Choledochocele: Choledochal Cyst Ora Distinct Entity?

Choledochocele represents a cystic dilatation of the distal common bile duct and it’s included in Todani’s classification as type III choledochal cysts. We report a case of a 66-years-old man who presented a suspected gallbladder lithiasis with colic abdominal pain, vomit, fever, jaundice and abnormal liver function tests. However the endoscopic retrograde cholangio-pancreatography revealed the absence of stones in the common bile duct and the presence of a 15mm-wide choledochocele that was successfully treated with an endoscopic sphincterotomy. Additionally a comprehensive review of the literature of the last 15 years was performed, collecting 105 cases of choledochocele. The available data were classified in 10 variables and subsequently analysed. Summarizing all data, we noticed that choledochocele presents different characteristics if compared with other types of choledochal cysts: The population affected is older, there isn’t a strong female prevalence, the most frequent manifestation is pancreatitis instead of jaundice and cholangitis, the association with anomalous pancreato-biliary duct junction is rare and the risk of malignancy is lower. The standard for the diagnosis is endoscopic retrograde cholangio-pancreatography instead of magnetic resonance cholangio-pancreatography and the most accepted treatment is endoscopic sphincterotomy in order to allow the correct outflow of the biliary juice. In conclusion, even if choledochocele is commonly considered a type of cystic dilatation of the common biliary duct and it is usually included in the choledochal cysts classification, it has to be considered as a distinct entity with its own features

Choledochocele: Choledochal Cyst Ora Distinct Entity?

Choledochocele represents a cystic dilatation of the distal common bile duct and it’s included in Todani’s classification as type III choledochal cysts. We report a case of a 66-years-old man who presented a suspected gallbladder lithiasis with colic abdominal pain, vomit, fever, jaundice and abnormal liver function tests. However the endoscopic retrograde cholangio-pancreatography revealed the absence of stones in the common bile duct and the presence of a 15mm-wide choledochocele that was successfully treated with an endoscopic sphincterotomy. Additionally a comprehensive review of the literature of the last 15 years was performed, collecting 105 cases of choledochocele. The available data were classified in 10 variables and subsequently analysed. Summarizing all data, we noticed that choledochocele presents different characteristics if compared with other types of choledochal cysts: The population affected is older, there isn’t a strong female prevalence, the most frequent manifestation is pancreatitis instead of jaundice and cholangitis, the association with anomalous pancreato-biliary duct junction is rare and the risk of malignancy is lower. The standard for the diagnosis is endoscopic retrograde cholangio-pancreatography instead of magnetic resonance cholangio-pancreatography and the most accepted treatment is endoscopic sphincterotomy in order to allow the correct outflow of the biliary juice. In conclusion, even if choledochocele is commonly considered a type of cystic dilatation of the common biliary duct and it is usually included in the choledochal cysts classification, it has to be considered as a distinct entity with its own features

Enantioselective organocatalytic strategies to noncanonical α‐amino acids

Organocatalytic asymmetric synthesis has evolved over the years and continues to attract the interest of many researchers worldwide. Enantiopure noncanonical amino acids (ncAAs) are valuable building blocks in organic synthesis, medicinal chemistry, and chemical biology. They are employed in the elaboration of peptides and proteins with enhanced activities and/or improved properties compared to their natural counterparts, as chiral catalysts, in chiral ligand design, and as chiral building blocks for asymmetric syntheses of complex molecules, including natural products. The linkage of ncAA synthesis and enantioselective organocatalysis, the subject of this perspective, tries to imitate the natural biosynthetic process. Herein, we present contemporary and earlier developments in the field of organocatalytic activation of simple feedstock materials, providing potential ncAAs with diverse side chains, unique three-dimensional structures, and a high degree of functionality. These asymmetric organocatalytic strategies, useful for forging a wide range of C–C, C–H, and C–N bonds and/or combinations thereof, vary from classical name reactions, such as Ugi, Strecker, and Mannich reactions, to the most advanced concepts such as deracemisation, transamination, and carbene N−H insertion. Concurrently, we present some interesting mechanistic studies/models, providing information on the chirality transfer process. Finally, this perspective highlights, through the diversity of the amino acids (AAs) not selected by nature for protein incorporation, the most generic modes of activation, induction, and reactivity commonly used, such as chiral enamine, hydrogen bonding, Brønsted acids/bases, and phase-transfer organocatalysis, reflecting their increasingly important role in organic and applied chemistry

Sulfoxonium Ylides in Aminocatalysis: An Enantioselective Entry to Cyclopropane-Fused Chromanol Structures

The 1,1a,2,7b-tetrahydrocyclopropa[c]chromene, aris-ing from fusion of chromane and cyclopropane rings is the core of medicinally relevant compounds. Engaging sulfoxonium ylides in enantioselective aminocatalytic reactions for the first time, a convenient entry to this scaffold is presented. Several ring-fused derivatives were obtained in moderate-to-good yields and enantiose-lectivities and with perfect diastereoselectivity at the cyclopropane, using an alpha,alpha-diphenylprolinol aminocatalyst. The versatility of the hemiacetal moiety in the products was leveraged to effect various synthetic manipulations

Creatine Supplementation to Improve Sarcopenia in Chronic Liver Disease: Facts and Perspectives

Creatine supplementation has been one of the most studied and useful ergogenic nutritional support for athletes to improve performance, strength, and muscular mass. Over time creatine has shown beneficial effects in several human disease conditions. This review aims to summarise the current evidence for creatine supplementation in advanced chronic liver disease and its complications, primarily in sarcopenic cirrhotic patients, because this condition is known to be associated with poor prognosis and outcomes. Although creatine supplementation in chronic liver disease seems to be barely investigated and not studied in human patients, its potential efficacy on chronic liver disease is indirectly highlighted in animal models of non-alcoholic fatty liver disease, bringing beneficial effects in the fatty liver. Similarly, encephalopathy and fatigue seem to have beneficial effects. Creatine supplementation has demonstrated effects in sarcopenia in the elderly with and without resistance training suggesting a potential role in improving this condition in patients with advanced chronic liver disease. Creatine supplementation could address several critical points of chronic liver disease and its complications. Further studies are needed to support the clinical burden of this hypothesis

Laparoscopic Treatment of Gastric Duplication in a Child

Introduction: Gastric duplication is a rare congenital anomaly with an incidence of 4-8% of all gastrointestinal duplications; enteric duplications are ectopic cystic or tubular structures with a mucous and muscular tunics and they can be in contiguity/continuity with the intestinal lumen.1 Gastric duplication is often an occasional finding, associated to aspecific sintomatology for which pre-operative diagnosis is not univoque; differential diagnosis with other retroperitoneal diseases or mesenteric cysts can be difficult.1 (Run time 8min). Material and Methods: We present a case of a one-year-old child with a pre-natal ultrasound (US) finding of endo-abdominal cystic lesion. After birth, US scans showed an anechogenic-cyst of 33x28mm in the left upper quadrant, between stomach, spleen and kidney. The magnetic resonance confirmed the presence of the lesion (40x34mm), imprinting the posterior gastric wall, the spleen and the anterior side of left kidney. An esophagous-stomach-duodenum contrast study was also performed, showing the imprinting cyst on the great curvature close to the gastric fundus without communication with gastric lumen. On follow-up, the child underwent to periodic US scans and no growth or ultrasonographic changes were described. At 13-months, the diagnosis was still unclear and the patient underwent explorative laparoscopy with esophagous-gastric-duodenoscopy (EGDS). The preliminary EGDS showed a 35mm convexity on the posterior wall of gastric fundus with no evidence of orifice. A 5mm trans-umbilical trocar was placed and 5mm trocar in the epigastric region and 10-12mm trocar in the left side were positioned. At the abdominal exploration the cyst resulted to be in continuity with the posterior gastric wall on the superior third of the great curvature. The lesion was isolated from other tissues, but the postero-medial wall of neoformation appeared to be not dissociable and in continuity with the stomach; a complete resection of the cyst, using 45mm linear stapler, was performed including a small portion of the great gastric curvature. At the following intra-operative endoscopic control no more evidence of irregularity of the gastric wall was seen and the suture was assured. Results: The operative time was 140-minutes. No complications occurred and the blood loss was minimal. The patient started oral intake on 5’ post-operative-day and was discharged on 6’ post-operative-day. The histological examination confirmed the gastric nature of cyst. At 1-year of follow-up no recurrences were diagnosed and the child presents in good health with a regular growth. Conclusion: We can assume that laparoscopic surgery is the correct procedure for gastric duplication cysts, to get both definitive diagnosis and treatment, and the radical surgical excision represents the treatment of choice in order to avoid neoplastic degeneration of internal lining mucosa.2 Furthermore surgical laparoscopy appears to be a feasible and safe technique

Robotic Versus Laparoscopic Adrenalectomy: Pluriannual Experience in a High-Volume Center Evaluating Indications and Results

Background: Robotic adrenalectomy offers several clinical benefits if compared with laparoscopic adrenalectomy; however, its superiority is still under debate. The aim of this study was the investigation of differences between the two techniques, and a comparison when approaching right or left side adrenal lesions was further conducted. Materials and Methods: All patients undergoing laparoscopic and robotic unilateral adrenalectomy at our institution from January 2006 to December 2019 were collected and retrospectively analyzed. Statistical analysis was conducted; differences between the two cohorts were reported. Results: A total of 160 cases were included (84 patients in laparoscopic adrenalectomy-group [LA-g] 76 cases in robotic adrenalectomy-group [RA-g]). The groups were homogeneous for demographic data. No intraoperative complications were reported; mean amount of intraoperative blood loss was comparable. No cases of conversion to open surgery were required. RA-g presented a longer operative time than LA-g for right adrenalectomy (P = .05), no differences were noted for left side (P = .187). Overall morbidity was 21% for LA-g and 10.5% for RA-g (P = .087), with an inferior rate of surgical complications for RA-g (P = .024), and for robotic left adrenalectomy than robotic right procedure (P = .03). Length of hospital stay was shorter for RA-g (P = .005). Conclusions: Robotic adrenalectomy presents similar outcomes as laparoscopic approach with some benefits for selected cases. Left adrenal lesions seem to receive greater advantages from robotic technique. Large randomized controlled trials are required to determine the role of robotic adrenal surgery and if the indication can be standardized based on the laterality of adrenal procedure

First cases of combined full robotic partial nephrectomy and colorectal resections: Results and new perspectives

Background: Nowadays the robotic platform is widespread in general surgery, urology, and gynecology. Combined surgery may represent an alternative to sequential procedures and it allows the treatment, at the same time, of coexisting lesions; in this perspective, full-robotic multiorgan surgery is starting to gain interest from surgeons worldwide. Methods: Between April and June 2019, two patients presenting with synchronous colorectal and kidney cancers underwent, respectively, full-robotic right colectomy with right partial nephrectomy and anterior rectal resection with left partial nephrectomy. Surgeries were performed by both the general surgery and urology team. Results: No intraoperative complications were registered and the postoperative course was uneventful in both cases. Conclusions: Combined multiple organ surgery with full robotic technique is safe and offers oncological adequate results. A multi-team surgical pre-planning is mandatory to reduce invasiveness and operative time. To the best of our knowledge, these are the first reports of full robotic partial nephrectomy combined with colorectal procedures

Role of Vitamin D in Liver Disease and Complications of Advanced Chronic Liver Disease

Vitamin D is a crucial nutrient with many pleiotropic effects on health and various chronic diseases. The purpose of this review is to provide a detailed report on the pathophysiological mechanisms underlying vitamin D deficiency in patients with chronic liver disease, addressing the different liver etiologies and the condition of advanced chronic liver disease (cirrhosis) with related complications. To date, patients with liver disease, regardless of underlying etiology, have been shown to have reduced levels of vitamin D. There is also evidence of the predictive role of vitamin D values in complications and progression of advanced disease. However, specific indications of vitamin D supplementation are not conclusive concerning what is already recommended in the general population. Future studies should make an effort to unify and validate the role of vitamin D supplementation in chronic liver disease