Biliary cystic disease and neoplasia: surgical management

Background Congenital cystic dilatation of the extra- and intrahepatic bile ducts is a rare condition with several potential complications, especially a high risk of malignant degeneration, which may develop from an anomalous arrangement of the pancreatico-biliary ductal junction. Patients Twenty-two patients with cystic dilatation of the biliary tree, subdivided according to the Todani classification, were observed and treated during a 17-year period. The intrahepatic ducts were involved in 15 patients. Results Surgical treatment involved either total excision of extrahepatic cysts, hepatic resection in cases of segmental intrahepatic disease or, in the presence of diffuse intrahepatic disease, a wide biliary-digestive anastomosis performed onto the biliary confluence, with the intent of reducing the risk of neoplastic degeneration. One patient with extensive and symptomatic liver involvement complicated by biliary cirrhosis has already undergone liver transplantation, and another two patients who are currently asymptomatic may require this procedure in future. Neoplastic degeneration was found in three patients (one each of Todani type I, type IVa and type V), or 14% of the series. The postoperative course was complicated by cholangitis in only two patients, who were treated successfully with antibiotics. Except for one patient with a type I cyst complicated by carcinoma, who died 14 months post-operatively, all patients are alive and well at a mean follow-up of eight years (range 8 months to 17 years). Discussion The ideal surgical procedures to cure the disease and prevent malignant degeneration are: (a) complete excision of the extrahepatic biliary cysts; (b) hepatic resection in cases of segmental intrahepatic involvement; (c) wide bilio-digestive anastomosis in cases of multiple intrahepatic involvement, or liver transplantation when this is complicated by secondary biliary cirrhosis

Total gastrectomy versus upper pole gastrectomy for the surgical therapy of Siewert type II adenocarcinoma of the esophagus: pathology may drive the choice

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Correlations between Molecular Alterations, Histopathological Characteristics, and Poor Prognosis in Esophageal Adenocarcinoma

Esophageal adenocarcinoma (EAC) is a severe malignancy with increasing incidence, poorly understood pathogenesis, and low survival rates. We sequenced 164 EAC samples of naïve patients (without chemo-radiotherapy) with high coverage using next-generation sequencing technologies. A total of 337 variants were identified across the whole cohort, with TP53 as the most frequently altered gene (67.27%). Missense mutations in TP53 correlated with worse cancer-specific survival (log-rank p = 0.001). In seven cases, we found disruptive mutations in HNF1alpha associated with other gene alterations. Moreover, we detected gene fusions through massive parallel sequencing of RNA, indicating that it is not a rare event in EAC. In conclusion, we report that a specific type of TP53 mutation (missense changes) negatively affected cancer-specific survival in EAC. HNF1alpha was identified as a new EAC-mutated gen

Laparoscopic Dor Fundoplication and oesophageal Myotomy

The laparoscopic approach to the Heller myotomy has become widely accepted. With the exception of rare situations, e.g. complications requiring conversion and complex redo surgery, laparoscopic myotomy, supplemented by the Dor fundoplication, is considered the standard technique. The general principles of the procedure are the same as that for the open technique. In this chapter, elements of the operation specific to the laparoscopic approach are presented

Metodologie di indagine statistica e matematica nell'approccio al Nodulo Solitario Polmonare: tra passato e futuro.

Nel capitolo vengono illustrate le metodiche di indagine statistica e matematica nell'approccio al nodulo solitario del polmone. Lo scopo è quello di introdurre il lettore alla conoscenza delle metodiche statistiche storicamente validate, l'analisi Bayesiana e l'analisi discriminante, e di illustrare nuove metodiche innovative di indagine matematica, la computazione della dimensione frattale, per lo studio del nodulo solitario del polmone

One hundred percent Follow up of a case series of patients operated upon for type II-IV Hiatus Hernia(II-IV HH) in the arch of 30 years..

Background: Medical and surgical literature often points out the risk of bias in interpreting results of GERD-HH surgery because of the frequent incompleteness and relatively short time of post operative follow up. Because of the peculiarity of the Italian NHS and society (low % of migration), we have the opportunity to report on a case series totally followed up according to a protocol for an unusually long time. Methods: 66 patients (median age 67.5 years) (41 women, 25 men) with II-IV HH underwent surgery from 1980 to 1994 with the “open” surgical approach and 34 (median age 69 years) (26 women, 8 men) in the period 1995–2010 with minimally invasive techniques. Patients at given time underwent interview, barium swallow and endoscopy. Results were considered poor in case of relapse of symptoms, endoscopic esophagitis any grade, hiatus hernia, post operative antirefl ux medical therapy. Follow up time was calculated from surgery to the last complete follow up. Results: The cumulative post-operative mortality was 3/100, 97 patients were followed up for a median period of 96 months (IQR 25.5–201) : 12 months, 11 patients; 13–36 months, 8 patients; 37–60 months, 17 patients; 61–120 months, 22 patients; 121–216 months, 22 patients; and 217–440 months, 17 patients. Hiatal hernia (HH) relapse occurred in 6/97 (6.2%). Satisfactory results were obtained in 92.8%, excellent in 39.2%, good in 43.2%, fair in 10.4%, and poor in 7.2% (6 HH relapse, 1 esophagitis without HH relapse). Discussion: Surgery for type II-IV hiatal hernia may be objectively satisfactory after years decades. Disclosure: All authors have declared no confl icts of interest