Trattamento chirurgico dei GIST gastrici non metastatici: due casi significativi e revisione della letteratura

I tumori stromali del tratto gastrointestinale (GIST) rappresentano un capitolo della chirurgia oncologica ancora in evoluzione e devono essere affrontati secondo criteri prognostici e terapeutici specifici. Nel sospetto di GIST il chirurgo deve vagliare tutte le opzioni terapeutiche, considerando tuttavia l’impossibilità frequente di predirne il comportamento biologico e quindi l’aggressività. La presenza di un GIST deve essere sempre sospettata nel caso di pazienti con emorragia del tratto gastroenterico, nei quali non emerga una diversa patologia causale. La strategia chirurgica deve considerare che, rispetto ai più comuni adenocarcinomi, una resezione conservativa in queste neoplasie ha un suo razionale anche per quanto riguarda la radicalità. L’estensione della resezione può variare, in relazione alle caratteristiche volumetriche e di sede, da interventi estremamente demolitivi condotti per via “aperta” tradizionale all’asportazione con accesso video-laparoscopico e demolizioni settoriali. La linfoadenectomia non è indicata di principio per la bassissima probabilità di diffusione linfatica di queste neoplasie. Vengono discussi di seguito due casi clinici giunti alla nostra osservazione per emorragia gastrointestinale. Nel sospetto di GIST gastrico le pazienti sono state sottoposte ad asportazione chirurgica della neoplasia: nel primo caso si è proceduto a una gastrectomia polare superiore, indicata per la contiguità della massa con il cardias; nel secondo caso è stata eseguita una resezione parziale del fondo gastrico a comprendere la neoformazion

A proposito di un caso di neuroma d'amputazione della via biliare dopo colecistectomia laparoscopica

Presentiamo un caso di neuroma del dotto epatico comune insorto 5 anni dopo colecistectomia (laparoscopica, convertita in laparotomica). Il paziente, di 73 anni, è stato ricoverato per ittero ostruttivo e sottoposto ad ecografia, TC e colangiografia retrograda endoscopica che evidenziavano una massa di 1 cm a livello del dotto epatico comune determinante una stenosi dello stesso. L?esame istologico sul pezzo operatorio ha dimostrato trattarsi di neuroma del dotto epatico comune. Basandoci sull?analisi di questo e di altri 42 casi descritti in letteratura, abbiamo potuto delineare le seguenti caratteristiche del neuroma delle vie biliari: 1) esiste un intervallo di tempo variabile tra la colecistectomia e l?insorgenza dell?ittero (da 2 mesi fino a 40 anni); 2) l?incidenza è simile dopo colecistectomia laparoscopica o laparotomica; 3) generalmente il decorso post-operatorio dell?intervento primitivo non è esente da complicanze; 4) la possibilità di variazioni nella localizzazione a livello dell?albero biliare (dotto cistico, via biliare principale, vie biliari intraepatiche); 5) l?ittero come primo segno di presentazione clinica; 6) la necessità di una diagnosi istologica; e 7) il trattamento di scelta è la resezione del tratto della via biliare interessata e la ricostruzione mediante epaticodigiunostomia. English version We report a case of neuroma of the common hepatic duct arising five years after cholecystectomy (laparoscopic then converted in laparotomic). A 73-years-old patient was admitted for obstructive jaundice. Ultrasonography, TC and cholangiography showed a nodular lesion of the common hepatic of 1 cm in diameter, causing a regular and important stenosis of the main bile duct. Histologic examination demonstrated neuroma. By the analysis of this and 42 other previously published cases, the following features of bile duct neuroma were outlined: 1) variable interval between cholecystectomy and the onset of jaundice (2 months to 40 years); 2) the same incidence after laparoscopic or laparotomic cholecystectomy; 3) the generally complicated postoperative course after first surgical approach; 4) the various localizations on the biliary tree (cystic, main bile duct, intrahepatic ducts); 5) the circumstances of onset are almost the same (obstructive jaundice); 6) the histologic examination is mandatory for a correct diagnosis; and 7) the best treatment is resection of the bile duct tract involved in neuroma and reconstruction of biliary tree with hepaticojejunostomy

Monocyte-derived tissue factor contributes to stent thrombosis in an in vitro system

none8sinonePalmerini T;Coller B;Cervi v; Tomasi L; Marzocchi A; Marrozzini C; Ortolani P; Branzi APalmerini T;Coller B;Cervi v; Tomasi L; Marzocchi A; Marrozzini C; Ortolani P; Branzi

HBV Reactivation in Patients with Past Infection Affected by Non-Hodgkin Lymphoma and Treated with Anti-CD20 Antibody Based Immuno-Chemotherapy: A Multicenter Experience

Hepatitis B virus reactivation (HBVr) can develop in HBV surface antigen (HBsAg) positive or HBsAg-negative and anti-hepatitis B core antigen antibodies (anti-HBc) positive (past HBV infection) patients receiving immuno-chemotherapy for hematological malignancies. A higher rate of HBVr is associated with the use of rituximab (R) in patients with past HBV infection, thus justifying an antiviral prophylaxis. In this study we evaluated the incidence of HBVr in a real-life cohort of 362 anti-HBc-positive subjects affected by non-Hodgkin lymphoma (NHL), mainly receiving lamivudine (LAM) prophylaxis (93%) and all undergoing a R-containing regimen. A retrospective, multicenter, observational study was conducted in 4 Italian Hematology Departments. The primary endpoint was the incidence of virologic (HBV DNA-positive), serologic (HBsAg-positive) and clinical (ALT increase > 3 × upper limit of normal) HBVr, which occurred in five, four and one patients, respectively, with a total HBVr rate of 1.4%. None of them had to discontinue the chemotherapy program, while two patients required a delay. Treatment-related adverse events (AEs) were reported during LAM prophylaxis in three patients (0.9%). In conclusion, this study confirms the efficacy and safety of LAM prophylaxis in anti-HBc-positive patients undergoing R-containing regimens

Results from the Multicenter Study on Aortoenteric Fistulization After Stent Grafting of the Abdominal Aorta (MAEFISTO)

Objective This study investigated the frequency, clinical features, therapeutic options, and results of aortoenteric fistulas (AEFs) developing after endovascular abdominal aortic repair (EVAR). Methods Eight Italian centers with an EVAR program participated in this retrospective multicenter study and collected data on AEFs that developed after a previous EVAR. Results A total of 3932 patients underwent EVAR between 1997 and 2013 at the participating centers. During the same period, 32 patients presented with an AEF during EVAR follow-up, 21 with original EVAR performed for atherosclerotic aneurysmal disease (ATS group) and 11 with the original EVAR performed for a postsurgical pseudoaneurysm (PSA group). The incidence of AEF development after EVAR was 0.46% in the ATS group and 3.9% in the PSA group. Anastomotic PSA as the indication to EVAR (P\ua0<.0001) and urgent/emergency EVAR (P\ua0=.01) were significantly associated with AEF development. Median time between EVAR and the AEF diagnosis was 32\ua0months (interquartile range, 11-75\ua0months) for the ATS group and 14\ua0months (interquartile range, 10.5-21.5\ua0months) for the PSA group. Among five AEF patients treated conservatively, two (40%) died, at 7 and 15\ua0months, and the remaining three were alive at a median follow-up of 12\ua0months. The AEF was treated surgically in 27 patients, including aortic stent graft explantation in all cases, in situ aortic reconstruction in 14 (52%), and extra-anatomic bypass in 13 (48%). Perioperative mortality was 37% (10 of 27). No additional aortic-related death was recorded in operated-on patients at a median follow-up of 28\ua0months. Conclusions Late AEFs rarely occur during EVAR follow-up, but the risk is significantly increased when EVAR is performed for PSA after previous aortic surgery and EVAR is performed as an emergency. Conservative and surgical treatment of post-EVAR AEF are both associated with high mortality. However, beyond the perioperative period, surgical correction of AEFs appears to be durable at midterm follow-up