of ischemic heart disease]. / Comportamento della pressione arteriosa sistolica nella fase di recupero dopo sforzo al cicloergometro. Suo valore nella diagnosi di cardiopatia ischemica.

The diagnostic utility of an abnormal decrease in systolic blood pressure (PAS) after exercise, have been evaluated by an index obtained by the ratio between PAS at the maximal stage of exercise and PAS at the 1', 3' and 5' of recovery (PAS index). The 58 patients studied have been divided in two groups: group A, 32 patients, aged 33-66 (means 51.5) with angina pectoris and significant coronary stenosis; group B, 26 subjects, aged 27-39 (mean 34.7), asymptomatic, without coronary stenosis (control group). PAS index at 1' of recovery have been 0.82 +/- 0.08 in the group B and 0.94 +/- 0.07 in the group A (p less than 0.0005); at the 3' of recovery 0.72 +/- 0.07 in the group B and 0.86 +/- 0.11 in CAD group (p less than 0.0005); at 5' of recovery 0.66 +/- 0.07 in the group B and 0.79 +/- 0.11 in the group A (p less than 0.0005). Diagnostic accuracy have been of 60%, 75% and 75% for PAS index respectively at first, third and fifth minute of recovery, while ST depression diagnostic accuracy have been of 88%.

[Gallopamil and chlorthalidone versus atenolol and chlorthalidone in the treatment of obstructive hypertrophic cardiomyopathy in patients with arterial hypertension: polycardiographic evaluation of the systolic and diastolic function of the left ventricle]. / Gallopamil e clortalidone versus atenololo e clortalidone nella terapia della cardiomiopatia ipertrofica ostruttiva di pazienti con ipertensione arteriosa: valutazione policardiografica della funzione sistolica e diastolica ventricolare sinistra.

In 13 patients, affected by hypertrophic obstructive cardiomyopathy (HOCM) and essential hypertension, antihypertensive-efficacy and effects of a new calcium-channel blocker (gallopamil) associated with a diuretic agent (chlorthalidone) on left ventricular systolic and diastolic performance assessed by phonocardiographic methods. The results were compared to those obtained, in the same group of patients, with a selective beta-blocker (atenolol) associated with the same diuretic agent (chlorthalidone). With both therapeutic regimens a statistically significant reduction of systolic and diastolic arterial pressure was observed; both agents were able to reduce hemodynamic gradient in systole which characterize HOCM; however, the treatment with gallopamil plus chlorthalidone determined greater effects on left ventricular diastolic function as compared to the treatment with atenolol plus chlorthalidone; both treatments determined bradycardia.