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Background. Mirizzi syndrome is a condition difficult to diagnose and treat, representing a particular "challenge" for the biliary surgeon. The disease can mimic cancer of the gallbladder, causing considerable diagnostic difficulties. Furthermore, it increases the risk of intraoperative biliary injury during cholecystectomy. The aim of this study is to point out some particular aspects of diagnosis and treatment of this condition. Methods. The clinical records of patients with Mirizzi syndrome, treated in the last five years, were reviewed. Clinical data, cholangiograms, preoperative diagnosis, operative procedures, and early and late results were examined. Results. Eighteen consecutive patients were treated in the last five years. Presenting symptoms were jaundice, pain, and cholangitis. Preoperative diagnosis of Mirizzi syndrome was achieved in 11 patients, while 6 had a diagnosis of gallbladder cancer and 1 of Klatskin tumor. Seventeen patients underwent surgery, including cholecystectomy in 8 cases, bile duct repair over T-tube in 3 cases, and hepaticojejunostomy in 4 cases. Two cases (11.1%) of gallbladder cancer associated with the Mirizzi syndrome were incidentally found: a patient underwent right hepatectomy and another patient was unresectable. The overall morbidity rate was 16.6%. There was no postoperative mortality. An ERCP with stent insertion was required in three cases after surgery. Sixteen patients were asymptomatic at a mean distance of 24 months (range: 6-48) after surgery. Conclusions. Mirizzi syndrome requires being treated by an experienced biliary surgeon after a careful assessment of the local situation and anatomy. The preoperative placement of a stent via ERCP can simplify the surgical procedure.

The chapter provides a detailed description of the correlations existing between severity of hypocholesterolemia and changes in plasma amino acid levels, with the related clinical implications, in a large series of measurements performed in septic patients

The chapter provides a detailed description of the correlations existing between severity of hypocholesterolemia and changes in plasma amino acid levels, with the related clinical implications, in a large series of measurements performed in septic patients

After surgery, in sepsis and various critical illnesses, factors such as severity of the acute phase response, liver dysfunction, and hemodilution from blood loss have cumulative impacts in decreasing cholesterol; therefore, degree of hypocholesterolemia often reflects severity of illness. The direct correlation between cholesterol and several plasma proteins is mediated by the parallel impact of commonly shared determinants. Cholestasis is associated with a moderation of the degree of hypocholesterolemia. In human sepsis, the poor implications of hypocholesterolemia seem to be aggravated by the simultaneous development of hypertriglyceridemia. Cholesterol and triglyceride levels reflect altered lipoprotein patterns, and the issue is too complex and too poorly understood to be reduced to simple concepts; nevertheless, these simple measurements often represent helpful adjunctive clinical tools.

The aim of this study was to review a series of patients submitted to hepatectomy for primary intrahepatic lithiasis to evaluate early and late results with an assessment of indications, methods and long-term outcomes. From January 1992 to December 2007, 40 patients (25 males and 15 females with a mean age of 51 years) underwent surgery for primary intrahepatic lithiasis in our Hepato-biliary Surgery Unit. Left hepatectomy (20 patients) and left lateral segmentectomy (12 patients) were the most common procedures performed. A cholangiocarcinoma was found in 4 patients (10%) and only two of these underwent liver resection, while an exploratory laparotomy was performed in the remaining two patients for an unresectable tumour, unexpected before surgery. There was no postoperative mortality. The morbidity rate was 22.5% with a prevalence of infectious complications related to bile leakage. Long-term results, assessed in 30 patients with a follow-up longer than 12 months, were good or fair in 28 patients (93.3%). Primary intrahepatic lithiasis is diagnosed increasingly in Western countries as a result of the improvement in imaging techniques. The stones originate inside the liver at the level of dilatations of the bile ducts above congenital strictures of the main hilar ducts. Biliary pain and cholangitis are the most common presenting symptoms, whereas cholangiocarcinoma represents the unfavourable complication of the disease. In the majority of cases, a single liver lobe or segment is involved and liver resection allows definitive treatment of the disease and prevention of cancer.

Premessa Le lesioni iatrogene della via biliare principale (VBP) costituiscono una grave complicanza della colecistectomia. Scopo dello studio Presentare l’esperienza di un centro di chirurgia epato-biliare nella gestione della fase acuta delle lesioni iatrogene della VBP. Metodi Nel periodo 1994-2007 sono stati trattati 103 pazienti per lesione iatrogena della VBP in corso di colecistectomia. Questo studio riguarda 62 pazienti trasferiti post-operatoriamente nella fase acuta della complicanza. Il riconoscimento della lesione è stato intraoperatorio in 21 pazienti (con conversione laparotomica in 19 e colangiografia in 2; tentata riparazione in 20 e semplice drenaggio sotto-epatico in 1), con 6 reinterventi per coleperitoneo. Il riconoscimento è stato post-operatorio in 41 pazienti (per ittero semplice in 7 e fistola biliare/coleperitoneo in 34), seguito da tentata riparazione in 27. Dopo il trasferimento nella nostra U.O. 7 pazienti con ittero hanno eseguito precocemente un’epatico-digiunostomia (Hepp-Couinaud). Per quanto riguarda i 55 pazienti con perdita biliare (di cui 12 rioperati subito per coleperitoneo), 13 con lesione minore/deiscenza del cistico hanno eseguito un trattamento endoscopico/ conservativo; dei 42 con lesione maggiore, 3 sono deceduti per sepsi prima di qualunque riparazione, 15 pazienti, con sezione parziale della VBP, sono stati sottoposti ad un trattamento endoscopico con stent e 24, con sezione completa/lesioni complesse della VBP, a ricostruzione chirurgica a 90 giorni in media dalla colecistectomia, dopo la risoluzione dei problemi acuti. Risultati Tre pazienti (4,8%) con storie complesse sono deceduti per sepsi prima di qualunque riparazione. Le 7 ricostruzioni chirurgicheper ittero semplice ed i trattamenti endoscopici/conservativi per lesioni minori/sezioni parziali della VBP hanno avuto risultati eccellenti/ buoni. Le 24 ricostruzioni chirurgiche per sezioni complete/lesioni complesse della VBP hanno avuto risultati eccellenti/ buon, Background Iatrogenic bile duct injury is a severe complication of cholecystectomy. Purpose To describe the experience of a hepatobiliary surgery unit in the management of iatrogenic bile duct injuries in the acute stage. Methods A total of 103 patients with iatrogenic bile duct injuries occurred during cholecystectomy were treated between 1994 and 2007. This study includes 62 patients who were referred to our Unit in the acute stage of the complication. The injury was intraoperatively identified in 21 patients (conversion to open surgery in 19, cholangiography in 2; attempted repair in 20 and simple abdominal drainage in 1), with 6 re-operations for choleperitoneum; it was postoperatively identified in 41 patients (obstructive jaundice in 7 and biliary fistula/choleperitoneum in 34), with attempted repair in 27. After referral to our Unit, 7 patients with jaundice underwent hepaticojejunostomy (Hepp-Couinaud). With regard to the 55 patients with bile leak (of whom 12 reoperated on immediately due to choleperitoneum), 13 with minor injury/cystic stump leak underwent endoscopic/conservative treatment. As regards the 42 patients with major injury, 3 died from sepsis prior to repair, 15 with partial common bile duct (CBD) transection underwent endoscopy with stenting, and 24 with complete CBD transection/complex injury underwent surgical reconstruction at a mean distance of 90 days from cholecystectomy, after fully recovering from acute problems. Results Three patients (4.8%) died from sepsis before any repair. The 7 surgical reconstructions for simple jaundice and the endoscopic/conservative treatments for minor injury/partial CBD transection yielded excellent/good results. The 24 surgical reconstructions for complete CBD transection/complex injury yielded excellent/good results; in 4 cases treatment was completed with percutaneous dilatation. Conclusions This analysis demonstrates that early referral and management of iatrogenic bile duct injuries in a specialised mu

BACKGROUND: The aim of the present study was to highlight the advantages of treatment of bile duct injury (BDI) occurring during cholecystectomy on the basis of a multidisciplinary cooperation of expert surgeons, radiologists, and endoscopists. METHODS: Sixty-six patients had major BDIs or short- or long-term failures of repair. BDI was diagnosed intraoperatively in 27 patients (40.9%) and postoperatively in 39 (59.1%) patients. Among referred patients, 30 had complications from bile leak, 15 from obstructive jaundice, and 20 from recurrent cholangitis. Two patients died from sepsis after delayed referral before repair was attempted. Eleven additional patients had minor BDIs with bile leak both with and without choleperitoneum. RESULTS: Of patients with major BDI, surgical repair was performed in 41 (64.1%). Postsurgical morbidity rate was 15.8%, and there was no mortality. The rate of excellent or good results after surgical repair was 78.0% (32 of 41 patients), and this increased to 87.8% (36 of 41 patients) by continuing treatment with stenting in postsurgical strictures. Biliary stenting alone was performed in 23 patients (35.9%), with excellent or good results in 17 (73.9%). More than 200 endoscopic and percutaneous procedures were performed for initial assessment, treatment of sepsis, nonsurgical repair, contribution to repair, and follow-up. Patients with minor BDIs underwent various combinations of surgical and endoscopic or percutaneous treatments, always with good results. CONCLUSIONS: A multidisciplinary approach was of paramount importance in many phases of treatment of BDI: initial assessment, treatment of secondary complications, resolution of sepsis, percutaneous stenting before surgical repair, dilatation of strictures after repair, final treatment in patients not repaired surgically, and follow-up.

No Abstract

Background: The Heyde syndrome consists of the association of gastrointestinal bleeding from angiodysplasia with aortic valve stenosis. Its existence has been repeatedly questioned or reconfirmed, and the proposed underlying mechanism is the degradation of a coagulation factor caused by the stenotic valve, which facilitates bleeding from angiodysplastic lesions. Patient Case: We report the case of a patient with severe recurrent small- intestinal bleeding from angiodysplasia, diagnosed by a videocapsule, and aortic valve stenosis. He underwent aortic valve replacement with a bioprosthesis as an extreme life- saving procedure. The operation was followed by the cessation of bleeding for 10 months, then bleeding recurred, emergency bowel resection was needed, and was followed by a chain of events which led to the patient's death. Conclusion: This case offers an extreme example of the challenging issues still involved in the management of patients with Heyde syndrome.

Aims and background: Intrahepatic cholangiocarcinoma (IHCC) is the second most common primary liver cancer, representing 10% of all primary liver malignancies. Despite the increase in its incidence, this tumor remains extremely rare in Western countries and few reports detailing experience with surgical resection have been published. The aim of this study was to analyze the experience with resection of IHCC in our center. Methods: From 1987 to 2003 we observed 35 patients with IHCC; 15 of them (42.8%) were submitted to hepatic resection. IHCCs accounted for 13% of all liver resections for primary liver tumors carried out at our center during this period. According to the classification of the Liver Cancer Study Group of Japan, the tumors were classified as "mass-forming" in 14 cases and as "periductal" in one case. Major resections were performed in ten cases and minor resections in five cases. In the patient with a periductal tumor a major resection was performed along with excision of the main billary confluence. In 14 cases (93.3%) tumor-free resection margins were obtained. Results: The intraoperative mortality was nil and the postoperative mortality 6.6%. The postoperative morbidity rate was 21.4%. The mean overall survival was 38.4 months, with 86% and 49% one- and three-year survival rates, respectively. Patients with mass-forming tumors and curative resections (R0) (mean survival 40.8 months; one- and three-year survival rates 92.3% and 52.7%), and those with TNM stage I-II tumors (mean survival 43.7 months; one- and three-year survival rates 100% and 66.7%) had a longer survival. The patient with the periductal tumor and R1 resection died after seven months. Conclusions: These results support a surgical approach based on accurate selection of patients with IHCC and aimed at radical resection whenever possible. The good survival rates observed in R0 resections emphasize the role of radical surgery as the only chance of cure for patients with this tumor.

Hypothesis: Bile duct injury (BDI) remains the most serious complication of cholecystectomy. With laparoscopic cholecystectomy (LC), the incidence has become more frequent. This study verifies the current incidence, mechanism, presentation, and treatment of BDI occurring during LC in general surgical practice. Design: Anonymous retrospective multicenter survey. Setting: Department of surgery at a university referral center, collecting data from general surgical units. Patients: Data from 56 591 patients who underwent LC between January 1, 1998, and December 31, 2000, in 184 hospitals in Italy were analyzed. Main Outcome Measures: Current incidence, mechanism, presentation, and treatment of BDI occurring during LC in general surgical practice. Results: Two hundred thirty-five BDIs; were reported, with an overall incidence of 0.42%. There were no risk factors in 80.0% of the patients. Poor identification of the anatomical features of the hepatic pedicle was the most frequently reported cause (36.8%), and technical problems accounted for 27.0% of causes. The incidence of BDI was higher during cholecystitis (P <.001) and decreased with increasing number of LCs performed by the surgical teams (P <.01). There was no difference in incidence according to technique (French or US) or to routine or selective intraoperative cholangiography. One hundred eight BDIs (46.0%) were recognized intraoperatively and immediately repaired in 89.8% of patients. One hundred twenty-seven BDIs (54.0%) were diagnosed postoperatively, the dominant manifestation being biliary fistula (44.1%). Conclusions: This study confirms a higher incidence of BDI during LC. It highlights the relevance of the number of previously performed LCs and of the correct surgical technique to avoid BDI. The need for correct procedures, adequate expertise of the repairing surgeon in BDI repairs, and a multidisciplinary approach in the management of BDI is emphasized.

Hepatic pedicle clamping (HPC) is widely used to control intraoperative bleeding during hepatectomy; intermittent HPC is better tolerated but is associated with blood loss during each period of reperfusion. Recently, it has been shown that ischemic preconditioning (IP) reduces the ischemia-reperfusion damage for up to 30 minutes of continuous clamping in healthy liver. We evaluated the safety of IP for more prolonged periods of continuous clamping in 42 consecutive patients with healthy liver submitted to hepatectomy. IP was used in 21 patients (group A); mean +/- SD of liver ischemia was 54 +/- 19 minutes (range, 27-110; in 7 cases >60 minutes). In the other 21 patients, continuous clamping alone was used (Group B); liver ischemia lasted 36 +/- 14 minutes (range, 13-70; in 2 cases >60 minutes). Two patients in Group A (9.5%) and 3 in Group B (14.2%) received blood transfusions. In spite of the longer duration of ischemia (P=.001), patients with IP had lower aspartate aminotransferase (AST; P=.03) and alanine aminotransferase (ALT; P=not significant) at postoperative day 1, with a similar trend at postoperative day 3. This was reconfirmed by multiple regression analysis, which showed that although postoperative transaminases increased with increasing duration of ischemia and of the operation in both groups, the increases were significantly smaller (P<.001) with the use of preconditioning. In conclusion, the present study confirms that IP is safe and effective for liver resection in healthy liver and is also better tolerated than continuous clamping alone for prolonged periods of ischemia. This technique should be preferred to continuous clamping alone in healthy liver. Additional studies are needed to assess the role of IP in cirrhotic liver and to compare IP with intermittent clamping.

Because the p16 locus is involved consistently in chromosomal losses found in malignant gastrointestinal stromal tumors (GISTs), we studied p16 in a series of 21 GISTs with complete follow-up using immunohistochemical analysis, semiquantitative reverse transcriptase-polymerase chain reaction (RT-PCR) and methylation-specific PCR (MSP). A fraction of cells of more than 20% with low or absent p16 immunostaining was detected in 12 GISTs, including all showing malignancy. RT-PCR revealed decreased p16 transcription in all except 2 p16 protein-deficient GISTs. By MSP, 7 cases showed p16 promoter methylation (all hypoexpressing p16; 6 malignant). A fraction of p16-deficient cells of more than 20% was associated with clinical malignancy (P = .003; log-rank test). The percentage of cells underexpressing p16, size, cellularity, mitotic count, and coagulative necrosis were associated with malignancy by Cox proportional hazards univariate analysis; only the former factor was selected by multivariate analysis (P = .039). Thus, p16 down-regulation, partly due to p16 promoter methylation, is implied in GIST progression. Furthermore, p16 immunohistochemical assessment seems a promising method for GIST prognostication.

Il libro (monografia) descrive i molteplici aspetti connessi alle lesioni iatrogene della via biliare principale, in particolare a quelle che possono verificarsi in corso di colecistectomia: fattori predisponenti, prevenzione, diagnosi, trattamento. Il libro riporta inoltre i risultati di un'inchiesta nazionale sull'argomento, coordinata dal relatore e dai suoi collaboratori, a cui hanno partecipato 184 ospedali., The book (monograph) describes multiple issues related to iatrogenic biliary lesions, in particular to those occurring during cholecystectomy: predisposing factors, prevention, diagnosis, treatment. The book also reports the results of an Italian national survey on the topic, coodinated by the main author and by his collaborators, with the participation of 184 hospitals.

Il libro (monografia) descrive i molteplici aspetti connessi alle lesioni iatrogene della via biliare principale, in particolare a quelle che possono verificarsi in corso di colecistectomia: fattori predisponenti, prevenzione, diagnosi, trattamento. Il libro riporta inoltre i risultati di un'inchiesta nazionale sull'argomento, coordinata dal relatore e dai suoi collaboratori, a cui hanno partecipato 184 ospedali., The book (monograph) describes multiple issues related to iatrogenic biliary lesions, in particular to those occurring during cholecystectomy: predisposing factors, prevention, diagnosis, treatment. The book also reports the results of an Italian national survey on the topic, coodinated by the main author and by his collaborators, with the participation of 184 hospitals.

Il libro (monografia) descrive i molteplici aspetti connessi alle lesioni iatrogene della via biliare principale, in particolare a quelle che possono verificarsi in corso di colecistectomia: fattori predisponenti, prevenzione, diagnosi, trattamento. Il libro riporta inoltre i risultati di un'inchiesta nazionale sull'argomento, coordinata dal relatore e dai suoi collaboratori, a cui hanno partecipato 184 ospedali., The book (monograph) describes multiple issues related to iatrogenic biliary lesions, in particular to those occurring during cholecystectomy: predisposing factors, prevention, diagnosis, treatment. The book also reports the results of an Italian national survey on the topic, coodinated by the main author and by his collaborators, with the participation of 184 hospitals.

A review of one-hundred cases of intra-hepatic lithiasis, observed between 1967 and 1996 by the same surgical team, was reported in this paper. There were 61 cases of migrated stones and 39 cases of primary duct stones (31 above a stenosis and 8 associated to biliary malformations). 83 patients underwent surgery: in 31 cases, gallstones were removed through the CBD, while a bilio-enteric anastomosis was required in 47 cases; 5 patients underwent a left liver resection. Finally, 17 patients were treated by non-surgical means (endoscopic or radiologic). In a first period, diagnosis was made intraoperatively by cholangiography or choledochoscopy and surgery was the only therapeutic option. After 1980, diagnostic procedure included ultrasonography, CT and direct cholangiography (endoscopic or percutaneous). Consequently to the development of endoscopic (ERCP) or percutaneous (PTC) approaches to remove intrahepatic gallstones, many patients were treated by these non-surgical means, which, in some cases, were associated with extracorporeal lithotripsy. Abnormalities of intrahepatic biliary tree represented an elective indication for liver resection in the last years. The clinical results improved progressively: mortality was 8.3% in the first ten years (67-76), 7.1% in the second decade (77-86) and there was no mortality in the last ten years. In the first decade, intrahepatic biliary tree was completely cleared from gallstones in the 70.8% of cases, in the second decade in the 80.9% of cases and, in the last ten years, in the 97% of cases.

A review of one-hundred cases of intra-hepatic lithiasis, observed between 1967 and 1996 by the same surgical team, was reported in this paper. There were 61 cases of migrated stones and 39 cases of primary duct stones (31 above a stenosis and 8 associated to biliary malformations). 83 patients underwent surgery: in 31 cases, gallstones were removed through the CBD, while a bilio-enteric anastomosis was required in 47 cases; 5 patients underwent a left liver resection. Finally, 17 patients were treated by non-surgical means (endoscopic or radiologic). In a first period, diagnosis was made intraoperatively by cholangiography or choledochoscopy and surgery was the only therapeutic option. After 1980, diagnostic procedure included ultrasonography, CT and direct cholangiography (endoscopic or percutaneous). Consequently to the development of endoscopic (ERCP) or percutaneous (PTC) approaches to remove intrahepatic gallstones, many patients were treated by these non-surgical means, which, in some cases, were associated with extracorporeal lithotripsy. Abnormalities of intrahepatic biliary tree represented an elective indication for liver resection in the last years. The clinical results improved progressively: mortality was 8.3% in the first ten years (67-76), 7.1% in the second decade (77-86) and there was no mortality in the last ten years. In the first decade, intrahepatic biliary tree was completely cleared from gallstones in the 70.8% of cases, in the second decade in the 80.9% of cases and, in the last ten years, in the 97% of cases.

Summary. The review addresses radical surgery and palliative measures for conditions of malignant biliary obstruction.