[Ultrasonic videolaparoscopic cholecystectomy: evolution of a revolutionary technique]

AIM

The present retrospective study, which lasted about six months from the beginning of March to the end of August 2008, involved 60 patients suffering from symptomatic calculosis of the gall bladder.

METHODS

The patients were operated on with laparoscopy: 30 with traditional instruments, 30 using ultrasound multifunctional scissors.

RESULTS

The numerous advantages for the patient and surgeon are immediately evident; in addition, from the economic viewpoint the procedure is advantageous compared to the traditional method because single-use material is employed exclusively. We found less tissue trauma and a lower incidence of short-term complications, such as reoperation for faulty closure of the cystic duct and the cystic artery. It was never necessary to use permanent haemostatic clips. The use of a single instrument for gripping, sectioning and closing haematic and biliary vessels permitted faster, safer and more accurate surgery in the absence of any production of smoke.

CONCLUSIONS

In lithiasic pathology of the gall bladder, videolaparoscopy for cholecystectomy is presently considered the operation of first choice. The technique enables the surgeon to respect to the utmost the patient's physical and mental integrity. As the third millennium dawns, technological innovation is able to bring a significant improvement to this procedure. The ultrasound dissector Ultracision is symbolic of development and constant progress.

Catheter seeding of hepatocellular carcinoma following placement of a total implantable access port system

A 61-year-old cirrhotic patient underwent hepatic resection for hepatocellular carcinoma and placement of a total implantable access port system in the hepatic artery for chemotherapy infusion. A year later, he developed a parietal metastasis at the port site as a consequence of tumor seeding along the arterial catheter. The metastasis was excised but the patient died because of disseminated disease two years after the first operation. Tumor seeding along the catheter should be included in the group of potential complications after placement of total implantable access port systems for intrahepatic chemotherapy The possible causes of this rare but life-threatening complication are discussed.

Combined immunosuppressive therapy with tacrolimus and mycophenolate mofetil for small bowel transplantation in pigs

In a swine model of orthotopic small bowel transplantation, we assessed the efficacy of combined therapy with a low dose of tacrolimus plus mycophenolate mofetil, compared with high-dose tacrolimus monotherapy. The bowel was replaced in 25 piglets: group 1 (n = 5), no immunosuppression; group 2 (n = 10), tacrolimus, 0.3 mg/kg daily i.m. for 7 days, followed by b.i.d. oral doses to maintain blood levels of 15-25 ng/ml; and group 3 (n = 10), tacrolimus, 0.1 mg/kg i.m., in a single dose on day 0 and thereafter oral doses to maintain blood levels of 5-15 ng/ml, plus oral mycophenolate mofetil (10 mg/kg twice daily). Follow-up time was limited to 60 days. Median survival time as 11, 27, and > 60 days in groups 1, 2, and 3, respectively (P = 0.001). Survival rates were 0%, 40%, and 80% at 30 days and 0%, 0%, and 70% at 60 days in groups 1, 2, and 3, respectively (P = 0.03), group 1 vs. group 2; P = 0.003, group 1 vs. group 3; P = 0.02, group 2 vs. group 3). One animal in group 1 (20%) and two animals each in groups 2 and 3 (20%) died of technical complications. Rejection was the cause of death of 80% of animals of group 1 and of no animals in either group 2 or 3. None of the immunosuppressed animals developed clinical or histopathological evidence of graft-versus-host disease. Sixty percent of animals in group 2 (n = 6) and 10% in group 3 (n = 1) died from infections; two other animals in group 2 died of emaciation. The seven animals of group 3 that were alive at 60 days had immunosuppression stopped at that time. All died of rejection within 1 month. In conclusion, double-drug therapy with tacrolimus and mycophenolate mofetil consistently allowed extended survival after small bowel transplantation in swine, preventing or controlling acute cellular rejection without a high incidence of lethal complications related to overimmunosuppression.

A rare case of pancreatic lipoma

During CT scanning, a pancreatic lipoma was diagnosed in a 70 year-old woman presenting with abdominal pain, elevated amylase and abnormal liver function tests. The patient underwent surgical excision of the lipoma located in the head of the pancreas. The postoperative course was uneventful. This is the third case of pancreatic lipoma described in the literature. It is a very rare neoplasm that should be included in the category of "non-ductal" tumors of the pancreas. The role of different diagnostic tools for the differential diagnosis of ductal pancreatic adenocarcinoma is discussed.

A search for double minute chromosomes in cultured lymphocytes from different types of tumors

Double minutes are considered the products of DNA amplification and are rare in normal human cells. They have been observed in cultured lymphocytes in selected samples of human populations as one of the characteristics of the so-called rogue cells. We scored 9500 metaphases of cultured lymphocytes from 65 subjects with a variety of heredity and sporadic tumors and from 30 healthy subjects. The 15 cells with double minutes were found in subjects with multiple endocrine neoplasia type 1 (14 cases) and with familial adenomatous polyposis (1 case). Only one rogue cell was found among the 15 cells with double minutes.

[Choledochocele: a rare cause of chronic pancreatitis of the head of the pancreas]

The authors critically review the literature in order to ascertain the current state of knowledge regarding the anatomopathological, clinical and therapeutic characteristics of choledochocele, or cystic dilation of the terminal portion of the biliary tract. In particular, the Authors examine the etiopathogenetic aspects to explain how the presence of a choledochocele may lead to the onset of chronic pancreatitis. A clinical case which was recently brought to their attention is examined in detail. It concerns a 27-year-old patient in whom the presence of a large choledochocele had led to the onset of severe cephalopancreatitis which resisted all forms of treatment. In the case in question, ERCP played a decisive role in the diagnosis of the choledochocele, whereas ultrasonography, CT and selective arteriography were useful above all in relation to pancreatitis. In the case described ultraradical surgery, namely duodenocephalopancreatectomy, allowed the severe pancreatopathy and its etiological cause (choledochocele) to be efficaciously treated, confirming that this type of surgery currently plays an important role in the treatment of chronic pancreatitis.

Chromosome abnormalities in lymphocytes and fibroblasts of subjects with multiple endocrine neoplasia type 1

A consistent degree of chromosome instability was found in cultured lymphocytes and in fibroblasts derived from skin biopsies of three patients with multiple endocrine neoplasia type 1 (MEN1). In both tissues, there was a significant increase in chromosomal breakage. Dicentrics and tricentrics, rings, translocations, deletions, acentric fragments, and presumptive double minutes were the most frequent abnormalities in lymphocytes. The fibroblasts of two patients had large clones consisting of trisomy 7 and trisomy 18 cells, respectively.

Evaluation of possible causes of delayed hypersensitivity impairment in cancer patients

The separate roles of malnutrition, advanced age, and stage of tumor growth as causes of impairment of delayed hypersensitivity response (DHR) was studied in 111 patients with solid tumors and in 56 nonneoplastic control patients matched for age, anatomical site of disease, degree of illness, and nutritional status. Pretreatment DHR to recall antigens (tuberculin, Candida, streptokinase-streptodornase, trichophyton) and to dinitrochlorobenzene in cancer patients with 9% anergic, 43% hypoergic, and 48% normoergic; the distribution of DHR in controls was not significantly different. In cancer patients, the serum albumin level showed an inverse correlation with the stage of tumor (p less than 0.01) and a positive correlation with the DHR (p less than 0.001); the serum albumin level was also in the controls positively correlated with the DHR (p less than 0.01), indicating that malnutrition in neoplastic or benign disease may cause depression of DHR. In well-nourished controls, age was inversely correlated with DHR (p less than 0.05), showing that aging itself may be another relevant cause of depression of DHR. The results of this study indicate that DHR in patients with solid tumors is similar to the DHR of nonneoplastic patients if matched for age, sex, and nutritional status. DHR impairment in cancer patients appears to be caused mainly by aging and by malnutrition due to the advanced progression of cancer.