Hepatocellular carcinomas and primary liver tumors as predictive factors for postoperative mortality after liver resection: a meta-analysis of more than 35,000 hepatic resections.

Liver resection is considered the therapeutic gold standard for primary and metastatic liver neoplasms. The reduction of postoperative complications and mortality has resulted in a more aggressive approach to hepatic malignancies. For the most part, results of liver surgery have been published by highly experienced institutions, but the observations of highly specialized units results may not reflect the current status of hepatic surgery, underestimating mortality and complications. The objective of this study is to evaluate morbidity and mortality as a result of liver resection for primary and metastatic lesions, analyzing a large number of studies with a meta-analytic process taking into account the overdispersion of data. An extensive literature search has been conducted, and 148 papers published between January 2000 and April 2008, including a total of 36,629 patients from both high-volume and low volume institutions, were included in the meta-analysis. A beta binomial model was used to provide a robust estimate of the summary event rate by pooling overdispersion binomial data from different studies. Overall morbidity and mortality after liver surgery were 29.32 per cent and 3.15 per cent, respectively. Significantly higher postoperative mortality was observed after liver resection for hepatocellular carcinomas and primary hepatic tumors. The application of a beta binomial model to correct for overdispersion of liver surgery data showed significantly higher postoperative mortality rates in patients with hepatocellular carcinomas or primary hepatic tumors after liver resection.

Misdiagnosed esophageal perforation treated with endoscopic stent placement: a case report.

Esophageal perforation has a high rate of mortality. Many strategies have been advocated for its management. Therapeutic options are surgical repair or resection, endoscopic placement of self-expandable metallic stents or, in selected cases, conservative management.We describe a case of a 75-year-old man admitted to our hospital for forceful vomiting since 24 hours. The patient was treated with endoscopic placement of a covered self expandable metallic stent. Although the late diagnosis delayed the treatment, the patient survived the usually fatal condition. The stent removal was performed 8 weeks after implantation.Immediate and correct diagnosis are the key elements in improving survival of patients with esophageal perforation. This has to be associated to the selection of the most appropriate treatment. Implantation of covered self-expandable metallic stents in compromised patients with esophageal perforation is a safe and feasible alternative to operative treatment.

[Successful endoscopic treatment of spontaneous esophageal perforation in the elderly]. / Trattamento endoscopico della perforazione esofagea spontanea nell'anziano.

AIM OF THE PAPER: To discuss the diagnostic and therapeutic aspects of spontaneous esophageal perforation. It is considered a surgical emergency with high rate of mortality. Its diagnosis can be difficult since the presentation is often nonspecific and can be confused with others disorders. Many strategies have been advocated for its management. Prompt diagnosis and early treatment are required to decrease the poor prognosis of this condition. A conservative therapy may be effective in selected cases. RESULTS: We described a successful non-surgical closure of a spontaneous esophageal perforation using an endoscopic stent, in an severely ill old patient. Although the treatment was delayed because of a late diagnosis, the patient survived the usually fatal condition. CONCLUSION: The key to improve the prognosis of this life-threatening emergency is the immediate and correct diagnosis and the most appropriate selection of the primary employed procedure.

[Right hemicolectomy for colon cancer: a prospective randomised study comparing laparoscopic vs. open technique]. / Emicolectomia destra per cancro del colon: studio prospettico randomizzato tra tecnica laparoscopica e laparotomica.

Since 2001 we have conducted a prospective randomised study of right laparoscopic-assisted hemicolectomy vs open right hemicolectomy for right colon cancer in order to assess the differences in intraoperative and postoperative results as well as oncological clearance. Thirty-three patients with right colon cancer received laparoscopic-assisted right hemicolectomy (LRH) and were compared with 33 patients who underwent open right hemicolectomy (ORH). We analysed morbidity and mortality, number of postoperative days of starving, postoperative days tolerating a liquid diet and a soft diet, duration of postoperative ileus, as well as the distance of the resection margin from the tumour (< 5 cm or >5 cm), and the number of lymph nodes found in the resected specimen. We also compared the length of operative time, blood loss, and any associated surgery. Morbidity occurred in 1 patient undergoing LRH (3.0%) as against 4 patients (12.1%) in the ORH group (p < 0.05). Postoperative ileus lasted 3.15 days (range: 3-5 days) in the LRH group vs 3.0 days (range: 1-4 days) in the ORH group. Median operative time was 251 min (range: 130-360 min) in the LRH group vs 222.9 min (range: 135-360 min) in the ORH group, while blood loss amounted to a median of 135 mi (range: 100-300 ml; SD +/- 42.9 mi) in the LRH group vs. 404.1 ml (range: 250-1000 ml; SD +/- 159.3 ml) in the ORH group (p <0.05). The distance of the resection margin from the tumour was more than 5 cm in both groups. In the LRH group a median of 12.7 lymph nodes were removed (range: 9-31; SD +/- 4.5) vs. 18 lymph nodes in the ORH group (range: 8-29; SD +/- 3.9) (p < 0.05). Associated surgery was performed in 15.1% of cases in both groups. In our experience LRH presents a statistically significant advantage in terms of morbidity and blood loss compared to ORH. Equivalent oncological clearance was obtained, fulfilling the stated criteria of 5 cm free resection margins and number of lymph nodes resected, though we removed fewer lymph nodes in LRH compared to ORH (p < 0.05).

Duodenal perforation and right hydronephrosis due to toothpick ingestion.

We report a case of a 36-year-old man who was admitted to the Emergency Department with right flank pain. The clinical presentation was suggestive of renal colic. However, a computed tomography scan showed the presence of a foreign body in the inferior duodenal flexure. Upper gastrointestinal endoscopy demonstrated a 6.5-cm wooden toothpick deeply embedded in the duodenal wall; this was removed via endoscopy. The peri-duodenal inflammatory reaction had encased the right ureter, resulting in hydronephrosis. The patient did well and was discharged on post-operative day 7. He did not recall toothpick ingestion. When evaluating patients with acute abdominal pain, foreign body ingestion should be considered. In patients with a history of toothpick ingestion, immediate diagnosis with endoscopic management should be performed.

Giant hepatic adenoma with bone marrow metaplasia not associated with oral contraceptive intake.

BACKGROUND: Hepatocellular adenomas are the most common benign liver tumors. They are usually related to oral contraceptive intake. CASE PRESENTATION: This case describes a 58-year-old woman admitted to our institution for a hepatic mass incidentally discovered during a routine examination. The patient, who was never on oral contraceptives, was asymptomatic upon admission. She underwent a thorough diagnostic evaluation and then a hepatic right trisegmentectomy. The histologic evaluation of the mass showed that it was a hepatocellular adenoma with areas of bone marrow metaplasia. CONCLUSION: Bone marrow metaplasia has rarely been found associated to liver tumors. The presence of marrow-derived hepatic progenitor cells might be the source of both adenoma hepatocytes and bone marrow differentiated cells. To our knowledge, this is only the second case in the English literature in which areas of bone marrow metaplasia were found in a hepatocellular adenoma.

[Impact of new lymph node staging on lymphadenectomy and on the prognosis of patients undergoing surgery for gastric cancer]. / Impatto della nuova stadiazione linfonodale sulla linfadenectomia e sulla prognosi dei pazienti operati per cancro gastrico.

The TNM system has become the principal method for assessing the extent of disease, determining prognosis in gastric cancer patients, and influencing therapeutic strategies. The extent of lymph node metastases is the most important prognostic factor. The aim of the study was to compare the 4th and 6th TNM edition N-classifications and to retrospectively evaluate the prognostic value of the 2002 TNM edition. We evaluated 344 patients who underwent curative total or subtotal gastrectomy. Our data confirm the simplicity and easy application of the new staging and the better prognostic stratification of the N-stage. In multivariate analysis the difference between the old and new TNM staging is minimal. We therefore suggest comparing lymph node location and number in larger series. For the purposes of correct N-staging, 10 lymph nodes in early gastric cancer and at least 16 in the other pT stages seem sufficient to achieve effective pNO staging.

[Critical analysis of the long-term management of a case of cancer of the breast]. / Analisi critica della gestione a lungo termine di un caso di cancro mammario: a proposito di un caso clinico.

We describe a case of gastric metastases from a lobular carcinoma of the breast in a 73-year-old woman who had undergone a left mastectomy with axillary dissection 15 years earlier. The initial diagnosis was diffuse-type gastric carcinoma as evaluated both by analysis of gastric biopsy findings and ultrasonographic endoscopy. The definitive diagnosis of metastatic breast cancer was confirmed after subtotal gastrectomy for a presumed primary gastric carcinoma and was obtained using a panel of specific immunohistochemical markers. The distinction between primary and secondary gastric malignancies in patients with a history of lobular breast carcinoma may not be merely an academy exercise, since the treatment and prognosis of the two situations are different.

[GIST: a clinical case as a model of surgical and pharmacological therapy of solid tumours]. / GIST: un caso clinico come modello della terapia chirurgica e farmacologica dei tumori solidi.

Gastrointestinal stromal tumour: report of a case as a model of surgical and pharmacological therapy of solid tumours. mutation of this protein is present in most of these tumours. Gastrointestinal stromal tumours are notoriously unresponsive to chemotherapy and radiotherapy and prior to the recent introduction of the kit inhibitor imatinib, there was no effective therapy for advanced, metastatic disease. We report a case of metastatic gastrointestinal stromal tumour located primarily in the ileum and examine it in detail in order to contribute both to identifying factors capable of predicting its clinical course and evaluating the efficacy of imatinib as adjuvant therapy for this rare type of tumour. We share the opinion that, given the present state of the art, surgical resection remains the gold standard of treatment for these tumours and imatinib is a valid systemic therapy for metastastic and locally unresectable gastrointestinal stromal tumours.