Increased B7H4 tissue expression correlates with high CA19.9 serum levels and a worse prognosis of pancreatic adenocarcinoma.

Pancreatic cancer (PC) is a leading cause of cancer death worldwide, especially in Western societies. Its aggressive nature and poor prognosis increase the need for identifying new and more accurate diagnostic and prognostic tools. We studied 41 patients who had undergone radical surgical resection for PC, investigated B7H4 protein expression in the PC tissue specimens of these patients by immunohistochemistry and analyzed several clinical and pathological features. The positive expression of the B7H4 antigen was associated with a negative impact of chemotherapy with gemcitabine on patient survival and also correlated with high CA19.9 serum levels and poorly differentiated tumors. Moreover, patients that overexpressed B7H4 antigen had worse prognosis compared to the ones that did not overexpress B7H4. B7H4 antigen is a negative prognostic marker for PC patients and also seems to express resistance of PC patients to chemotherapy with gemcitabine.

Incidental thyroid carcinoma diagnosed after total thyroidectomy for benign thyroid diseases: incidence and association with thyroid disease type and laboratory markers.

Objective. Currently, total thyroidectomy (TT) is widely used to treat benign thyroid diseases and thyroid carcinoma. The differential diagnosis between benign and malignant thyroid disorders and the potential identification of thyroid microcarcinomas with biochemical markers remain controversial. This retrospective study aimed to estimate the prognostic validity of thyroid autoantibodies, thyroglobulin (Tg), and the thyroid disease type in diagnostic approaches regarding the co-existence of incidental thyroid carcinoma (ITC) with benign thyroid diseases. Methods. A cohort of 228 patients was treated with TT for benign thyroid disorders between 2005 and 2010. Thyroid autoantibodies and Tg were preoperatively estimated. Patients were classified according to the preoperative and histologically established diagnoses, and the median values of the biochemical markers were compared between the groups. Results. ITC was detected in 33/228 patients and almost exclusively in the presence of nontoxic thyroid disorders (P = 0.014). There were no statistically significant differences in the median values of the biochemical markers between the benign and malignant groups. There was also no significant association between ITC and chronic lymphocytic thyroiditis. Conclusions. The co-existence of ITC with benign and especially nontoxic thyroid diseases is significant, and treatment of these disorders with TT when indicated can lead to the identification and definitive cure of microcarcinomas. Further studies are required to establish precise markers with prognostic validity for TC diagnosis.

Laparoscopic cholecystectomy in acute cholecystitis: an analysis of the risk factors.

BACKGROUND AND AIM: Laparoscopic cholecystectomy (LC) is increasingly being used as the initial surgical approach in patients with acute cholecystitis (AC). We describe our experience with LC in the treatment of AC. MATERIALS AND METHODS: In this study 2 412 patients underwent LC, in 315 cases for AC. The diagnosis was based on clinical, laboratory and intra-operative findings. Rates of conversion, complications, length of hospital stay, operating times, and factors associated with conversion or morbidity were analysed. RESULTS: Conversion to open cholecystectomy was necessary in 60 patients (19.04%) with AC. Factors associated with conversion were age >65 years, male gender, presence of empyema, previous abdominal surgery, and fever (temperature >37.5oC). There were no deaths, and the complication rate was 6.4%. The only risk factor for morbidity was a bilirubin level of >20.52 µmol/l. The operating time and hospital stay were significantly longer in AC than in elective cases. CONCLUSIONS: LC for AC is technically demanding but safe and effective. With patience, experience, careful dissection and identification of vital structures, the laparoscopic approach is safe in the majority of cases.

Peri-operative management of a patient with hereditary angioedema undergoing laparoscopic cholecystectomy.

Hereditary angioedema is a rare genetic disorder resulting from an inherited deficiency or dysfunction of the C1-esterase inhibitor of the classic complement pathway. It is characterised by recurrent episodes of angioedema, without urticaria or pruritus, most often affecting the skin or the mucosal tissues of the upper respiratory and gastrointestinal tracts. We describe the peri-operative care of a woman with hereditary angioedema undergoing laparoscopic cholecystectomy with emphasis on the role of anaesthetists as peri-operative physicians.

A dose escalation study of docetaxel plus capecitabine in combination with oxaliplatin in patients with advanced solid tumors.

OBJECTIVES: Capecitabine (CAP), Oxaliplatin (OX) and Docetaxel (DOC) have shown considerable activity in a wide range of solid tumors. A phase I study was conducted in order to determine the maximum-tolerated dose (MTD) and dose-limiting toxicities (DLTs) of their combination in patients with advanced solid tumors. PATIENTS AND METHODS: Twenty-one patients were enrolled. The patient's median age was 68 years, 15 were male, and 12 were chemo-naïve. DOC was administered on day 1 as an 1-hour (iv) infusion at a standard dose of 50 mg/m(2). OX was administered on day 1 as a 2-hour (iv) infusion at escalating doses ranging from 70-80 mg/m(2). CAP was administered orally on days 1 to 7 at escalating doses ranging from 2,000-2,750 mg/m(2) given as two daily divided doses. Treatment was repeated every two weeks. RESULTS: Six different dose-levels were examined. At dose-level VI, two of three enrolled patients presented DLTs (one patient diarrhea and asthenia grade 3 and another grade 3 diarrhea), and thus, the recommended MTD for future phase II studies is CAP 2,750 mg/m(2) , DOC 50 mg/m(2) and OX 75 mg/m(2). A total of 121 treatment cycles were administered. Grade 3 neutropenia was observed in six (5%) treatment cycles and grade 3 thrombocytopenia in one (1%). There was no febrile episode. Grade 3 asthenia was observed in three (14%) patients, grade 3 diarrhea in four (19%), grade 3 neuropathy in one (5%), and grade 1/2 hand-foot syndrome in three (14%). Other toxicities were uncommon. There was no treatment related death. Four (29%) PRs and seven (50%) SD were observed among 14 evaluable patients. Responses were seen in patients with renal (n = 1), gastric (n = 2) and pancreatic (n = 1) cancer. CONCLUSIONS: These results demonstrate that CAP, DOC and OX can be safely combined at clinically relevant doses and this regimen merits further evaluation.

Double gall-bladder--two pathologies: a case report.

True gall-bladder duplication is a rare biliary anomaly, which is usually discovered as an incidental finding. There are reports of double gall-bladders missed during the first operation. We present the case of a double gall-bladder which, albeit suspected during the operation, was confirmed post-operatively. The patient underwent successful laparoscopic cholecystectomy and the examination of the resected gall-bladder revealed two chambers, only one containing stones. Predisposing factors for the development of gall-stones in one gall-bladder only, as well as surgical options, are briefly discussed.

Port-site metastasis of extrahepatic bile duct carcinoma after laparoscopic cholecystectomy without evidence of a primary tumour.

A 75-year-old man suffering from symptomatic cholelithiasis underwent laparoscopic cholecystectomy using the four-port technique. No malignancy was observed in the resected gall-bladder and the patient exhibited a good postoperative course. Eleven months postoperatively he presented with two subcutaneous tumours: one at the port-site on the right anterior axillary line (at the position of the vacuum drain) and the other at the subumbilical port-site. The patient underwent an incisional biopsy, which revealed metastatic adenocarcinomas of the primary extrahepatic duct, with no evidence of a primary tumour or other distant metastasis. The patient underwent wide excision of the subcutaneous tumours. Six months later he again presented with subcutaneous tumours at the same positions. Magnetic resonance imaging of the abdomen revealed only the subcutaneous tumours. The patient again underwent wide excision of the subcutaneous tumours, followed by radiotherapy. At a 21-month follow-up the patient was symptom-free. Magnetic resonance imaging of the abdomen and magnetic resonance cholangiopancreatography results were normal, and there was no evidence of other metastasis. Four months later the patient died from metastatic disease of the abdomen.

Subcutaneous metastasis from a gastrointestinal stromal tumor of the stomach: a case report.

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms of the stomach, which account for approximately 3.6% of all gastric tumors. They may or may not be malignant. Malignant GIST rarely metastasizes to distant organs. We report a case of a gastric GIST diagnosed in a 69- year-old woman presented with a synchronous subcutaneous paraumbilical metastasis. Computed tomography (CT) scan demonstrated a space-occupying lesion arising from the gastric wall with a second well-circumscribed lesion in the subcutaneous tissue which infiltrated the aponeurosis of the right rectus abdominis. The patient underwent total gastrectomy and resection of the subcutaneous mass. Pathologic examination of the gastric tumor and subcutaneous mass showed histological and immunohistochemical characteristics of a GIST. The patient succumbed on the 4th postoperative day. Gastric stromal tumor metastasis must be taken into consideration in the differential diagnosis of a palpable paraumbilical mass in a patient diagnosed with malignant GIST.

Primary adrenal hydatid cyst: a case report.

A rare case of primary adrenal hydatid cyst is reported in a 56-year-old male. The cyst was discovered incidentally. The only symptom was hypertension. Partial excision of the gland and pericystectomy were performed. Surgical treatment was also therapeutic for the hypertension.

Comparison of angiogenic activity after urethral reconstruction using free grafts and pedicle flap: an experimental study.

PURPOSE: An experimental study was undertaken in order to estimate the angiogenic activity in different free grafts and pedicle flap in urethral reconstruction in an animal model. METHODS: Twenty-eight white New Zealand rabbits were randomly divided into five groups (O, A, B, C and D). A ventral urethral defect was created in all groups. In the group O, (n = 4), a simple closure of the defect was performed. Free penile skin graft (group A, n = 6), buccal mucosal graft (group B, n = 6), bladder mucosal graft (group C, n = 6), and pedicle penile skin graft (group D, n = 6) were used to bridge the urethral defect as an onlay patch. The animals were euthanized on the 21st postoperative day. The angiogenic activity was assessed with immunohistochemistry, using the anti-CD31 MoAb and the alkaline phosphatase antialkaline phosphatase procedure. The native vascularity of penile skin as well as buccal and bladder mucosa was assessed in rabbits from group O (n = 3). Statistical analysis was performed using one-way ANOVA. RESULTS: The angiogenesis seen with a magnification of x 200 in groups O, A, B, C, and D was 34.1 +/- 4.1 (mean +/- SD), 61.7 +/- 6.4, 94.3 +/- 6.4, 91.5 +/- 7.2, and 30.8 +/- 5.2 vessels per optical field, respectively. There were statistically significant differences (p < 0.001) between group O and groups A, B, C and between group A and groups B, C, D, but not (p > 0.5) between groups B and C and groups O and D. The native vascularity of penile skin, buccal mucosa and bladder mucosa was 23.3 +/- 3.0, 24.6 +/- 3.7 and 17.0 +/- 2.6 vessels per optical field, respectively. CONCLUSION: Buccal and bladder mucosal grafts exhibit a higher angiogenic activity than free and pedicle penile skin flap when transplanted in urethral defects. As the buccal mucosal graft showed the higher angiogenic activity and its harvesting is easier than bladder mucosa, we propose that in urethral reconstruction surgery the use of this graft might offer more reliable results.

Hypoxia inducible factors 1alpha and 2alpha are associated with VEGF expression and angiogenesis in gallbladder carcinomas.

AIMS: To investigate the significance of the hypoxia inducible factors HIF-1alpha and HIF-2alpha in gallbladder adenocarcinomas and their relation to angiogenesis and to the expression of VEGF, an angiogenic factor transcriptionally regulated by HIFalphas. METHODS: HIF-1alpha and 2alpha expression was assessed immunohistochemically in 60 patients with early gallbladder adenocarcinomas, treated with surgery alone. In addition, the vascular density (VD) and the expression of the angiogenic factors VEGF and thymidine phosphorylase (TP) were examined. The results were correlated with clinico-pathological features and prognosis. RESULTS: Overexpression of HIF-1alpha and 2alpha was significantly associated with increased tumor angiogenesis and VEGF expression, while HIF-2alpha was linked with upregulation of TP. None of these factors were associated with T-stage and tumor grade. Although HIFs did not relate significantly with prognosis, patients with HIF-1/2 expression who failed to switch-on VEGF or intratumoral angiogenesis had a favorable outcome. CONCLUSION: Hypoxia inducible factors are upregulated in a large proportion of gallbladder adenocarcinomas, a feature strongly related to increased expression of VEGF and intensified angiogenesis.

Primary hydatid disease in femoral muscles.

Usually, intramuscular hydatid cysts are secondary, resulting from the spread cysts from other areas either spontaneously or after operations for hydatidosis in other regions. We present an unusual case of a primary hydatid cyst found in the left thigh of a 35-year-old woman, presenting as an enlarging soft-tissue tumour. Ultrasound, computed tomography and magnetic resonance imaging examinations revealed a multilocular intramuscular cyst in the anterior aspect of her left thigh, and no disease at any other location. We removed the entire cyst surgically, and macroscopic and microscopic histopathological examinations confirmed the diagnosis of muscular hydatidosis. Three years after the operation there had been no recurrence. In regions where hydatidosis is endemic, a tumour in any part of the body should be considered a hydatid cyst until proven otherwise.

Delayed perforation of the large bowel due to thermal injury during laparoscopic cholecystectomy.

We report a case of delayed perforation of the large bowel because of thermal injury during a laparoscopic cholecystectomy. A 78-year-old male with symptomatic cholelithiasis underwent a difficult laparoscopic cholecystectomy because of multiple adhesions resulting from two previous cholecystitis episodes. The patient recovered well after surgery and was discharged on post-operative day 2. On postoperative day 10, the patient returned to the hospital with peritonitis. An exploratory laparotomy revealed perforation of the wall of the hepatic flexure of the large bowel, which was centred in a necrotic area 1 cm in diameter. The perforation was sutured and a temporary ileostomy performed, which was closed at a later date. The patient was doing well at a 10-month follow-up review. A delayed rupture of any part of the bowel after laparoscopic surgery can be potentially fatal if not treated during an emergency exploratory laparotomy, even if the clinical signs are not severe.

Risk factors for conversion of laparoscopic cholecystectomy to open cholecystectomy.

BACKGROUND: Conversion to open cholecystectomy is still required in some patients. The aim of this study was to evaluate preoperative factors associated with conversion to open cholecystectomy in elective cholecystectomy and acute cholecystitis. METHODS: The records of 1,804 patients who underwent cholecystectomy from May 1992 to January 2004 were reviewed retrospectively. The demographics and preoperative data of patients who required conversion to laparotomy were compared to those with successful laparoscopic cholecystectomy. RESULTS: Conversion to open cholecystectomy was needed in 94 patients (5.2%),of which 44 (2.8%) had no inflammation and 50 (18.4%) had acute inflammation of the gallbladder. Male gender, age older than 60 years, previous upper abdominal surgery, diabetes, and severity of inflammation were all significantly correlated with an increased conversion rate to laparotomy. Also, the conversion from laparoscopic to open cholecystectomy in acute cholecystitis patients was associated with greater white blood cell count, fever, elevated total bilirubin, aspartate transaminase, and alanine transaminase levels, and the various types of inflammation. CONCLUSIONS: None of these risk factors were contraindications to laparoscopic cholecystectomy. This may help predict the difficulty of the procedure and permit the surgeon to better inform patients about the risk of conversion from laparoscopic to open cholecystectomy.

Laparoscopic cholecystectomy in a patient with situs inversus using ultrasonically activated coagulating scissors. Report of a case and review of the literature.

Situs inversus totalis is a rare defect with a genetic predisposition, which can present difficulties in the management of abdominal pathology, especially in laparoscopic surgery, due to the mirror-image anatomy. Herein, we report on a patient with situs inversus totalis and symptomatic cholelithiasis. The patient had a successful laparoscopic cholecystectomy, using ultrasonically activated coagulating scissors. Diagnostic pitfalls and technical details of the laparoscopic cholecystectomy are discussed and a review of the relevant literature is presented.

Colostomy type in anorectal malformations: 10-years experience.

AIM: The aim of this study was to evaluate the influence of colostomy type on morbidity during the treatment of anorectal malformations. METHODS: Sixty-eight infants (male: female ratio 1.3:1) with anorectal malformations that required colostomy were treated in our clinics during the period 1991-2001. Of these patients, 26 had received a loop colostomy: 14 of these underwent posterior sagittal anorectoplasty (PSARP) at the age of 9-12 months (Group A), and 12 underwent PSARP at the age of 2-4 months (Group B). Forty-two infants received a separated-stomas colostomy and underwent PSARP at the age of 9-12 months (Group C). The incidence of complications among groups was compared using the 2 sided Fisher's exact test. RESULTS: Eight cases from group A were complicated with prolapse of the stomas, perianal wound infection, pull-through dehiscence, and anal fibrotic stricture. The only complication observed in groups B and C was perianal wound infection, which occurred in 1 case from each group. A statistically significant difference was observed in the incidence of complication between groups A and C (p<0.001) and between groups A and B (p=0.014). The results from groups B and C did not differ significantly (p=0.398). When the cases complicated with colostomy prolapse were removed from the statistical analysis, groups A and C still differed significantly (p=0.001) but groups A and B did not (p=0.069). CONCLUSIONS: As the incidence of complications increases with time after a loop colostomy, we encourage either an early corrective procedure or the modification into separated-stomas colostomy (SSC) before PSARP is performed for those cases that would involve definitive surgery in late infancy.