Case Report: Cytoreductive Surgery and HIPEC Associated With Liver Electrochemotherapy in a Cholangiocarcinoma Patient With Peritoneal Carcinomatosis and Liver Metastasis Case Report

Introduction: Cholangiocarcinoma (CCA) is the second most common primary tumor of the liver, and the recurrence after hepatic resection (HR), the only curative therapy, is linked with a worse prognosis. Systemic chemotherapy (SC) and liver loco-regional treatments, like trans-arterial chemoembolization (TACE) or radio embolization (TARE), have been employed for the treatment of unresectable intrahepatic metastasis (IM) with benefit on overall survival (OS), but SC has a limited effect on peritoneal metastasis (PM). In the last years, novel treatments like electrochemotherapy (ECT) with bleomycine (BLM) for IM and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS and HIPEC) for PM have been applied in small series but with encouraging results. We hereby describe the first synchronous application of ECT and CRS and HIPEC for the treatment of a patient with IM and PM from CCA. Case Description: A 47-year-old male patient with CCA underwent HR followed by adjuvant SC. After 14 months, for the occurrence of IM, the patient underwent a second HR and SC. Nonetheless, a new recurrence occurred and a third attempt of HR was proposed. Due to the intraoperative finding of unresectable IM with PM, no resective procedure was performed and the patient was referred to our center. CRS and HIPEC with cisplatin and mitomycin for PM and ECT with BLM on a bulky metastasis of the hepatic hilum were performed after 38 months from the first HR. The length of hospital stay was 19 days. At the computed tomography (CT) performed 11 days after treatment complete necrosis of the treated IM was detected. Results: CT scan after 3 and 6 months and magnetic resonance after 9 months were performed. Necrosis of the treated IM nor PM but progression of the residual liver lesions was observed. After 3 months, the patient received SC and underwent TACE after 8 months and TARE after 9 months for the residual liver metastases. At 14 months from CRS and HIPEC, the patient is alive, in good condition, and with stability of the disease. Conclusions: The association of ECT and CRS and HIPEC could be safe and effective for the treatment of unresectable recurrent intrahepatic CCA with PM.

Ventilator associated pneumonia following liver transplantation: Etiology, risk factors and outcome

AIM: To determine the incidence, etiology, risk factors and outcome of ventilator-associated pneumonia (VAP) in patients undergoing orthotopic liver transplantation (OLT).

METHODS: This retrospective study considered 242 patients undergoing deceased donor OLT. VAP was diagnosed according to clinical and microbiological criteria.

RESULTS: VAP occurred in 18 (7.4%) patients, with an incidence of 10 per 1000 d of mechanical ventilation (MV). Isolated bacterial etiologic agents were mainly Enterobacteriaceae (79%). Univariate logistic analysis showed that model for end-stage liver disease (MELD) score, pre-operative hospitalization, treatment with terlipressin, Child-Turcotte-Pugh score, days of MV and red cell transfusion were risk factors for VAP. Multivariate analysis, considering significant risk factors in univariate analysis, demonstrated that pneumonia was strongly associated with terlipressin usage, pre-operative hospitalization, days of MV and red cell transfusion. Mortality rate was 22% in the VAP group vs 4% in the group without VAP.

CONCLUSION: Our data suggest that VAP is an important cause of nosocomial infection during postoperative period in OLT patients. MELD score was a significant risk factor in univariate analysis. Multiple transfusions, treatment with terlipressin, preoperative hospitalization rather than called to the hospital while at home and days of MV constitute important risk factors for VAP development.

Intestinal derotation in emergency surgery

Intestinal derotation (ID) is a rarely used surgical technique which allows elegant and effective surgical access to the superior mesenteric axis and third and fourth portion of the duodenum. ID proves an extremely useful technique especially in the emergency setting when access to the "surgical soul" is needed. To master this technique the surgeon has to become familiar with the anatomical landmarks of that area along with the embryological background.

Bile duct injuries during laparoscopic cholecystectomy: a 1994-2001 audit on 13,718 operations in the area of Rome

BACKGROUND

Bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC) still are reported with greater frequency than during open cholecystectomy (OC).

METHODS

In 1999, a retrospective study evaluating the incidence of BDIs during LC in the area of Rome from 1994 to 1998 (group A) was performed. In addition, a prospective audit was started, ending in December 2001 (group B).

RESULTS

In group A, 6,419 LCs were performed (222 were converted to OC; 3.4%). In group B, 7,299 LCs were performed (225 were converted to OC; 3.1%). Seventeen BDIs (0.26%) occurred in group A and 16 (0.22%) in group B. Overall, mortality and major morbidity rates were 12.1% and 30.3%, respectively, without significant differences between the two groups.

CONCLUSIONS

The incidence and clinical relevance of BDIs during LC in the area of Rome appeared to be stable over the past 8 years and were not influenced by the use of a prospective audit, as compared with a retrospective survey.

[Cancer of the male breast]

BACKGROUND

Male breast cancer is a rare type of neoplasm, being 1% of all breast tumors. An increasing relevance is given to genetic factors. Familiarity is present in 10% of cases reported in literature. Gynecomastia is frequently associated. Personal experience about this pathology is compared with the most recent data of the literature.

METHODS

Nine cases of male breast cancer observed among 519 breast tumors operated between 1982 and 1997 are reported. Etiologic and prognostic aspects, surgical and complementary therapy of breast cancer in man are examined and the high rate of II-III stage patients, mostly ER+ and PR+ is underlined. Diagnosis is reached by ultrasonography and mammography, after an accurate clinical examination and confirmed by cytology after needle biopsy. The choice operation is total mastectomy with axillary lymphadenectomy according to Patey.

RESULTS

According to our experience, 5 patients died for non neoplastic pathology, 1 patient lost at follow-up, 3 patients still alive after 66, 60 and 12 months respectively.

CONCLUSIONS

Male breast cancer is similar to the female one, but characterized by a higher hormone receptors positivity. Our survival data have no statistic significance. It is still discussed if prognostic difference between men and women is present or not.

Minimally invasive treatment of giant CSF pseudocyst complicating ventriculoperitoneal shunt

A two-liter cerebrospinal fluid pseudocyst complicating a ventriculoperitoneal shunt was drained and a distal catheter retrieved from the peritoneal cavity by laparoscopy. Adoption of such a minimally invasive approach allowed the prompt resolution of the complication and an early recovery for out patient.

[Mechanical occlusion of the small intestines by gallstones. Our experience]

The authors report their experience of biliary ileus, namely 8 cases out of 533 intestinal occlusions of the small bowel operated from 1982-1994. The patients included 5 women and 3 men with a F/M ratio = 1.7. Mean age was 79 years. Past medical history involving the biliary tract was only recorded in 3 cases. At the time of hospitalization occlusive symptoms had been present for between 2 and 7 days: pain in 7 patients, abdomen closed to gas and feces in 6, and vomiting in 7. Direct abdominal X-ray was only performed in 3 cases. A diagnosis of intestinal occlusion was made in 6 cases and biliary ileus in 2. During surgery it became clear that the occlusion was primarily localized at the level of the terminal ileum. Cholecysto-duodenal fistula was present in 5 cases. Enterolithotomy alone was performed in 5 cases. In 4 patients postoperative progress was normal leading to recovery. Two patients died: one immediately after surgery and the other on day 12. In conclusion, the authors confirm the increasingly frequent presence of cholecysto-duodenal fistula and the increasing age of patients, with a prevalence of females. They also emphasize the importance of an early diagnosis, supported by direct abdominal radiography so that surgery can be performed as rapidly as possible. Lastly, the need to perform cholecystectomy at a subsequent date is underlined.