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Hypoglycemia due to endogenous hyperinsulinism (EH) is diagnosed in a symptomatic patient with low levels of plasma glucose concomitant with elevated plasma insulin and C-peptide. Causes of EH are pancreatic islet-cells disease, use of insulin secretagogues, and autoimmune hypoglycemia. In this review, the authors studied 24 patients with hypoglycemia due to endogenous hyperinsulinism in order to describe aspects of diagnosis and treatment. Our study demonstrated that after 12 hours of fasting (mini-fasting test; at least three samples), all patients presented the diagnostic criteria for EH. Additionally, we found that 11 of 12 patients (91.7%) who underwent glucagon test achieved glucose levels less than 50 mg/dL and below baseline after 120 minutes. Mini-fasting (3 samples) and glucagon test may be useful to prevent prolonged fasting test to clarify the diagnosis of endogenous hyperinsulinism.

Background: Pancreatic ductal adenocarcinoma (PDAC) is known by its aggressiveness and lack of effective therapeutic options. Thus, improvement in current knowledge of molecular changes associated with pancreatic cancer is urgently needed to explore novel venues of diagnostics and treatment of this dismal disease. While there is mounting evidence that long noncoding RNAs (lncRNAs) transcribed from intronic and intergenic regions of the human genome may play different roles in the regulation of gene expression in normal and cancer cells, their expression pattern and biological relevance in pancreatic cancer is currently unknown. In the present work we investigated the relative abundance of a collection of lncRNAs in patients' pancreatic tissue samples aiming at identifying gene expression profiles correlated to pancreatic cancer and metastasis., Methods: Custom 3,355-element spotted cDNA microarray interrogating protein-coding genes and putative lncRNA were used to obtain expression profiles from 38 clinical samples of tumor and non-tumor pancreatic tissues. Bioinformatics analyses were performed to characterize structure and conservation of lncRNAs expressed in pancreatic tissues, as well as to identify expression signatures correlated to tissue histology. Strand-specific reverse transcription followed by PCR and qRT-PCR were employed to determine strandedness of lncRNAs and to validate microarray results, respectively., Results: We show that subsets of intronic/intergenic lncRNAs are expressed across tumor and non-tumor pancreatic tissue samples. Enrichment of promoter-associated chromatin marks and over-representation of conserved DNA elements and stable secondary structure predictions suggest that these transcripts are generated from independent transcriptional units and that at least a fraction is under evolutionary selection, and thus potentially functional.Statistically significant expression signatures comprising protein-coding mRNAs and lncRNAs that correlate to PDAC or to pancreatic cancer metastasis were identified. Interestingly, loci harboring intronic lncRNAs differentially expressed in PDAC metastases were enriched in genes associated to the MAPK pathway. Orientation-specific RT-PCR documented that intronic transcripts are expressed in sense, antisense or both orientations relative to protein-coding mRNAs. Differential expression of a subset of intronic lncRNAs (PPP3CB, MAP3K14 and DAPK1 loci) in metastatic samples was confirmed by Real-Time PCR., Conclusion: Our findings reveal sets of intronic lncRNAs expressed in pancreatic tissues whose abundance is correlated to PDAC or metastasis, thus pointing to the potential relevance of this class of transcripts in biological processes related to malignant transformation and metastasis in pancreatic cancer., (© 2011 Tahira et al; licensee BioMed Central Ltd.)

Background: The in vitro culture of insulinomas provides an attractive tool to study cell proliferation and insulin synthesis and secretion. However, only a few human beta cell lines have been described, with long-term passage resulting in loss of insulin secretion. Therefore, we set out to establish and characterize human insulin-releasing cell lines., Results: We generated ex-vivo primary cultures from two independent human insulinomas and from a human nesidioblastosis, all of which were cultured up to passage number 20. All cell lines secreted human insulin and C-peptide. These cell lines expressed neuroendocrine and islets markers, confirming the expression profile found in the biopsies. Although all beta cell lineages survived an anchorage independent culture, none of them were able to invade an extracellular matrix substrate., Conclusion: We have established three human insulin-releasing cell lines which maintain antigenic characteristics and insulin secretion profiles of the original tumors. These cell lines represent valuable tools for the study of molecular events underlying beta cell function and dysfunction.

Background: Experience with laparoscopic procedures and recent advances in laparoscopic devices have created an evolving interest in the application of these techniques to liver resection. However, laparoscopic liver resection has not been widely developed and anatomical segmental liver resection is not currently performed due to difficulty to control segmental Glissonean pedicles laparoscopically., Methods: Seven consecutive patients underwent laparoscopic liver resection using an intrahepatic Glissonian approach from April 2007 to September 2007. Three patients underwent laparoscopic bisegmentectomy 6-7 and 4 patients underwent laparoscopic right hemihepatectomy., Results: Blood transfusion was required in 1 patient. Mean operation time was 460 minutes (range 300-630 minutes). The median hospital stay was 5 days (range 3-8 days). One patient developed bile leakage that was treated conservatively. No patient had postoperative signs of liver failure. No postoperative mortality was observed., Conclusions: The main advantage over other techniques is the possibility to gain a rapid and precise access to the right posterior and anterior sheaths facilitating right hemihepatectomy, and right anterior and posterior sectionectomies. We believe that the described technique facilitates laparoscopic liver resection by reducing the technical difficulties in pedicle control and may increase the development of segment-based laparoscopic liver resections.

The authors describe their initial experience and immediate results with laparoscopic liver resection in the treatment of four patients with liver metastasis. Three patients underwent laparoscopic anatomic bisegmentectomy 6-7 and one laparoscopic right hemihepatectomy. Mean operation time was 360 minutes and median hospital stay was 4 days. One patient developed bile leakage that was treated conservatively. No postoperative mortality was observed. This initial experience demonstrates that laparoscopic liver resection can be safely done with excellent immediate results. However larger and comparative studies are still needed to establish indications and limits for laparoscopy in the treatment of liver metastasis.

Development of immunity to hepatitis B virus in cirrhotic patients waiting for liver transplantation is highly desirable. Though a double-dose regimen is available, little is know about its effectiveness. We examined the efficacy of double-dose hepatitis B virus vaccination in cirrhotic patients waiting for liver transplantation. We studied 43 patients who were waiting for liver transplantation. They were vaccinated with three doses of 40 mg hepatitis B vaccine at 0, 1 and 6 months; the normal dose is 20 microg. Efficacy was measured based on seroconversion of anti-HBs. Global response to the primary vaccination scheme was 67.5% (29 patients). Forty-one per cent of responders had anti-HBs titers above 1,000 IU/mL. No factors were associated with response, based on multivariate analysis. The vaccination scheme of 40 microg at 0, 1 and 6 months was superior to conventional vaccination doses (20 microg) for cirrhotic patients on a waiting list for liver transplantation.

Background: Solid pseudopapillary neoplasm of the pancreas is a distinctive pancreatic neoplasm with low metastatic potential. This study examines clinical differences and prognosis between male and female patients., Methods: The medical records of 34 consecutive patients with pancreatic solid pseudopapillary neoplasms between 1990 and 2006 were reviewed. Whenever feasible, organ-preserving operation was performed. Statistical analysis was performed using chi-square and Student t test., Results: There were 27 women (79%) and seven men (21%) with median age of 23 years. Mean diameter of the tumor was 7 cm. Tumor size tended to be smaller in patients treated in more recent years. Conservative surgery was possible in 11 patients including spleen-preserving distal pancreatectomy in 3, central pancreatectomy in 5, and enucleation in 3 patients. Median hospital stay was 11 days, morbidity rate was 62%, including 17 patients with grade A pancreatic fistula, and there was no operative mortality. Mean follow-up time was 84 months. Tumor recurred in 2 patients (6%). Overall late morbidity rate was 12%. At the time of diagnosis, age was (x +/- SD) higher among male patients (25 +/- 2 years vs 37 +/- 7 years; P <.05) with no difference in tumor size. The neoplasms were more aggressive in male patients; therefore, conservative surgery was less likely. There was no correlation between tumor aggressiveness and age of the patient or size of tumor., Conclusion: This is the first single center study to demonstrate that solid pseudopapillary neoplasms in male patients have distinct patterns of onset and aggressiveness when compared with female patients. Although valid prognostic criteria are still lacking, it appears that male patients may be best treated by more radical operation and should be observed more closely during follow-up.

Unlabelled: We analyzed the opinion and understanding of medical students about organ donation and transplantation., Methods: 347 students voluntarily completed a questionnaire with 17 queries concerning organ donation and transplantation. They were analyzed to identify general tendencies and divided into five groups, according to their year of study (first through sixth year), to assess differences among the years. Students of the fifth and sixth years were placed in the same group. Results were analyzed by the Chi-square test., Results: The intention to become a post mortem or living donor was of 89% and 90% respectively; however, only 62% were aware of living donation risks. 70% of the 347 students admitted regular or little knowledge of the subject, 90.2% considered organ transplantation an important issue for a medical graduation program, 76.9% considered informed/expressed consent the best organ donation criterion and 64.3% of them chose severity of patient disease as the best allocation condition. As students progressed in their studies their understanding about transplantation improved. Students of the fourth, fifth and sixth year manifested a negative attitude about organ donation to alcohol addicts, non donors, drug users, law offenders and foreigners., Conclusion: This data show the great interest and positive attitude of medical students toward organ donation and transplantation, despite the fact that most of them admitted having insufficient knowledge on the subject. A negative attitude by students of the fourth, fifth and sixth year on organ donation to alcohol addicts, non donors, drug users, law offenders and foreigners was also observed.

Background: Progress in liver surgery has enabled hepatectomy with concomitant venous resection for liver malignancies involving the inferior vena cava (IVC). The authors describe an alternative technique for IVC reconstruction without the need of graft., Methods: Parenchymal transection is performed from anterior surface of the liver down to the anterior or left lateral surface of the IVC using combination of two techniques reported elsewhere. IVC is clamped above and below the tumor and the liver in continuity with an invaded segment of IVC is removed en bloc. A transverse anastomosis of IVC is performed starting with running suture on the posterior wall followed by the anterior wall., Results: This approach has been successfully employed in eight consecutive patients with IVC involvement. The procedures performed were 5 right hepatectomies, 1 right posterior sectionectomy, 1 right trisectionectomy, and 1 left trisectionectomy. Two patients needed total vascular exclusion (TVE) for 11 and 10 min, respectively. Blood transfusion was necessary in three patients. Pathologic surgical margins were free in all cases. No postoperative mortality was observed., Conclusion: This technique of IVC reconstruction precludes the use of graft and minimizes the use of TVE decreasing ischemic damage to the remnant liver., (Copyright 2007 Wiley-Liss, Inc.)

Objective: There is evidence that endothelin (ET) 1 affect neutrophil functions and that patients with severe acute pancreatitis have increased plasma levels of ETs. Under appropriate conditions, neutrophils are able to injure the endothelium. In the present study, we compared healthy donors with acute pancreatitis patients for neutrophil degranulation and its ability to injure the endothelium and the contribution of ET-1 to this injury., Methods: Injury was evaluated by measuring the detachment of endothelial cells (ECV-304) growing in monolayer in coculture with human neutrophils for 4 hours. Neutrophil degranulation was assessed by myeloperoxidase (MPO) activity in coculture supernatants. In some experiments, neutrophils were pretreated with the antagonist of ET(A) receptor (BQ-123, 10(-6) M), which has high affinity for ET-1., Results: Neutrophils from both healthy donors and acute pancreatitis patients caused detachment of endothelial cells, and levels of MPO activity were increased in coculture supernatants. Neutrophils from acute pancreatitis patients caused significantly higher levels of detachment and MPO in the supernatants. Pretreatment of neutrophils with BQ-123 inhibited the detachment caused by neutrophils from healthy donors but not by neutrophils from acute pancreatitis patients., Conclusions: These results show that neutrophils taken from healthy donors damage the endothelium by a mechanism dependent on ETs acting via ET(A) receptor, whereas neutrophils from acute pancreatitis patients cause more severe damage that is not dependent on ETs in the in vitro system used.

Unlabelled: BACKGROUND Hepatic ischemia-reperfusion injury is responsible for a considerable morbidity and mortality., Aim: To evaluate the effect of a platelet glycoprotein IIb/IIIa receptor inhibitor (tirofiban) on hepatic and pulmonary disturbances associated with hepatic ischemia-reperfusion injury., Methods: Twenty-three Wistar rats divided in three groups: rats sham-operated (n = 6), rats submitted to ischemia-reperfusion that received saline solution (n = 8), and rats submitted to ischemia-reperfusion treated with 0.7 mg/kg of tirofiban (n = 9). Serum aminotransferases (AST and ALT) were also determined, and the study of hepatic tissue histology was carried out. The evaluation of the pulmonary disturbances was done using the Evans blue test and the tissular determination of myeloperoxidase. Hepatic mitochondrial oxidation and phosphorylation were also measured., Results: There was an increase in the state 3 respiration, ADP/O ratio and respiration control rate in the group treated with tirofiban. This group had also lower levels of aminotransferases and the histological findings were significantly less intense. Pulmonary evaluation demonstrated decrease of the Evans blue test in the tirofiban group and an increase of its tissular determination of myeloperoxidase., Conclusion: The inhibition of glycoprotein IIb/IIIa receptor with tirofiban protected the hepatic disturbances and prevented the increase of pulmonary vascular permeability secondary to the ischemia-reperfusion injury of the liver.

Background/aims: Obesity and diabetes mellitus (DM) are associated with pancreatic cancer. The present study evaluated tumor staging and resection of pancreatic adenocarcinoma (PaC) according to previous Body Mass Index (BMI), BMI on admission and DM duration., Methods: A retrospective analysis of 151 consecutive patients with PaC was performed: 73 were evaluated according to BMI preceding tumor-related weight loss and BMI on admission; 118 according to DM diagnosis; and 38 were assessed according to DM duration (less than 1 year [recent-onset] versus more than 2 years [long-standing])., Results: There was no difference in the prevalence of tumor stage III or IV between previously normal weight and overweight/obese patients (56 vs. 42%, NS). Tumor resection rate was higher in previously obese than in previously lean patients (58 vs. 24%, p < 0.05). Tumor staging and resection were similar between normal weight and overweight/obese patients considering BMI on admission and diagnosis of DM. Weight loss was more pronounced in diabetic than in non-diabetic patients (21.7 vs. 13.3%, p < 0.01). Tumor staging and resection were similar between recent-onset and long-standing diabetic patients., Conclusion: Tumor resection rate was lower in previously normal weight patients. Diabetics lost more weight than non-diabetic patients. Neither BMI on admission nor the presence of DM nor DM duration influenced tumor staging or resection in PaC patients., ((c) 2007 S. Karger AG, Basel and IAP.)

Background: Parenchymal transection is the most important step of liver resection, and during this phase, blood loss may lead to morbidity and mortality. Liver parenchyma can be transected by different ways such as finger fracture, clamp crushing, or instrument-based techniques., Methods: A simple and cost-efficient method has been developed for liver transection using a technique based on silk crushing of the liver substance., Results: We have successfully employed this technique in 278 consecutive liver resections from July 2001 to March 2006. The average duration of hepatic transection varied according to the type of liver resection: 22 min (range 15-42), 19 min (range 11-37), and 12 min (range 7-21) for right hepatectomy, left hepatectomy, and bisegmentectomy 2-3, respectively. The mean transection speed was 6.9 +/- 2.3 cm(2)/min. Blood transfusions were necessary in 42 patients (15.1%), and there were three operative deaths (1.1%). Morbidity rate was 20.9% (58 patients)., Conclusions: This technique allows a safe and quick liver transection without the use of expensive hemostatic devices, and also precludes the use of inflow occlusion maneuvers. We recommend the use of this technique in centers with low economic resources.

Background/aim: During acute experimental pancreatitis, inflammatory mediators/cytokines are released by the pancreas and enter the portal venous system, reaching the liver. We investigate some aspects of the liver cell function under conditions of acute pancreatitis and the effect of in vivo treatment with a selective platelet-activating factor (PAF) antagonist., Methods: Cells were isolated from Wistar rats 24 h after induction of acute pancreatitis by retrograde injection of sodium taurocholate into the main pancreatic duct. The non-parenchymal cell population was separated by Percoll gradient and the adherent cell population (Kupffer cells) obtained. The cells were cultured for 24 h and supernatants assayed for nitrite by Griess reaction and for tumour necrosis factor (TNF) by bioassay in L929 cells. The microbicidal activity was evaluated by killing of Candida albicans. The PAF antagonist WEB2170 (10 mg/kg i.v.) was administered 30 min before induction of pancreatitis., Results: We found that liver cells produce nitric oxide (NO) only under lipopolysaccharide stimulation and that WEB-2170 treatment reduces the NO production by liver cells in the pancreatitis group only. Cells from both groups produced TNF spontaneously, and the levels were further increased after lipopolysaccharide stimulation. WEB-2170 treatment did not affect the TNF levels. Moreover, killing of C. albicans by Kupffer cells wassignificantly increased by the PAF antagonist., Conclusion: These results suggest that PAF released during acute pancreatitis upregulates the NO production by non-parenchymal liver cells and inhibits Kupffer cell microbicidal activity which could explain the increased bacterial dissemination observed in acute pancreatitis.

The main goal of segmental technique is to preserve the maximum amount of liver parenchyma. Liver-preserving techniques are especially important for patients with hepatocellular carcinoma and cirrhosis. We report the technique for segmental liver resection in cirrhotic patients and detail technical difficulties and immediate surgical outcome. For right segmental liver resections the intrahepatic access is performed through small incisions around the hilar plate. Left segmental resection technique also consists of small incisions following specific anatomic landmarks. Nineteen cirrhotic patients underwent segmental liver resections. A blood transfusion was required in 2 patients. No patient experienced major bleeding from the liver incisions made for intrahepatic access. The median hospital stay was 5 days. No surgical mortality occurred. The intrahepatic access technique allows individual resections of liver segments and is feasible even in cirrhotic patients. Knowledge of segmental liver resection techniques is an essential armamentarium in the modern era of liver surgery.

Unlabelled: During orthotopic liver transplantation for fulminant hepatic failure, some patients may develop sudden deterioration of cerebral perfusion and oxygenation, mainly due to increased intracranial pressure and hypotension, which are likely responsible for postoperative neurological morbidity and mortality. In the present study, we hypothesized that the favorable effects of hypertonic saline solution (NaCl 7.5%, 4 mL/kg) infusion on both systemic and cerebral hemodynamics, demonstrated in laboratory and clinical settings of intracranial hypertension and hemorrhagic shock resuscitation, may attenuate the decrease in cerebral perfusion pressure that often occurs during orthotopic liver transplantation for fulminant hepatic failure., Methods: 10 patients with fulminant hepatic failure in grade IV encephalopathy undergoing orthotopic liver transplantation with intracranial pressure monitoring were included in this study. The effect on cerebral and systemic hemodynamics in 3 patients who received hypertonic saline solution during anhepatic phase (HSS group) was examined, comparing their data with historical controls obtained from surgical procedure recordings in 7 patients (Control group). The maximal intracranial pressure and the corresponding mean arterial pressure values were collected in 4 time periods: (T1) the last 10 min of the dissection phase, (T2) the first 10 minutes at the beginning of anhepatic phase, (T3) at the end of the anhepatic phase, and (T4) the first 5 minutes after graft reperfusion., Results: Immediately after hypertonic saline solution infusion, intracranial pressure decreased 50.4%. During the first 5 min of reperfusion, the intracranial pressure remained stable in the HSS group, and all these patients presented an intracranial pressure lower than 20 mm Hg, while in the Control group, the intracranial pressure increased 46.5% (P < 0.001). The HSS group was the most hemodynamically stable; the mean arterial pressure during the first 5 min of reperfusion increased 21.1% in the HSS group and decreased 11.1% in the Control group (P < 0.001). During the first 5 min of reperfusion, cerebral perfusion pressure increased 28.3% in the HSS group while in the Control group the cerebral perfusion pressure decreased 28.5% (P < 0.001). Serum sodium at the end of the anhepatic phase and 3 hours after reperfusion was significantly higher in the HSS group (153.00 +/- 2.66 and 149.00 +/- 1.73 mEq/L) than in the Control group (143.71 +/- 3.30 and 142.43 +/- 1.72 mEq/L), P = 0.003 and P < 0.001 respectively., Conclusion: Hypertonic saline solution can be successfully used as an adjunct in the neuroprotective strategy during orthotopic liver transplantation for fulminant hepatic failure, reducing intracranial pressure while restoring arterial blood pressure, promoting sustained increase in the cerebral perfusion pressure.

Background: The current study sought to evaluate the results of liver resection as the treatment for unilateral non-oriental primary intrahepatic lithiasis (PHIL)., Methods: Twenty-seven symptomatic patients (mean age 42 years) were submitted to liver resection; the indications were parenchymal fibrosis/atrophy in 22 and biliary stenosis in 5. Resection was associated with a Roux-en-Y hepaticojejunostomy in patients with a significant degree of dilation of the extrahepatic biliary duct., Results: There was no operative mortality and the morbidity rate was 7.4% (2 patients with biliary fistula). After a median follow-up of 41.2 months, the overall rate of good results was 92.6%. All patients submitted to liver resection alone presented good late results, while 80% of those with associated hepaticojejunostomy did not have complications (P = .12). Late complications were observed in 2 patients (7.4%): 1 with a liver abscess and 1 with cholangitis and recurrent stones. There was no mortality during long-term follow-up., Conclusions: Liver resection showed low incidence of complications and good long-term results. None of the patients with unilateral disease without associated extrahepatic bile duct dilation presented complications and they were considered cured. We believe that resection indications should be expanded and the procedure should be indicated as routine in patients with unilateral PHIL even in the absence of parenchymal fibrosis/atrophy or biliary stenosis.

Background: Right superior liver resection or bisegmentectomy 7-8 is defined as the anatomical removal of segments 7 and 8 of the liver. According to recent reports, this type of resection requires the presence of a large accessory right inferior hepatic vein to drain the remaining segment 6. However, anatomic studies have shown that segment 6 has multiple veins presenting several anastomosis with the surrounding hepatic veins. Therefore, the maintenance of the veins from segment 5 that ultimately drain into the middle hepatic vein can be enough to assure venous drainage of both segments., Methods: Describe an alternative technique for bisegmentectomy 7-8 using intrahepatic glissonian access in patients with absence of a large inferior right hepatic vein., Results: The technique was successfully performed in four consecutive patients without immediate or long-term venous or venous related complications., Conclusions: Bisegmentectomy 7-8 may increase resectability rate in patients with bilateral lesions and may also enhance the opportunity to perform repeated resections in cases of tumor recurrence. Our study confirms the anatomical assumption that bisegmentectomy 7-8 did not result in segmental outflow block even in the absence of a thick inferior right hepatic vein and therefore should be performed more often than reported so far. The absence of this vein should not be a straightforward indication for right hepatectomy in cases where a liver-sparing procedure such as bisegmentectomy 7-8 can be safely employed., ((c) 2006 Wiley-Liss, Inc.)

The technique of left trisegmentectomy was first published in 1982 and consists in the removal of the left liver (segments II, III, and IV) along with the right anterior sector (segments V and VIII). This procedure is based on the knowledge of the segmental liver anatomy. There are only a few technical reports describing this complex procedure. We describe an anatomic and standardized way to identify and isolate the glissonian sheaths of the left liver segments along with the portal pedicles from right anterior sector (segments V and VIII). The middle and left hepatic veins are dissected using Arantius ligament as landmark. With this technique, it is possible to achieve inflow and outflow control of the involved liver segments without hilar dissection or clamping. This technique provides a safe way to perform a left extended hepatectomy without warm ischemia of the relatively small remnant liver.

An experience with the diagnosis and treatment of patients with non-Oriental primary intrahepatic lithiasis (PIHL) is described. A group of 48 native Brazilian patients with symptomatic PIHL were studied, and the patients' characteristics, diagnoses, treatment protocols based on the presentation of the disease, prognostic factors, and late results were analyzed. Liver resection was performed in patients with an irreversible lesion, such as parenchymal atrophy or biliary stenosis; and biliary drainage procedures were employed in patients with bilateral disease. Late results were considered good when no postoperative symptoms were observed and poor if there was pain recurrence or cholangitis. Overall good results were observed in 73.4% of the patients. Good late results were observed in 94.1% and 62.1% of the patients with unilateral and bilateral stones, respectively. None of the analyzed parameters (gender, age, previous biliary surgery, bilirubin level, serum leukocyte counts, prothrombin activity, previous history of cholangitis, stone location) predicted poor late results, but the risk for patients with bilateral stones to develop late complications was 7.2 times higher than for those with unilateral disease. Non-Oriental PIHL is a rare disease, and the patients' characteristics are similar to those of patients with Oriental PIHL. We believe that personalized treatment based on the presentation of the disease led to the high incidence of good late results in this series.

Background: Among several liver resection techniques, the use of stapler in the portal pedicles is an interesting option., Aim: To describe the technique of liver resection using a vascular stapling device., Patients and Methods: A total of eight patients underwent hepatic resections with stapling techniques. The authors have used intrahepatic approach glissonian pedicles with the application of a vascular stapler device in all cases. Liver parenchyma and hepatic veins were transected as usual., Results: There were no deaths. No complications directly attributable to stapler ligations of portal pedicles were observed., Conclusion: Stapling techniques can be helpful in hepatic resection procedures. The vascular stapler may significantly reduce glissonian pedicle section time.

Celiac trunk or superior mesenteric artery stenosis are usually innocuous conditions. In such patients, arterial blood supply to the stomach, spleen, liver and bowel is sustained through extraordinarily well-developed pathways through the pancreas. If division of these collateral vessels is necessary during a surgical procedure such as pancreaticoduodenectomy, life-threatening celiac organ or bowel ischemia may occur. The authors describe a new test, using pancreatic inflow occlusion, to reliably identify celiac trunk or superior mesentery artery stenosis. The authors describe two cases of celiac axis occlusion and one case of superior mesenteric artery stenosis. In all three presented cases the gastroduodenal artery clamping test was negative and ischemia was only noticed after pancreatic section, suggesting that in severe occlusions this test may fail in diagnosing the vascular abnormality. All patients were successfully treated by revascularization with no operative mortality. If the diagnosis is unsuspected and in cases where appropriate angiographic studies have not been obtained before pancreatic resection, a test occlusion of the gastroduodenal artery should always precede its ligation. However, this test may not be effective in all cases and in instances where high suspicion of celiac axis or mesenteric stenosis is present, other maneuvers, such as pancreatic inflow test, could be helpful for the diagnosis of these rare and morbid situations.

Pancreaticoduodenectomy is the only curative treatment for pancreatic head tumors. The possibility to achieve a potentially curative surgical treatment is limited to patients in which a complete tumor resection can be performed with free surgical margins. In a small number of patients with localized pancreatic cancer, negative margins are only accomplished with portal vein resection. Pancreaticoduodenectomy is often avoided in these patients due to the mistaken concept that venous resection may be followed by higher mortality and carries poorer survival. Actually, these patients present the same survival rate as patients similarly staged in whom portal vein resection was not performed. Therefore, venous resection is worthwhile. The authors describe an alternative technique for venous reconstruction after resection of a long segment of portal or superior mesenteric vein. The use of a venous graft as proposed in this study is feasible, easy to perform, and may simplify the venous reconstruction even in extensive mesentericoportal venous resection.

Objectives: To assess the result of surgery for adrenal neoplasia with thrombus in the supra-diaphragmatic infra-atrial inferior vena cava., Patients and Methods: Five patients with adrenal cortex carcinoma and three with phaeochromocytoma were reviewed. All the thrombi were removed through a right thoracophrenolaparotomy in the fifth intercostal space, with clamping of the intrathoracic portion of the inferior vena cava, with no cardiopulmonary bypass. In the first two cases the thrombi were removed in a second surgical procedure after resecting the tumours. In the other six the complete procedure was done in one surgical stage., Results: There were no surgery-related deaths. The major complications after surgery were pulmonary atelectasis, acute renal failure, a large retroperitoneal collection, deep vein thrombosis and pulmonary embolism, each in one patient. Of the five patients with adrenal cortex carcinoma one is still alive after 15 years with no evidence of disease, one is alive with pulmonary metastases 15 months after surgery and the other three died from widespread disease after 5, 12 and 15 months. Of the three patients with phaeochromocytoma, two show no evidence of the disease 2.5 and 11 years later and one died from myocardial infarction, with no evidence of the disease, 9 years later., Conclusion: Thrombi from adrenal neoplasia in the supra-diaphragmatic infra-atrial inferior vena cava may be removed with no need for cardiopulmonary bypass and cardiac arrest, thus avoiding the associated morbidity and high cost.

Background/aims: Cholecystectomy for treatment of gallbladder stones in patients with portal vein thrombosis can be a hazardous procedure. Dissection into an area of thin-walled collateral vessels can trigger troublesome bleeding and consequent blood coagulation disorders., Methodology: In order to avoid dissection, cholecysto-jejunostomy was used as the treatment of choice in three patients with symptomatic gallbladder stones and portal vein thrombosis., Results: Surgical procedure was uneventful, blood or plasma transfusions were not required either at surgery or afterwards. Pre- and postoperative hematocrit evaluations showed no difference, as well as liver function tests. The procedure was well tolerated and patients were discharged from day 5 to 7. Follow-up ranged from 2 to 3 years, no biliary complications were found during this period., Conclusions: Choleysto-jejunostomy is a safe procedure and can be used as an effective treatment of symptomatic gallbladder stones in patients with portal vein thrombosis.

Cystic neoplasms of the pancreas are uncommon lesions but are becoming increasingly prevalent. Herein we report a case of an oligolocular cystic lesion in the head of the pancreas in a young female that had undergone a cystenteroanastomosis 10 years ago. She underwent a duodenopancreatectomy with an uneventful recovery. The histology showed a serous oligocystic adenoma of the pancreas and the immunohistochemistry study confirmed the diagnosis. There is no sign of recurrence after the surgery. The role of pre-operative diagnosis based on tomographic, echoendoscopy and fine needle aspiration are discussed., (Copyright 2003 S. Karger AG, Basel)

Background: Severity of systemic lesions and mortality of experimental acute pancreatitis (AP) are reduced after pancreatic enzyme content reduction induced by cerulein administration. Octreotide has been used both prophylatically and therapeutically in AP. The possible effects of octreotide on pancreatic enzyme content and its influence on pulmonary lesions of experimental AP were assessed in this study., Methods: Wistar male rats were divided in two branches: BRANCH I - Animals divided into three groups: Group Sa (n = 10) intravenous saline infusion; Group Ce (n = 10) intravenous cerulein infusion, (0.133 micro g/kg(-1).h(-1)) and Group Oc (n = 10) SC octreotide (10 micro g/kg(-1)). Trypsin, elastase and amylase pancreatic contents as well as serum amylase were determined thereafter in all three groups; BRANCH II - Rats treated as in branch I, were submitted to sodium taurocholate AP (Groups Sa+AP, Ce+AP and Oc+AP). Two hours thereafter amylase and TAP assays were performed in serum, ascites and pancreatic tissue in eight animals of each group. Pulmonary histology was studied by morphometry 24 h after AP in the remaining animals., Results: Increased serum amylase and pancreatic enzyme contents were observed in octreotide-treated animals when compared to animals receiving saline or cerulein. After AP increases of serum and ascitic fluid amylase and of pancreatic TAP were observed in octreotide pre-treated animals when compared to saline and cerulein groups. Pulmonary interstitial and alveolar edema after AP was significantly increased in rats receiving octreotide as compared to the cerulein group., Conclusion: Octreotide administration acutely increases the enzymatic content of the pancreas and thus may have a potential deleterious influence in the evolution of AP., (Copyright 2003 S. Karger AG, Basel and IAP)

Patients with chronic pancreatitis presenting with lesions at the head of the pancreas and in the uncinate process associated with duct dilatation at the body and tail of the gland are inadequately treated by partial pancreatic head resection or by standard pancreatic drainage procedures. A new technique for the surgical treatment of this form of chronic pancreatitis, based on the performance of a pylorus-preserving pancreaticoduodenectomy associated with a longitudinal pancreatojejunostomy, is proposed herein. Nine patients with chronic pancreatitis were operated on according to this technique with no postoperative complications or mortality. Complete symptom control was achieved in all patients. Follow-up periods varied from one month to five years.

Background: The use of stapling devices for performing gastrointestinal anastomosis has gained wide acceptance in the last decade. Linear cutting devices have been used routinely during gastrointestinal operations in our hospital since 1992. However, we still have shortage of stapling devices due to cost reduction politics., Methods: We propose a modification of the standard technique in order to reduce the number of devices used. Our technique employs a single stapled including the section of the jejunum and the side-to-side jejunoanastomosis., Results: We have used this technique for 1 year without complications related to the stapled anastomosis., Conclusions: This technique may reduce the time of reconstruction of Roux-en-Y anastomosis without interfering in its final result. This modified technique may be useful in hospitals with reduced economic resources.