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BACKGROUND The perivascular epithelioid cell tumour (PEComa) family of tumours mainly includes renal and hepatic angiomyolipomas, pulmonary lymphangioleiomyomatosis and clear cell “sugar” tumour of the lung. Several uncommon tumours with similar morphological and immunophenotypical characteristics arising at a variety of sites (abdominal cavity, digestive tract, retroperitoneum, skin, soft tissue and bones) are also included in the PEComa family and are referred to as PEComas not otherwise specified. CASE SUMMARY We present a 37-year-old female patient who underwent resection of an 8.5 cm × 8 cm × 4 cm retroperitoneal tumour, which eventually was diagnosed as PEComa of uncertain biological behaviour. Three years after the operation, the patient remains without any evidence of recurrence. A search was performed in the Medline and EMBASE databases for articles published between 1996 and 2018, and we identified 31 articles related to retroperitoneal and perinephric PEComas. We focused on sex, age, maximum dimension, histological and immunohistochemical characteristics of the tumour, follow-up and long-term outcome. Thirty-four retroperitoneal (including the present one) and ten perinephric PEComas were identified, carrying a malignant potential rate of 44% and 60%, respectively. Nearly half of the potentially malignant PEComas presented with or developed metastases during the course of the disease. CONCLUSION Retroperitoneal PEComas are not as indolent as they are supposed to be. Radical surgical resection constitutes the treatment of choice for localized disease, while mammalian target of the rapamycin (mTOR) inhibitors constitute the most promising therapy for disseminated disease. The role of mTOR inhibitors as adjuvant or neoadjuvant therapies needs to be evaluated in the future.

More than 2 decades ago, the discovery of osteoprotegerin (OPG) as inhibitor of the receptor of activator of nuclear factor Kb (RANK) ligand (RANKL) revolutionized our understanding of bone biology and oncology. Besides acting as decoy receptor for RANKL, OPG acts as decoy receptor for tumor necrosis factor-related apoptosis-inducing ligand (TRAIL). OPG, RANKL, and TRAIL are ubiquitously expressed, stimulating per se pivotal signaling cascades implicated in cancer. In the context of cancer cell-bone cell interactions, cancer cells skew the OPG/RANKL/RANK (RANKL cognate receptor) balance towards bone destruction and tumor growth through favoring the RANKL/RANK interface, circumventing OPG. Numerous preclinical and clinical studies demonstrate the dual role of OPG in cancer: antitumor and tumor-promoting. OPG potentially conveys an antitumor signal through inhibiting the tumor-promoting RANKL signaling-both the osteoclast-dependent and the osteoclast-independent-and the tumor-promoting TRAIL signaling. On the other hand, the presumed tumor-promoting functions of OPG are: (i) abrogation of TRAIL-induced apoptosis of cancer cells; (ii) abrogation of RANKL-induced antitumor immunity; and (iii) stimulation of oncogenic and prometastatic signaling cascades downstream of the interaction of OPG with diverse proteins. The present review dissects the role of OPG in bone oncology. It presents the available preclinical and clinical data sustaining the dual role of OPG in cancer and focuses on the imbalanced RANKL/RANK/OPG interplay in the landmark "vicious cycle" of skeletal metastatic disease, osteosarcoma, and multiple myeloma. Finally, current challenges and future perspectives in exploiting OPG signaling in bone oncology therapeutics are discussed.

To investigate the expressions of caspase-3 and survivin in colorectal cancer patients and their possible associations with clinicopathological parameters and the oncological outcome.Between January 2008 and December 2011, 85 patients with sporadic colorectal cancer were submitted to colectomy with curative intent. Postoperatively, all patients were followed every three months up to the 36th month. Immunohistochemical detection of the apoptosis-related proteins was carried out on 4-μm-thick deparaffinized sections from all primary tumors. Univariate and multivariate analyses were performed by using the R software for Windows, version 3.3.2.Setting the cut-off point for caspase-3 positivity at 5%, 48% of the patients were characterized as caspase-3(+). Caspase-3 positivity was not found related either to any clinicopathological parameter or to the oncological outcome. Choosing simple survivin positivity as the cut-off point for its expression, 78% of the patients were considered as survivin(+). Survivin inexpression predisposed to poorly differentiated tumors of advanced T stage. However, neither a dismal nor a favorable prognostic role for survivin expression or inexpression was disclosed. By dividing all enrolled patients in four different groups, a trend for worse 3-year overall survival rate in the caspase-3(-)/survivin(-) subgroup of patients was noticed (p=0.067).Caspase-3 expression was unrelated to the oncological outcome in colorectal cancer patients. The proposed favorable prognostic role for survivin inexpression was not confirmed. On the contrary, survivin(-) tumors were mainly of poor differentiation and advanced T stage. An inverse relationship between caspase-3 and survivin expressions was also not confirmed. Future studies focusing on specific survivin isoforms expression or inexpression may give answers on apoptotic-antiapoptotic interactions on cancer cell death.

Replication Protein A (RPA) consists of three subunits (RPA1, RPA2 and RPA3) essential for all major DNA metabolic pathways. Although RPA seems to be a promising therapeutic target, its role in human cancers has not been fully elucidated. This is the first study investigating the expression of all the three RPA subunits in a series of 74 resected gastric carcinomas and analyzing the possible correlations with clinicopathologic parameters (histological type, grade, lymphovascular invasion, lymph node status and disease stage), Ki-67 proliferative index, Topoisomerase IIa expression and patients' survival.Immunohistochemistry using monoclonal antibodies. Univariate and multivariate statistical analysis.All the three subunits showed widespread nuclear expressions in gastric carcinomas with significant associations among their expressions. RPA2 demonstrated higher expression levels in low grade carcinomas and a gradual significant decrease from N0 to N3 and from stage I to stage IV carcinomas. All the three subunits were statistical significantly more abundant in lymph node negative and earlier stage (stage III) gastric carcinomas. No associations were established among RPAs and the proliferative marker Ki-67. In patients with positive lymph nodes and advanced tumor stage, RPA1 expression seemed to predict a better overall survival implying a probable predictive role.The widespread expression of RPA(1-3) suggests one or more roles in gastric cancer. Their presence in earlier stage tumors probably offers an opportunity for early targeted therapy. Their probable predictive value in node positive and advanced stage tumors needs further investigation with respect to specific chemotherapeutic treatments.

Objectives Gastrointestinal neuroendocrine carcinoma (NEC) is a lethal, uncommon, and understudied neoplasm. We present the efficacy and safety of first-line capecitabine (CP), oxaliplatin, irinotecan, and bevacizumab (CAPOXIRI-BEV) combination followed by pazopanib plus CP maintenance therapy in patients with advanced high-grade poorly differentiated gastrointestinal NEC. Methods This was a two-stage phase II study conducted at multiple institutions. Patients were consecutively enrolled and had advanced NEC of the colon or small bowel. Patients received irinotecan 125 mg/m, oxaliplatin 80 mg/m on day 1, CP 1000 mg/m twice daily on days 1 to 14, plus bevacizumab 8 mg/kg on day 1 for six 21-day cycles. Maintenance therapy was given to those who responded (complete response/partial response) or had stable disease after 6 cycles with CAPOXIRI-BEV with pazopanib 800 mg daily plus CP 1600 mg/m daily on days 1 to 14 every 3 weeks until disease progression or unacceptable toxicity. Patients who progressed on CAPOXIRI-BEV received standard etoposide-carboplatin. The primary endpoint was overall response rate. Results Twenty-two patients were enrolled of whom 19 were evaluable. The median age was 60 years. The overall response rate (3 complete response/6 partial response) was 47.4% (95% confidence interval: 29.5-76.1), the overall disease control rate was 78.9% (95% confidence interval: 62.6-99.6), and, at median 30 (11 to 41 mo) months' follow-up, 5 patients (26.3%) were still alive. Median progression-free survival was 13 months, and the 1-year progression-free survival rate was 52.6%. The median overall survival was 29 months. The median overall survival of the 9 patients who responded versus those with stable disease/progressive disease was 30.5 versus 14 months, respectively. The median duration of response was 16 months. Predictable toxicity was observed. Conclusions First-line CAPOXIRI-BEV followed by pazopanib plus CP maintenance therapy for advanced NEC demonstrates promising efficacy and predictable toxicity. Further investigation is warranted.

Background The incidence of colorectal cancer (CRC) is expected to increase by 80% in year 2035. Even though advantages in treatment of CRC have being made over the last decades, the outcome remains poor. Recently, several inflammatory markers including pretreatment neutrophil to lymphocyte ratio (NLR), have being used as prognostic factors, since host inflammatory response to cancer is believed to determine disease progression. The aim of this study is to evaluate the prognostic significance of pretreatment NLR, in terms of overall survival (OS), 5-year survival, disease-free survival (DFS) and recurrence, in CRC patients who underwent curative resection. Methods We retrospectively reviewed 296 patients, who were submitted to elective surgery as first therapeutic option in curative intent, between January 2010 and December 2015. Pretreatment NLR, as well as demographics, clinical, histopathologic, and laboratory data were analyzed. Univariate and multivariate analyses were conducted to identify prognostic factors associated with OS, 5-year survival, DFS and recurrence. Results The cutoff point of NLR was calculated with Kaplan-Meier curves and log-rank test to 4.7. Univariate and multivariate analyses disclosed elevated NLR as a significant dismal prognostic factor for DFS (HR 1.88; 95% CI 1.01–3.52; p = 0.048), 5-year survival (HR 2.14; 95% CI 1.12–4.10; p = 0.021) and OS (HR 2.11; 95% CI 1.11–4.03; p = 0.023). In a subgroup analysis, in patients with stage II CRC, NLR > 4.7 was a stronger poor predictor for DFS (HR 2.76; 95% CI 1.07–7.13; p = 0.036), 5-year survival (HR 3.84; 95% CI 1.39–10.63; p = 0.01) and OS (HR 3.62; 95% CI 1.33–4.82; p = 0.012). After adjusting stage for gender, age, location of the primary tumor, differentiation, as well as the presence of perineural, vascular, and lymphovascular invasion, the significance of NLR > 4.7 became more prominent for DFS (HR 2.85; 95% CI 1.21–6.73; p = 0.0176), 5-year survival (HR 4.06; 95% CI 1.66–9.93; p = 0.002) and OS (HR 4.07; 95% CI 1.69–9.91; p = 0.002) in stage II patients. Conclusion Pretreatment NLR > 4.7 is a poor prognostic factor for DFS, 5-year survival and OS in CRC patients undergoing curative resection. The dismal prognostic effect of NRL is magnified in Stage II CRC patients.

Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are the most frequent bariatric surgery procedures worldwide. In this prospective study, we examined the association of a genetic risk score (GRS) with loss of excess weight after bariatric surgery. A total of forty-seven morbidly obese Greek patients who underwent SG (81%) or RYGB were recruited, followed up for 2 years and genotyped. Weight loss after surgery was reported as the percentage of excess weight that was lost (%EWL) at 12 and 24 months after surgery. A GRS was constructed based on previously BMI- and WHR-related single nucleotide polymorphisms (SNPs) that were found significantly correlated with weight loss after bariatric surgery in our population. The level of post-surgery %EWL after 12 and 24 months was estimated through two multiple linear regression models that considered the effects of relevant genetic risk variants. The first proposed model suggested that the predictor variables of GRS, age, and BMI had a significant effect on %EWL12m. GRS was significantly associated with %EWL12m, indicating a 4.618% decrease of %EWL12m per score unit. The second model indicated a positive correlation between %EWL24m and %EWL12m, suggesting that while post-surgery weight loss increased during the first 12 months, an increase was expected in the next 12 months as well. GRS was also significantly associated with %EWL24m, indicating approximately 3% decrease of %EWL24m per score unit. GRS can be used in the future together with other preoperative parameters in order to predict the outcome of bariatric surgery.

Background Although the effect of the recent Greek economic crisis and austerity on the population’s health and the health system effectiveness have been discussed a lot recently, data on common surgical conditions affecting large part of the population are missing. Using inguinal hernia as a model we investigated possible changes of citizens’ attitude regarding the time of referral, the perioperative details and the intraoperative findings of the emergency hernioplasties. Methods The present retrospective study was conducted by a Department of Surgery in a tertiary public hospital of the Greek capital. We reviewed the records of all hernioplasties performed during two 5-year periods: 2005–2009 and 2012–2016, i.e. before and during the crisis focusing on the emergency ones (either incarcerated or strangulated). Results An equal number of hernioplasties was performed in both periods. During the crisis however, an emergency hernioplasty was significantly more probable (HR 1.269, 95% CI 1.108–1.1454, p = 0.001), at a younger age (p = 0.04), mainly in patients younger than 75 years old (p = 0.0013). More patients presented with intestinal ischemia (7 vs 18, p = 0.002), requiring longer hospitalization (5.2 vs 9.6 days, p = 0.04), with higher cost (560 ± 262.4€ vs 2125 ± 1180.8€ p

To retrospectively evaluate the short-term and the long-term oncological outcome between two groups of patients who had undergone either high or low ligation of inferior mesenteric vessels (IMV) in rectal cancer surgery.Between January 2009 and December 2014, 120 patients with rectosigmoid and rectal adenocarcinoma were operated with curative intent as first therapeutic option. Patients were divided in two groups depending on the level of the inferior mesenteric artery (IMA) ligation. High ligation was defined as the division of the IMA less than 2cm from the aorta followed by the ligation of the inferior mesenteric vein at its origin from the lower border of the pancreas (n=76), while low ligation was defined as the division of IMA immediately distal to the origin of the left colic artery (n=44).The median follow up was 51 months. Univariate analyses disclosed that low ligation was related to a higher postoperative complications rate, mainly related to the higher rate of urinary dysfunction but it was also related to a favorable 5-year overall survival (OS) rate. However, multivariate analyses among factors which might influence the short- and long-term outcomes did not disclose the level of ligation as a factor influencing the postoperative course, the recurrence, the disease free survival (DFS) and the 1-, 3- and 5-year OS rates.The present study disclosed no differences in surgical, histological, short-term and long-term oncological outcomes between patients treated with either high or low ligation of IMA.

The Dutch D1D2 Trial revealed a noncompliance rate of 51% in gastric cancer patients who should have undergone a D2 dissection, while it disclosed that the D2 lymph node dissection group of patients exhibited a higher 15-year overall survival (OS) rate, lower rates of local and regional recurrence, lower rates of liver metastases and lower cancer-related death rates compared to the D1 group, implying that the surgical technique per se may influence outcomes. On the other hand, the predominant up-regulation of invasive and metastatic genes in the Western tumor libraries, the differences in the criteria used for gastric cancer diagnosis in the East and the steady fnding that the Asian ethnicity is a favorable prognostic factor for patients with gastric cancer treated in the US, have been proposed as possible explanations for the differences observed in the gastric cancer outcome between the East and the West. Moreover, literature addresses that gastric cancers in the East are mainly diagnosed at younger ages, they are of intestinal type, located distally, diagnosed at an early stage of disease, while gastric cancers in the West are mainly affecting elderly patients with comorbidities, they are of diffuse type, located proximally, and diagnosed at an advanced stage of disease. Future discoveries in genetics and molecular biology may clarify the characteristics of each tumor, while future achievements in imaging modalities and biological or target therapies may establish "personalized" therapies. Until that time, all efforts for improving our surgical techniques and optimizing the perioperative care are mandatory.

The widespread use of endoscopy and imaging in combination with the continuous update of the staging systems for neuroendocrine tumors has led to an increase in the incidence of small intestinal neuroendocrine tumors (si-NENs) globally. Despite high survival rates, severe complications may occur even in early stages due to the anatomic location of the primary site and the desmoplastic reaction. Surgery plays a central role in the management of patients with si-NENs. Excision of locoregional disease along with extensive lymph node dissection should be performed in fit patients, even in the presence of metastases. Multimodality treatment of liver metastases includes hepatectomy, ablative techniques and liver transplantation. Hormone therapy with somatostatine analogs is of high importance for symptomatic control; special caution should be exercised both pre- and intra-operatively. A multidisciplinary approach is essential in order to provide personalized therapeutics for patients with si-NENs. Clinical research and specialization in this field should be further encouraged.

Background/aim The cullin (CUL) family of proteins is involved in the ubiquitin/mediated degradation of proteins, regulating cell proliferation, cell-cycle control, migration, invasion and metastasis in the process of tumor progression. The aim of the present study was to examine if there is any correlation between the immunohistochemical (IHC) expression of Cullin-1 and -2 proteins in colorectal cancer tissue specimens with several clinicopathological variables. Materials and methods Between January 2012 and December 2014, 96 consecutive adenocarcinoma patients were submitted to oncological colectomy, as the first therapeutic option, with a curative intent. CUL-1 and -2 protein expression was examined with IHC on paraffin-embedded tissue sections. CUL-1 and -2 protein positivity, was correlated with patients' age, gender, stage, histological grade, proliferative capacity (Ki-67 labeling index) and mutant p53 protein expression. The positivity for CUL-1, CUL-2, mutant p53 protein and Ki-67 index, was determined by the percentage of their IHC expression in the total number of cancer cells. Results Choosing as a cut-off point for CUL-1 positivity the 10%, a statistically significant relationship of the expression of the mutant p53 protein (p=0.04) and the co-expression of CUL-2 (p=0.003) were noticed. By setting the cut-off limit for CUL-2 expression to 10%, no statistically significant differences were observed between its expression and the examined clinicopathological variables. However, by increasing the cut-off limit for CUL-2 expression to 30%, a statistically significant correlation of its expression to the mutated p53 protein was noticed (p=0.047). Co-expression of CUL-1 and -2 in more than 10%, significantly correlated to the coexistence of adenomatous polyps along the large bowel (p=0.0329). Multivariate analysis of CUL-1 and -2 co-expression in more than 10% disclosed their expression as an independent factor for adenomatous polyps development in the large bowel (p=0.035, RR=2.1). Conclusion CUL-1 overexpression may happen early in the process of carcinogenesis mainly affecting the vulnerable p53(+) large bowel cells, arresting them in the G1 phase of cell-cycle, while it may also induce the expression of CUL-2. Co-expression of CUL-1 and CUL-2, in the arrested (in G1 phase) large bowel cells, promotes carcinogenesis up to adenomatous polyp formation. Since no relationship between cullins expression and development of cancer on adenoma was found, the results of the present study may be useful explaining the initiation but not the progression of carcinogenesis in colorectal cancer. Further molecular and clinical studies are needed in order to delineate the clinical importance of these proteins in the management of colorectal cancer patients.

Background Liver resection is currently the most efficient curative approach for a wide variety of liver tumors. The application of modern techniques and new surgical devices has improved operative outcomes. Radiofrequency ablation is used more often for liver parenchymal transection. This study aimed to assess the efficacy and safety of radiofrequency ablation-assisted liver resection. Methods A retrospective study of 145 consecutive patients who underwent radiofrequency ablation-assisted liver resection was performed. Intraoperative blood loss, need for transfusion or intraoperative Pringle maneuver, the duration of liver parenchymal transection, perioperative complications, and postoperative morbidity and mortality were all evaluated. Results Fifty minor and ninety-five major liver resections were performed. The mean intraoperative blood loss was 251 mL, with a transfusion rate of 11.7%. The Pringle maneuver was necessary in 12 patients (8.3%). The mean duration for parenchymal transection was 51.75 minutes. There were 47 patients (32.4%) with postoperative complications. There is no mortality within 30 days after surgery. Conclusions Radiofrequency ablation-assisted liver resection permits both major and minor liver resections with minimal blood loss and without occlusion of hepatic inflow. Furthermore it decreases the need for blood transfusion and reduces morbidity and mortality.

The conversion of a laparoscopic cholecystectomy (LC) to an open procedure seems to be multifactorial, be affected by factors related to the patient, the gallbladder’s pathology and the surgeon. Among the more than twenty parameters which have been studied as possible predisposing factors for conversion, current literature addresses that: a male patient, above 65 years old, with American Society of Anaesthesiology (ASA) score >= 3, suffering from acute cholecystitis, with a thickened gallbladder’s wall on preoperative CT and an impacted stone in infundibulum or Mirizzi syndrome as intraoperative finding, who was operated on more than 72 hours from the onset of symptoms, by a non-laparoscopic surgeon, represents the most likely candidate for conversion from LC to open surgery. The probability increases further in the presence of malnutrition and/or cirrhosis. The proposed predictive scores for conversion have not yet found worldwide acceptance and their use is limited to theoretical or training purposes. Even patients with maximum predictive score, do not have a 100% probability for conversion. An experienced surgeon can complete a difficult LC successfully in high-risk surgical patient using the subtotal LC. The need for conversion to laparotomy should be considered as neither a failure nor a complication, but as an attempt to be avoided intra-or post-operative complications. The present review attempts to present the most recent knowledge on the field “conversion from LC to open surgery”.

The contradictory long-term results following D2 lymphadenectomy have revealed the necessity for a more tailored lymphadenectomy in cases of gastric cancer. Among the patients who had undergone a modified D2 lymphadenectomy for gastric cancer, we further analyzed the subgroup in which histologically and immunohistochemically solitary lymph node metastases were detected. Classifying the primary tumors as towards to the lesser and towards to the grater curvature, we propose possible routes of lymphatic spread and possible clinical implications.Between January 2007 and December 2016, 212 patients suffering from gastric adenocarcinoma underwent a modified D2 lymphadenectomy. Solitary lymph node metastases were detected by histology in 14 patients (7 skip metastases) and by immunohistochemistry in an additional 10 patients (5 skip micrometastases).The incidence of the histologically detected solitary lymph node metastases was 6.6% for the whole cohort, increasing to 11.3% with the use of immunohistochemistry. The incidence of the histologically detected skip solitary lymph node metastases was 3.3% for the whole cohort, increasing to 5.7% with the use of immunohistochemistry. Tumors of the lower and middle third of the stomach were equally drained both to the level I and II lymph node stations. However, tumors towards the lesser curvature were mainly drained in the level II lymph node stations (12 out of 19; 63%), while tumors towards the greater curvature were all drained in the level I lymph node stations (5 out of 5; 100%).Primary gastric tumors towards the lesser curvature should be treated by a modified D2 lymphadenctomy. However, for tumors towards the greater curvature, a D1(+) lymphadenectomy always including the no. 79 lymph node stations complex, might be enough.

Novel molecular markers that address the heterogeneity of breast cancer (BC) and provide meaningful prognostic information for BC patients are needed. Kallikrein-related peptidase 6 (KLK6) is aberrantly expressed and functionally implicated in BC and, like other members of the KLK family, may prove a useful molecular tool for clinical management. Our objective was to assess, for the first time, the clinical relevance of KLK6 mRNA expression in BC. Total RNA was isolated from 165 breast tumors, as well as 100 adjacent non-cancerous tumor specimens. After cDNA synthesis, and following quality control, quantitative real-time PCR for KLK6 expression analysis took place. Receiver operating characteristic curves were constructed in order to assess the ability of KLK6 mRNA expression levels to differentiate between molecular BC subtypes. Survival analyses, using DFS as endpoint, were performed at the univariate and multivariate levels. Publicly available BC databases and online survival analysis tools were used to validate our findings. A significant downregulation of KLK6 mRNA expression was observed in BC tissue sections compared to the non-cancerous component (P

Introduction: Surgical site infections (SSI) and especially organ/space infection after resection or ablation of liver tumors are associated with increased morbidity and mortality. A secondary bloodstream infection is considered an organ/space infection but the exact prevalence is unknown. We aimed to investigate the incidence of Organ Space Infections (O/SI) and Blood Stream Infections (BSI) in a cohort of consecutive patients after liver resection or ablation, to seek for a possible connection between them and to search for potential risk factors. Materials and Methods: We reviewed all patients who underwent hepatic resection or intraoperative liver ablation between January 2012 and December 2016 in our department. We focused on age, gender, Child-Pugh score, preoperative biliary drainage, indication for surgery, type of resection, resection or ablation of tumor, need for bilioenteric reconstruction, additional procedure to hepatectomy, blood transfusion, operative time, postoperative admission to ICU and antibiotic chemoprophylaxis. All positive cultures from intraabdominal fluids and blood were recorded. O/SI and BSI were diagnosed by the criteria set by CDC. All variables were compared between the group with organ/space infection and the group without infection. Bloodstream infections were associated with these infections also. Results: 81 consecutive patients with a mean age of 64y.o. were enrolled. 15 patients presented a positive culture postoperatively: intraabdominal fluid in 8, blood cultures in 6 and both blood and intraabdominal fluid in 1 patient. The directly estimated incidence of O/SI amounted to 11.1%. Four blood cultures were secondary to O/SI, and the remaining 2 secondary to central line catheter. O/SI was diagnosed indirectly, through the BSI in an additional 4.9% of the patients, raising the incidence of SSI to 16%. Among the factors studied only admission to the ICU was found to be statistically significant as a risk factor for the development of O/SI (p=0.026). Conclusion: O/SI should be actively seeked for after liver surgery including blood cultures. Patients with affected physical status, comorbidities are in greater risk of developing organ/space infection.

Intraductal papillary mucinous neoplasms (IPMNs) are presumed to evolve from low-grade dysplasia to high-grade dysplasia to invasive carcinoma. Resection of lesions before the development of pancreatic cancer may prevent the development of an incurable process as, once IPMNs progress to invasive cancer, the prognosis may be as poor as resected conventional pancreatic ductal adenocarcinoma. Resection of IPMNs, particularly in the setting of high-grade dysplasia, is presumed to provide a survival benefit. IPMNs also present many challenges as the identification of high-grade dysplasia and early invasive carcinoma and the timing and frequency of malignant progression are not yet established. The limited predictive accuracy presents a challenge as pancreatic resection is associated with a risk of substantial morbidity and mortality; 20-30% and 2-4%, respectively. Diagnostic armamentarium contains pancreas-protocol computed tomography (CT) scan, gadolinium-enhanced magnetic resonance imaging (MRI) with or without magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS). The most promising method is endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) as this technique allows analysis of cyst fluid using biomarkers. Until now, in clinical practice, we utilize two biomarkers, carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9); however, DNA analysis of pancreatic cystic fluid and genomic analysis could offer new tools to the diagnosis and administration of IPMNs. Novel genomic and serum biomarkers could play an important future role to identify those individuals who will benefit from an early operation and those who will benefit from watchful waiting approach. More prospective studies are needed.

Sleeve gastrectomy (SG) has gained enormous popularity both as a first-stage procedure in high-risk super-obese patients and as a stand-alone procedure. The objective of this study was to evaluate the long-term weight loss results after SG published in the literature and compare them with the well-documented short-term and mid-term weight loss results. A detailed search in PubMed using the keywords "sleeve gastrectomy" and "long-term results" found 16 studies fulfilling the criteria of this study. A total of 492 patients were analyzed, with a follow-up of at least 5 years after laparoscopic sleeve gastrectomy (LSG) (373 at 5 years, 72 at 6 years, 13 at 7 years, and 34 at 8 or more years). Of the total number of patients, 71.1% were women (15 studies, n = 432 patients). Mean patient age was 45.1 years (15 studies, n = 432 patients). Mean preoperative body mass index in all 16 studies was 49.2 kg/m(2). The mean percentage excess weight loss (%EWL) was 62.3%, 53.8%, 43%, and 54.8% at 5, 6, 7, and 8 or more years after LSG, respectively. The overall mean %EWL (defined as the average %EWL at 5 or more years after LSG) was 59.3% (12 studies, n = 377 patients). The overall attrition rate was 31.2% (13 studies). LSG seems to maintain its well-documented weight loss outcome at 5 or more years postoperatively, with the overall mean %EWL at 5 or more years after LSG still remaining>50%. The existing data support the role of LSG in the treatment of morbid obesity.

BACKGROUND The emphasis for research in inguinal hernia repair has shifted from hernia recurrence to groin pain, which is considered the most important factor for poor quality of life. AIM : To evaluate hernia recurrences and pain at trocar site and at inguinal hernia site, in patients who underwent tacks-free transabdominal preperitoneal inguinal hernia repair, using a lightweight nonfixed 3-dimensional mesh with peritoneal suturing. MATERIALS AND METHODS Between 2009 and 2011, 32 patients (2 female) with mean age 51 years underwent hernia repair. The mean follow-up period was 12.4 months. RESULTS The mean operative time was 84 minutes. There was minimal blood loss. No bowel or urinary bladder injury had occurred. Mean hospital stay was 1 day. One patient developed seroma 4 months postoperatively. There were no conversions to open repair, no hernia recurrence, and no deaths. The mean value of pain at trocar site and inguinal hernia site 12 hours postoperatively was 1.469 and 0.875, respectively. The pain was more intense bearing a peak at 12 hours postoperatively at the trocar site, compared with the inguinal site. CONCLUSIONS It is demonstrated with this technique that there are no recurrences and the chronic pain is negligible. These findings call for confirmatory randomized trials in larger series with longer follow-up.

Background Since its introduction in the early 1990s, laparoscopic splenectomy (LS) has gained worldwide acceptance for spleen removal, especially in hematological patients. Aim The present review summarizes the current knowledge and results of LS for the treatment of benign hematological diseases in adults. Materials and methods A MEDLINE/PubMed database research was performed using the terms: "laparoscopic splenectomy" OR "laparoscopy" OR "splenectomy" AND "hematological disorders" OR "hematological disease" OR "hematology" AND "adults" as key words. We set our analysis starting date as January 1st 2010 and the end date as December 31st 2016. We identified 247 relative articles. All the references from the identified articles were searched for relevant information. Results Twenty-seven articles were deemed appropriate for our analysis. LS was found to be feasible and safe in the majority of patients with benign hematological disorders, with a mortality rate ranging from 0% to less than 4% and the postoperative complications rate from 0% to 35.7%. The conversion rate was also very low (4%) and response (complete or partial) was achieved in more than 80% of patients. Lateral approach with four trocars was the most commonly used approach with concommitant cholecystectomy being correlated with increased operative time and morbidity. Conclusion Current literature holds that whenever splenectomy is required for the treatment of hematological disorders in adults, a laparoscopic approach should be offered as the gold standard. However, to strengthen the clinical evidence in favor of LS, more high-quality clinical trials on several issues of the procedure are necessary.

After liver transplantation with a small-for-size liver graft or after extensive hepatectomy for liver malignancies or other non malignant conditions with an insufficient liver volume, the survival of patients depends on liver regeneration. This study was carried out in order to create a new porcine model for the study of small-for-size syndrome (SFSS) after extensive hepatectomy.In the present study we used 23 domestic Landrace pigs weighing 28.3±3 kg and aged 19-21 weeks. We describe our detailed surgical procedure for 75% partial hepatectomy a in porcine model, using the saline-coupled bipolar sealing device (Aquamantys®) for hepatectomy.The Aquamantis 2.3 bipolar sealer was connected to the Aquamantis generator and was adjusted to produce 150 watts at a medium flow rate of 20 ml/min. The device temperature was programmed to remain at approximately 100° C and, as a consequence, it produced a tissue ablation without charring. The mean operating time was 153.8 min and the mean blood loss 81.9 ml. The estimated residual liver weight (ERL) was 177 g, whereas the mean proportion of ERL was 24.5%. There was no perioperative mortality.A large animal model, such as pig, is extremely useful in order to reproduce and understand the SFSS. Our simple technique for successful resection of 75% of the liver in pigs, using the Aquamantys system, achieves effective and safe liver parenchymal transection with significant decrease of intraoperative blood loss and can provide useful information for researchers.

The role of hepatic hemodynamic modulation in the development of "small-for-size" syndrome (SFSS) after extended hepatectomy (EH) or living-donor liver transplantation is still controversial. We have designed an experimental study to investigate the effect of hemodynamic parameters of the liver circulation on the development of SFSS after EH in a porcine model.Eighteen pigs were randomly divided into two groups: group A has received EH (75%-80%) without splenectomy, and group B with EH and simultaneous splenectomy was carried out. Portal hemodynamics, liver function tests, histologic findings, injury and survival rates were compared between groups A and B.The 7-d survival rate in the splenectomy group was significantly improved compared with group A (88.9% versus 44.4%, P 0.05). Portal vein pressure, portal vein flow, and liver function tests in the splenectomy group were significantly lower than in group A immediately after splenectomy and postoperatively until the day of sacrifice. Histologic findings in group A clearly illustrate severe inflammation, bridging necrosis, ischemic cholangitis, and severe congestion, while in group B there were less serious histologic changes.Our experimental study indicates that perioperative portal modulation can successfully prevent the manifestation of SFSS after EH. Therefore, by focusing on "flow" rather than on "size," researchers may understand better the pathophysiology of this syndrome.

Background: Topographic correlation between the primary gastric tumor and the first peri- and extragastric lymphatic drain basin (solitary lymph node metastasis) on gastrectomy specimens, represents a reliable method to investigate and understand the exact pattern of lymphatic drainage from a gastric tumor. Analyzing that correlation, useful information regarding the extent of the appropriate oncological perigastric lymphadenectomy will be provided. We retrospectively evaluate the usefulness of a modified D2 lymphadenectomy in gastric cancer patients, based on the topographic correlation between the primary tumor and the location of the solitary lymph node metastases, as they were detected by histology and immunohistochemistry. Materials and Method: Between April 2003 and March 2010, 134 gastric cancer patients were submitted to a modified D2 lymphadenectomy. Postoperatively, the standard histological examination by hematoxylin and eosin (HE) staining, disclosed metastatic infiltration of at least two lymph nodes in 90 patients, solitary lymph node metastases were histologically detected in 10 patients, while the remaining 34 patients were classified as pN0. All lymph nodes of the ten patients with histological solitary lymph node metastases, as well as the 34 patients who had been classified as pN0 by histology, were further submitted to immunohistochemistry for micrometastases detection. More than one micrometastases were detected in none of them, while in seven patients solitary micrometastases were detected either in the level I perigastric or in the level II extragastric lymph nodes stations (skip micrometastases). Results: Solitary lymph node metastases were detected by histology in ten patients and by immunohistochemistry in additional seven (nine females and eight males). Solitary metastases were detected in the level I LN stations in seven patients (four by histology and three by immunohistochemistry) and in the level II LN stations in ten patients (six by histology and four by immunohistochemistry). In order of frequency, the solitary lymph node metastases were located in the no 7 (n = 6), no 6 (n = 4), no 9 (n = 2), no 5 (n = 2), no 4 (n = 1), no 8 (n = 1) and no 12 (n = 1) LN stations. Skip metastases encountered the 60% of the histologically detected, 57% of the immunohistochemically detected and 59% of all solitary lymph node metastases. 80% of solitary metastases in the level II LN stations, were mainly located in the nos 7–9 lymph node stations complex. Tumors of the lower and middle-third of the stomach were equally drained both to the level I and level II lymph node stations, while 67% of the tumors towards the lesser curvature, were mainly drained in the level II lymph node stations. Conclusion: D2 lymphadenectomy increases the number of true R0 resections. Thus, a modified D2 lymphadenectomy should be routinely performed in gastric cancer patients.

The aim was to evaluate whether patients with calcifications in the carotid region detectable by panoramic radiograph differ in the prevalence of risk factors for stroke development compared with those without calcifications.Forty consecutive individuals suffering from proven carotid artery atherosclerotic occlusive disease were submitted to carotid endarterectomy. Seventeen patients were symptomatic at the time of referral, having suffered at least 1 episode of ischemic cerebral event during the preceding 6 months, mainly transient ischemic attacks or amaurosis fugax, and the remaining 23 patients were asymptomatic and the diagnosis was reached during a thorough investigation of coexisting coronary or peripheral vascular disease. Preoperatively, all patients had undergone panoramic radiograph examination, as the presurgical protocol commanded. Based on the panoramic radiograph results, patients in whom calcifications were detected either unilaterally (n = 10) or bilaterally (n = 18) constituted group A (n = 28) and patients in whom no calcifications were detected constituted group B (n = 12) of this study.Univariate analysis among several risk factors for stroke development between the 2 groups of patients disclosed a stastistically significant lower incidence of diabetes mellitus (P = .005) but a higher incidence of symptomatic plaques (P.030) in the group of patients with detectable calcifications in the panoramic radiograph.Patients with calcified carotid plaques detectable by panoramic radiography are more likely to have suffered cerebrovascular events. Therefore, patients with detectable carotid plaque in panoramic radiographs require referral to their physician for further investigation.

Background: Oxaliplatin has become one of the major cytotoxic agents for the treatment of gastrointestinal tumors. As a result, several cases of the so-called oxaliplatin-associated hypersensitivity reaction have been documented. Patients and Methods: We have retrospectively evaluated and characterized these reactions in our patient group by reviewing the files of 1,224 patients exposed to an oxaliplatin-containing regimen in order to provide useful clinical information for diagnosis and management. Results: Three hundred and eight (308) patients who have never been exposed to platinum compounds developed symptoms compatible with a reaction to oxaliplatin that was verified by manifestation of at least similar symptoms on rechallenging. The reactions occurred after the first 5 courses, with a median course number of 9 (range 1–24). These reactions could be distinguished as (1) mild reactions occurring in 195 (63%) patients manifesting with itching and small area erythema either during treatment or within the next hours, and (2) severe reactions occurring in 113 (37%) patients within minutes of drug infusion manifesting with diffuse erythroderma, facial swelling, chest tightness, bronchospasm and changes in blood pressure. Oxaliplatin withdrawal was not required in patients with a mild reaction. Forty-eight (42%) patients having a severe reaction with appropriate premedication and prolongation of the infusion duration could tolerate 2–4 subsequent courses. For the remaining 65 (58%) patients, oxaliplatin withdrawal was inevitable because of the very severe reactions occurring on rechallenging. In addition, 3 patients presented with thrombocytopenia and 3 others with hemolytic anemia, all reversible upon oxaliplatin discontinuation. Conclusions: Hypersensitivity reactions to oxaliplatin are underestimated. Although the reactions are not frequent during first courses, in extensively pretreated patients, they may become a serious problem. In the majority of patients, drug discontinuation might not be necessary. In patients manifesting a severe reaction, re-exposure to oxaliplatin should be considered only if the patient can tolerate the reaction and there has been clinical benefit from this therapy. Physicians and nursing staff should be aware of the risk and be well prepared.

Objective The aim of this study was to evaluate the safety and effectiveness of percutaneous cholecystostomy without interval cholecystectomy as definitive treatment for acute cholecystitis in elderly or critically ill patients with various coexisting diseases who were unfit for surgery under general anesthesia. Design Between July 2004 and June 2006, 24 consecutive elderly and critically ill patients unfit for surgery, suffering from acute cholecystitis, and in whom significant comorbid factors were present, underwent percutaneous cholecystostomy as an emergency procedure at Laiko General Hospital. The diagnosis and the severity of acute cholecystitis were based on the Tokyo Guidelines, whereas the American Society of Anesthesiologists' (ASA) physical status classification was used for the perioperative risk stratification for cholecystectomy. Results There were 14 male and 10 female patients with a median age of 79 years. Acute cholecystitis was classified as grade 2 in 20 patients and as grade 3 in 4 patients; 17 patients were classified as ASA score III and 7 as ASA score IV, whereas a total of 52 comorbid factors were present. Gallstones were disclosed as the underlying etiology in 23 patients, whereas one patient was diagnosed as suffering from acalculous cholecystitis. Percutaneous cholecystostomy was technically feasible in all patients (100%). Clinical improvement was noticed in 14 patients within 24 hours and in all patients within 72 hours. Statistically significant reduction in the values of white blood cells, C-reactive protein, and axillary body temperature were observed within 72 hours. The procedure-related mortality was 4%, whereas within a median follow-up of 17.5 months, definitive and effective control of symptoms was achieved in 90.5% of the patients. Conclusions For the subgroup of extremely high-risk and unfit for surgery patients, percutaneous cholecystostomy might be considered as the definitive treatment since it controls the local symptoms and the systemic inflammatory response.

Background. Surgical treatment of hydatid liver disease (HLD) is divided into conservative and radical procedures. While conservative techniques are easier and faster to perform, there is an emerging need to reduce their morbidity and recurrence rates. Our aim was to present and evaluate the efficiency and safety of the application of radiofrequency energy (TissueLink® and Aquamantys® systems) in hepatic bed during partial cystectomy.Materials and Methods. Eighteen consecutive patients with hydatid liver cysts were referred to our department between April 2006 and June 2014. Data about demographics, mortality, morbidity, and recurrence rate were obtained and analyzed retrospectively.Results. The mean follow-up was 38 months (range: 4–84 months). The postoperative course of most patients was uneventful. One case of recurrence was found in our series in a patient with 4 cysts in the right lobe, 3 years after initial treatment. He was reoperated on with the same method.Conclusions. Saline-linked RF energy seems to be an effective means to be employed in conservative surgical procedures of HLD, with satisfactory postoperative morbidity. Recurrence rates appear to be low, but further follow-up is needed in order to draw safer conclusions.

Cystic hygroma is a congenital anomaly of lymphatic origin, which mainly develops during childhood. Its development in adulthood, however, has been proposed to be related to several predisposing factors such as trauma, infection, tumor growth or iatrogenic stimuli. The development of cystic hygroma in the extremities of adults is extremely rare and moreover, its development in the axillary region has, to our knowledge, been reported only once in the literature. We describe an unusual case of a cystic hygroma which developed rapidly in the axillary region of a female patient in the absence of any predisposing factor. The diagnostic workup and the need for surgical excision of the mass to obtain an accurate, histologic diagnosis is presented.

A 75-year-old woman suffering from symptomatic cholelithiasis was admitted to our hospital for elective laparoscopic cholecystectomy (LC). Intraoperatively, because of severe inflammation and dense adhesions in the region of the Calot triangle and bleeding arising from the porta hepatis which obscured the operating field, the method was converted to a conventional open approach. Copious hemostasis was achieved using sutures, clips and diathermy, and no bile duct or vascular injuries were recognized intraoperatively. Because of severe right upper quadrant abdominal pain and significant deterioration of the liver function tests (LFTs) on the first postoperative day, the patient underwent a Doppler ultrasound scan which showed absence of blood flow at the level of porta hepatis. Urgent relaparotomy revealed an ischemic liver on the right, a transected common bile duct at the level of its confluence, a divided and ligated right hepatic artery and thrombosed portal vein down to its confluence. Thrombectomy and reconstruction of the portal vein were performed to salvage the left hemiliver, and after restoration of blood flow to the left hemiliver, a right hemihepatectomy and a Roux-en-Y hepaticojejunostomy on the left were performed. Liver resection serves an important role in the case of parenchymal necrosis due to combined biliary, hepatic artery and portal vein injury following laparoscopic cholecystectomy and moreover, the operation can be safely performed in the acute setting.

Complete mesocolic excision (CME) for the treatment of colon cancer was first introduced in the West in 2008. The first aim of this procedure is to remove the afflicted colon and its accessory lymphovascular supply by resecting the colon and mesocolon in an intact envelope of visceral peritoneum, which holds potentially involved lymph nodes. The second component of CME is a central vascular tie to remove completely all lymph nodes in the central (vertical) direction. In its original iteration, CME was performed via laparotomy, although many centers preferentially perform laparoscopic surgery, with its associated benefits and similar oncological outcomes, as the standard treatment for colonic cancer. Here, we present the surgical techniques for CME in open and laparoscopic surgery, as well as the surgical, pathological and oncological outcomes of the procedure that are available to date. Because there are no randomized control trials comparing CME to "standard" colon surgery, the principles underlying CME seem anatomical and logical, and the results published from the Far East, reporting an 80% 5-year survival rate for Stage III cancer, should guide us.

Several studies addressed that preoperative endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct (CBD) clearance, followed by interval laparoscopic cholecystectomy (two-stage approach), constitutes the most common practice in cases of uncomplicated mild acute biliary pancreatitis. Between June 1998 and December 2002, 44 patients (35 females and 9 males with a median age of 62 years) suffering from uncomplicated mild acute biliary pancreatitis were treated in our unit. All patients were electively submitted to surgery after subsidence of the acute symptoms, and for definitive treatment we favored the single-stage laparoscopic management, avoiding preoperative ERCP. All patients underwent laparoscopic cholecystectomy plus fluoroscopic intraoperative cholangiogram (IOC). If filling defect(s) were detected in the IOC, a finding suggestive of concomitant choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) was added in the same sitting. Twenty patients were operated upon within 2 weeks since the attack of the acute symptoms and constitute the early group (n = 20), whereas 24 patients underwent an operation later on and constitute the delay group (n = 24). We retrospectively compare the safety, effectiveness, and outcome after the single-stage laparoscopic management between the two groups of patients. Laparoscopic cholecystectomy alone constituted the definitive treatment in 38 patients, while an additional LCBDE was performed in the remaining 6 patients (14%), and all operations were achieved laparoscopically. There was no statistically significant difference between the groups in terms of operative time, incidence of concomitant choledocholithiasis, morbidity rate, and postoperative hospital stay. During the follow-up, none of the patients experienced recurrent pancreatitis. In uncomplicated mild acute biliary pancreatitis cases, a single-stage definitive laparoscopic management, avoiding preoperative ERCP, can be safely performed during the same admission, after the improvement of symptoms and local inflammation. Postoperative ERCP should be selectively used in patients in whom the single-stage method failed to resolve the problem.

Background: Recent reports have noted that postoperative complications following open or laparoscopic choledochotomy for common bile duct (CBD) exploration are mainly related to the T-tube presence, and that there has been no trend of decrease in the laparoscopic era. Laparoscopic endobiliary stent placement with primary closure of the CBD has been proposed as a safe and effective alternative to T-tube placement. Methods: Between January 1999 and January 2003, 53 consecutive patients suffering from proven choledocholithiasis underwent laparoscopic common bile exploration (LCBDE) via choledochotomy. In the early period, a T-tube was placed at the end of the procedure (group A, n = 32) while, from June 2001 onwards, laparoscopic biliary stent placement and primary CBD closure were chosen as the drainage method (group B, n = 21). Results: Six patients developed T-tube-related complications postoperatively. Univariate analysis revealed statistically significant lower morbidity rate and shorter postoperative hospital stay for the stent group. Although not statistically significant, a median saving of £780 per patient was observed in the stent group. Conclusion: Biliary endoprosthesis placement following laparoscopic choledochotomy avoids the well-known complications of a T-tube, leading to a shorter postoperative hospital stay. The method is safe and effective and it should also be considered as cost-effective compared to T-tube placement. Further studies are required in order to document cost-effectiveness of the method.

Background. To evaluate the effect of timing of management and intervention on outcomes of bile duct injury.Materials and Methods. We retrospectively analyzed 92 patients between 1991 and 2011. Data concerned patient’s demographic characteristics, type of injury (according to Strasberg classification), time to referral, diagnostic procedures, timing of surgical management, and final outcome. The endpoint was the comparison of postoperative morbidity (stricture, recurrent cholangitis, required interventions/dilations, and redo reconstruction) and mortality between early (less than 2 weeks) and late (over 12 weeks) surgical reconstruction.Results. Three patients were treated conservatively, two patients were treated with percutaneous drainage, and 13 patients underwent PTC or ERCP. In total 74 patients were operated on in our unit. 58 of them underwent surgical reconstruction by end-to-side Roux-en-Y hepaticojejunostomy, 11 underwent primary bile duct repair, and the remaining 5 underwent more complex procedures. Of the 56 patients, 34 patients were submitted to early reconstruction, while 22 patients were submitted to late reconstruction. After a median follow-up of 93 months, there were two deaths associated with BDI after LC. Outcomes after early repairs were equal to outcomes after late repairs when performed by specialists.Conclusions. Early repair after BDI results in equal outcomes compared with late repair. BDI patients should be referred to centers of expertise and experience.

Background Ectopic liver tissue is occasionally found either attached to the gallbladder or elswhere in the upper abdomen. Case Outlines A 49-year-old man and a 39-year-old woman were found to have a tongue of liver tissue attached to the serosa of the gallbladder (but separate from the liver) during laparoscopic cholecystectomy for gallstones. The ectopic liver was removed with the gallbladder and was histologically normal in each case. Discussion Several embryological hypotheses have been advanced to explain the development of ectopic liver. The anomaly is usually discovered incidentally at operation. Although the tissue is histologically normal.it can develop the same conditions as orthotopic liver.

Biliary endoprosthesis has been proposed as an alternative to T-tube placement after laparoscopic choledochotomy in an attempt to eliminate the complications associated with T-tubes. Biliary endoprostheses have been, until now, placed under fluoroscopic guidance. We present a modification of Gersin's method for endoprosthesis placement under direct vision.As of July 2001, seven patients who fulfilled the criteria for common bile duct (CBD) exploration through a choledochotomy, a biliary endoprosthesis was inserted under direct vision at the end of the procedure with primary closure of the CBD above it. In all cases, plastic biliary stents 10F in diameter were used ranging from 5 to 10 cm in length. We describe in detail the technique of CBD stent placement using the choledochoscope as the advancing device. We also propose the use of intraoperative cholangiography instead of on-table endoscopy to check the final correct position of the stent.The median postoperative hospital stay was 2 days. Two patients developed transient hyperamylasemia in the immediate postoperative period. None of the patients developed short-term complications (30 days), namely bile leak, CBD erosion, stent occlusion, or stent migration. The long-term results revealed early return to full daily activities and normal liver function tests. Stents were removed endoscopically 4 weeks after the initial procedure except in two patients who spontaneously passed them.We propose a 10F 10-cm biliary endoprosthesis placed under direct vision as a safe, effective, time-sparing, and cost-effective adjunct to CBD exploration through a choledochotomy. Placement of the endoprosthesis is associated with low morbidity and eliminates the complications related to T-tubes.

Resumen Introduccion En la actualidad no esta claro cual es el mejor abordaje para la coledocolitiasis con vesicula in situ. Recientemente en algunos centros se ha adoptado la exploracion laparoscopica de la via biliar (ELVB) como tecnica de eleccion. Material y metodos Presentamos la experiencia de ELVB en una unidad con especial interes en cirugia laparoscopica. Durante 30 meses 44 pacientes con una edad mediana de 65 anos y sospecha de litiasis de la via biliar principal fueron intervenidos por laparoscopia. Resultados En mas del 90% se completo la extraccion de calculos laparoscopicamente y solo un paciente requirio conversion a cirugia abierta. Un 18% presento complicaciones y hubo un fallecimiento en un paciente de 75 anos debido a una complicacion con el tubo en “T”. Conclusiones Consideramos que, en manos entrenadas, el abordaje laparoscopico de la via biliar tiene al menos los mismos resultados que el abordaje tradicional (colangiopancreatografia retrograda endoscopica [CPRE]) con menos ingresos y probablemente inferior mortalidad en el grupo de enfermos jovenes.

OBJECTIVE: Gastric neuroendocrine neoplasms Type 1 (GEN type 1) are mostly localized indolent tumors, with only a minority developing lymph node or distant metastasis. Although they are usually managed conservatively, large, invasive, recurrent and grade 2 lesions may require surgical treatment. The aim of this case series is to evaluate the validity of current guidelines regarding surgical management of patients with GEN type 1. CASES: Seven patients (5 female) with GEN type 1 underwent peri-gastric lymphadenectomy when at least one of the following criteria employed in previous guidelines was present: (i) multiple recurrent lesions, (ii) lesions with positive margins following endoscopic resection, (iii) lesions with malignant potential (deep gastric parietal wall invasion, lymph node enlargement, Ki67 proliferative index >2%), or (iv) presence of metastatic disease. Four patients met one and three two of the previously defined criteria; fifteen to thirty-six peri-gastric lymph nodes were resected. Following surgery there was no alteration in tumor staging status compared to pre-surgical staging. During a median follow-up of 34 months, all patients remain without any evidence of disease recurrence. CONCLUSION: Peri-gastric lymphadenectomy did not prove to be necessary for localized GEN type 1, neither for staging nor for therapeutical reasons. Further parameters need to be evaluated to identify the small subset of patients that will develop more aggressive disease.

The Rapunzel syndrome refers to an uncommon and rare form of trichobezoar that extends past the stomach into the small intestines. The Rapunzel syndrome is usually found in young female patients with a history of psychiatric disorders, mainly trichotillomania and trichophagia. We describe a case of Rapunzel syndrome in a 15-year-old girl who presented with abdominal pain, vomiting, and weight loss. We performed a surgical laparotomy and successfully removed a huge trichobezoar extending into the small intestine.

True ectopic mediastinal thyroid goiters are rare devel- opmental anomalies, accounting for less than 1% of all thyroid ectopies, whereas Graves disease in an ectopic mediastinal thyroid goiter has been reported only twice in the international literature. A 51-year-old female patient with poorly controlled hyperthyroidism, secondary to Graves disease was referred to our unit for thyroidec- tomy. A preoperative thyroid scan disclosed an ectopic thyroid goiter below the lower pole of the left thyroid lobe completely isolated from the cervical pretracheal thyroid gland. Intraopera- tively, an ectopic mass, macroscopically compatible to thyroid tissue, attached to the posterior surface of the left upper horn of the thymus gland, was found. The patient underwent total thyroid- ectomy followed by resection of the ectopic goiter. Histologic examination confirmed the thyroid nature of the ectopic tissue, showing findings compatible with Graves disease, in both the thyroid gland and the ectopic tissue. There were also loci of papillary carcinoma in the cervical thyroid gland. When a pretra- cheal thyroidectomy for symptomatic thyroid disease is planned, preoperative thyroid scan should be performed to detect possible ectopic thyroid tissue. The English literature reports that untreated ectopic mediastinal thyroid tissue can lead to failure to cure the hyperthyroidism in Graves disease or leave untreated coexisting malignancy in the ectopic tissue.

Abscesses and cellulitis represent the leading causes for emergency department visits and hospital admissions for intravenous drug addicts’ patients. Since these patients frequently use the neck for vascular access, neck abscesses are also commonly developed causing serious airway problems. A 28-year old Intravenous Drug Addict (IVDA) Caucasian male patient, presented to the casualty Department due to progressive neck swelling and pain after self-administered, unsterile, deep-cervical intravenous injection of heroin. Emergency contrast computed tomography scan revealed a large abscess causing significant dislocation of the trachea. The patient was urgently treated by percutaneous neck abscess drainage, via an 8Fr catheter, under ultrasound guidance Emergency computed tomography scan of the affected area and ultrasound scan of the major vascular supply are helpful in designing the therapeutic approach in terms of percutaneous drainage or surgery in cases of neck abscess that may cause airway obstruction in intravenous drug addicts. Percutaneous drainage under ultrasound guidance represents an effective treatment option relieving the life threatening trachea dislocation and eliminating the need for surgical intervention.

We present a 63-year-old man who wasinvestigated for a lesion in the apex of theleft lung and a coexisting osteolytic lesion inthe right major trochanter. FNA of the thoracicmass was suggestive for malignancy yet notdiagnostic regarding the tumor type and thesite of the primary tumor. A diagnosis of astage IV lung cancer was favored and heunderwent a left exploratory thoracotomy inview to resect the primary tumor. Anextrapulmonary mass localized to the pleura notinvolving the ipsilateral lung was disclosed.Multiple biopsies revealed metastatic clearcell RCC. A 5×7 cm left renal tumor wasrevealed in a postoperative abdominal CT scan.He was treated with combination of interferon Aand vinblastin followed by radical nephrectomy.Twenty-four months after the diagnosis he is alivewithout evidence of local or distant recurrence.Pleural metastases from RCC are mainlypresented as malignant pleural effusions.Thoracic metastatic lesions localized to thepleura, forming solitary or multiple mass(es)have been rarely reported. We review theliterature regarding this rare clinicalmanifestation of the disease and we discussdiagnostic and therapeutic options.

The combination of docetaxel, cisplatin and fluorouracil is considered to be one of the reference regimens for advanced gastric cancer, but due to its major myelotoxicity, its use in clinical practice has become limited. This prospective phase II study evaluated the activity and toxicity of a modified regimen with lower doses of docetaxel and cisplatin combined with oral capecitabine instead of fluorouracil for patients with advanced gastric cancer. Treatment consisted of docetaxel at 60 mg/m(2) i.v. followed by cisplatin at 60 mg/m(2), both administered on day one, every three weeks. Capecitabine at 2 g/m(2) per day was administered in two divided doses for 14 days (days 2-15). Thirty six patients were enrolled in the study. The median age was 64 years and performance status (ECOG) was 0-1. All patients had advanced disease, 78% with liver metastases, 100% with intra-abdominal lymph node metastases and 67% with peritoneal implants. Out of the 36 patients, 13 had undergone gastric resection, 13 had received adjuvant chemotherapy with irinotecan-leucovorin-fluorouracil, while seven patients had undergone adjuvant radiotherapy. The remaining 23 patients presented with advanced inoperable disease. Among 36 evaluable for response cases, there were 16 (44.4%) (Confidence Internal (CI) 95%=28-60%), partial responses. Stable disease was recorded in 12 (33.3%), resulting in an overall disease control rate of 78% (CI 95%=69-87%), while 8 (22.3%) patients progressed on chemotherapy. The median response duration was 6 (range=3-8) months. The median time-to-progression was 5 (range=3-6) months and the median survival (after the administration of a second-line chemotherapy in 12 patients), was 12 (range=5-24) months. Myelotoxocity was the main toxicity, with grade 3-4 neutropenia occurring in 18 (50%) and febrile neutropenia in six (16%) patients. Granulocyte-Colony Stimulating Factor (G-CSF) support was given to 16 (44.4%) patients, while grade 3 thrombocytopenia was recorded in two (6%). In conclusion, this modified regimen of docetaxel-cisplatin-capecitabine appears to have comparable efficacy with that reported for the reference regimen, with acceptable toxicity when G-CSF support is provided. However, because due to the small size of the study, further investigation is warranted.

The 7th TNM classification clearly states that micrometastases detected by morphological techniques (HE stain and immunohistochemistry) should always be reported and calculated in the staging of the disease (pN1mi or M1), while patients in whom micrometastases are detected by non-morphological techniques (e.g., flow cytometry, reverse-transcriptase polymerase chain reaction) should still be classified as N0 or M0. In gastric cancer patients, micrometastases have been detected in lymph nodes, the peritoneal cavity and bone marrow. However, the clinical implications and/or their prognostic significance are still a matter of debate. Current literature suggests that lymph node micrometastases should be encountered for the loco-regional staging of the disease, while skip lymph node micrometastases should also be encountered in the total number of infiltrated lymph nodes. Peritoneal fluid cytology examination should be obligatorily performed in pT3 or pT4 tumors. A positive cytology classifies gastric cancer patients as stage IV. Although a curative resection is not precluded, these patients face an overall dismal prognosis. Whether patients with a positive cytology should be treated similarly to patients with macroscopic peritoneal recurrence should be evaluated further. Gastric cancer cells are detected with high incidence in the bone marrow. However, the published results make comparison of data between groups almost impossible due to severe methodological problems. If these methodological problems are overcome in the future, specific target therapies may be designed for specific groups of patients.

Introduction. Laparoscopic greater curvature plication is an operation that is gaining ground in the treatment of morbid obesity, as it appears to replicate the results of laparoscopic sleeve gastrectomy with fewer complications.Aim. Review of current literature, especially results on weight loss and complications.Method. 11 (eleven) published articles on laparoscopic gastric plication, of which 1 preclinical study, 8 prospective studies for a total of 521 patients and 2 case reports of unusual complications.Results. Reported Paracentage of EWL in all studies is comparable to Laparoscopic Sleeve Gastrectomy (around 50% in 6 months, 60–65% in 12 months, 60–65% in 24 months) and total complication rate is at 15,1% with minor complications in 10,7%, major complications in 4,4%. Reoperation rate was 3%, conversion rate was 0,2%, and mortality was zero.Conclusion. Current literature on gastric plication and its modifications is limited and sketchy at times. Low cost, short hospital stay, absence of prosthetic material, and reversibility make it an attractive option. Initial data show that LGCP is effective for short- and medium-term weight loss, complication and reoperation rates are low, and GERD symptoms are unaffected. More data is required, and randomized control trials must be completed in order to reach safe conclusions.

Background: Appendiceal carcinoids (AC) are usually adequately treated by appendectomy. The European Neuroendocrine Tumours Society (ENETS) has recently reconsidered the previous pathologic criteria to identify patients at high risk of extra-appendiceal disease, who are thought to require right hemicolectomy (RHC). Aim: The aim of this retrospective, observational study was to evaluate previous and currently introduced criteria, in identifying patients with AC in whom RHC is justified. Subjects and methods: Twelve patients who underwent RHC for AC were retrospectively identified. Demographic and follow-up data were collected and appendectomy specimens were reviewed for the presence of indications leading to RHC defined as: tumor diameter ≥2 cm, tumor location at the base, mesoappendiceal extension, mitotic index Ki-67≥2%. RHC specimens were examined to identify evidence of extra-appendiceal disease, remaining and/or metastatic disease. Results: Four patients fulfilled two criteria and 8 one criterion for RHC. Two patients had tumors ≥2.0 cm, 5 located at the base, 8 invading the mesoappendix and periappendiceal fat; Ki-67 PI was 1% in all cases measured except one, in which it was 3%. Post-RHC, 3 patients (25%) had extra-appendiceal disease (no residual disease was identified in surgical margins); 1 had tumor at the colon specimen and 2 had lymph node metastasis. All 3 patients fulfilled only one pathologic criterion; 1 had tumor mesoappendiceal extension and 2 tumor location at the base of the appendix. Conclusions: Applying previous and currently introduced pathologic criteria, 25% of high-risk patients with AC had identifiable extra-appendiceal disease following RHC that might be not detected following the recently introduced ENETS criteria.