Surgical management of hydatid liver disease

BACKGROUND

large retrospective clinical study describing the long-term experience of a single center in the surgical management of liver echinococcosis in an endemic area.

METHODS

232 patients were operated for liver hydatid disease between 1978 and 2012. Seventy-three patients (Group A) underwent a radical procedure (total pericystectomy or hepatectomy), while 145 (Group B) were treated with a more conservative method (partial cystectomy, with external drainage, omentoplasty or capitonnage) and 14 (Group C) received a combination of total and partial cystectomies. Morbidity, mortality, post-operative complications and recurrence rates in the long-term setting were retrospectively evaluated.

RESULTS

Group A patients were treated with zero mortality and a morbidity rate of 10.95%. No recurrence was documented. In Group B, mortality reached 2.76%, (p = 0.153 compared to Group A) morbidity 24.13% (p = 0.021) and there were 10 cases of relapse (6.9%) at three-year complete follow-up (p = 0.989). Extrahepatic sites of disease were not uncommon.

DISCUSSION

radical surgical procedures were better tolerated by patients and yielded better results in terms of recurrence rates.

Unusual locations of hydatid disease: a 33 year's experience analysis on 233 patients

Hydatid disease is caused by the tapeworm Echinococcus granulosus and it is an endemic parasitic disease of the Mediterranean countries. Although the liver is the most involved organ by this disease, hydatidosis can be found anywhere in the human body. Rare forms of location may pose diagnostic and therapeutic dilemmas. Herein we report our experience with unusual located hydatid disease diagnosed and treated at our center the last 33 years. A total of 233 patients were treated for echinococcosis (91 males: 39% and 142 females: 61%) between 1980 and 2013 at our center. 18 of them (7, 8%) with uncommon located hydatid disease, were analyzed retrospectively. 18 patients (8 males and 10 females) were presented with unusual location of hydatid disease in our series. Two of them had only extrahepatic cysts (0, 9%). A total of 64 hydatid cysts with unusual location were analyzed. The most prevalent extrahepatic sites were peritoneal cavity and spleen. Total cystectomy with or without tube drainage or omentopexy was performed for hydatid cysts of the peritoneal cavity in our series. Splenectomy was performed in all cases of splenic hydatidosis. The mean time of post operative stay was 16, 3 days (range 7-35 days), morbidity 11% and mortality 5, 4%. Although echinococcosis is found most often in the liver and lungs, it seems that any organ can be involved by this zoonotic disease. The operating surgeon must always consider the possibility of unusual location of echinococcal cyst when dealing with patients with cystic mass in endemic areas, because any misinterpretation may result in unfavorable outcomes.

Continuous Intraoperative Neuromonitoring (C-IONM) Technique with the Automatic Periodic Stimulating (APS) Accessory for Conventional and Endoscopic Thyroid Surgery

One of the most important trends in intraoperative neural monitoring (IONM) in thyroid surgery is currently the real-time monitoring of the vagus nerve (VN) in order to prevent recurrent laryngeal nerve (RLN) iatrogenic damages. Notably, continuous intraoperative neuromonitoring (C-IONM) seems to be superior to intermitted intraoperative neural monitoring (I-IONM) because it enhances standardization by permanent vagus nerve (VN) stimulation, and it provides entire and constant RLN function monitoring as the surgeon dissects and removes the thyroid gland. It also has to be highlighted that the surgical maneuvers for the automatic periodic stimulating (APS) placement must be accurate and standardized in order to avoid a potential iatrogenic morbidity on the VN function. We recommend the experienced surgeon be very careful in each step, with cautious dissection. With this review article we provide a comprehensive analyses of C-IONM technique with the APS accessory for conventional and endoscopic thyroid surgery.

Intraoperative neuromonitoring of the external branch of the superior laryngeal nerve during thyroidectomy: the need for evidence-based data and perioperative technical/technological standardization

The external branch of the superior laryngeal nerve (EBSLN) is surgically relevant since its close anatomical proximity to the superior thyroid vessels. There is heterogeneity in the EBSLN anatomy and EBSLN damage produces changes in voice that are very heterogenous and difficult to diagnose. The reported prevalence of EBSLN injury widely ranges. EBSLN iatrogenic injury is considered the most commonly underestimated complication in endocrine surgery because vocal assessment underestimates such event and laryngoscopic postsurgical evaluation does not show standardized findings. In order to decrease the risk for EBSLN injury, multiple surgical approaches have been described so far. IONM provides multiple advantages in the EBSLN surgical approach. In this review, we discuss the current state of the art of the monitored approach to the EBSLN. In particular, we summarize, providing our additional remarks, the most relevant aspects of the standardized technique brilliantly described by the INMSG (International Neuromonitoring Study Group). In conclusion, in our opinion, there is currently the need for more prospective randomized trials investigating the electrophysiological and pathological aspects of the EBSLN for a better understanding of the role of IONM in the EBSLN surgery.

Evidence-based Analysis on The Clinical Impact of Intraoperative Neuromonitoring in Thyroid Surgery: State of the Art and Future Perspectives

Laryngeal nerve injuries are one the most critical complications during thyroid and parathyroid surgery. Iatrogenic damages to the recurrent laryngeal nerve (RLN) are relevant in terms of clinical implications, economic costs, and for malpractice litigation. In order to minimize potential neural damages, a standardized surgical technique is mandatory. Intraoperatory neuromonitoring (IONM) of the RLN is an important adjunct to the traditional approach and is a reliable tool for neural mapping and in dissection and prognostication of postoperative neural function 4. Because of this, most of the iatrogenic damages are not related to direct transection, but they are visually undetectable. Notwithstanding the increasing use of IONM at this stage, there is still the need for prospective, randomized, well-powered, and well-designed trials in order to further validate (via evidence-based data) the role of IONM in thyroid surgery. The aim of this review is to provide a critical analysis of the scientific evidences on the clinical impact of IONM in thyroid surgery showing the unsolved problems and the future challenges.

BMI and lymph node ratio may predict clinical outcomes of gastric cancer

AIM

BMI and the lymph node (LN) ratio can affect short- and long-term outcomes of patients with gastric cancer.

PATIENTS & METHODS

This study includes 104 consecutive patients with gastric adenocarcinoma who underwent curative gastrectomy divided in two groups: overweight group (group A) and normal weight group (group B).

RESULTS

We found that 53.4% of our patients were overweight (group A). The overall rate of postoperative complications was 16.3%, while mortality was 1%. Statistical analyses revealed that postoperative morbidity was significantly higher in group A (p < 0.05). Long-term survival was significantly higher in group B. Cox regression showed a statistically significant correlation between higher BMI and poor long-term survival after curative gastrectomy. Multivariate analysis has identified age and the LN ratios as independent prognostic factors of survival.

CONCLUSION

In this retrospective analysis, BMI and LN ratio were independently associated with survival in patients with gastric cancer. Further studies are needed to confirm our findings.

Potential of antibody-drug conjugates and novel therapeutics in breast cancer management

Progress in the treatment of cancer over the past decade has been slow. Targeting a mutated gene of an individual patient tumor, tumor-guided agents, and the first draft of the human genome sequence have created an overenthusiasm to achieve personalized medicine. However, we now know that this effort is misleading. Extreme interpatient and intratumor heterogeneity, scarce knowledge in how genome-wide mutational landscape and epigenetic changes affect transcriptional processes, gene expression, signaling transduction networks and cell regulation, and clinical assessment of temporary efficacy of targeted drugs explain the limitations of these currently available agents. Trastuzumab and a few other monoclonal antibodies or small-molecule tyrosine kinase inhibitors (TKIs) represent an exception to this rule. By blocking ligand-binding receptor in patients with human epidermal growth factor receptor 2 (HER2) amplification and overexpression, trastuzumab added to chemotherapy in HER2-positive patients has been proven to provide significant overall survival benefit in both metastatic and adjuvant settings. Lapatinib, a small-molecule dual inhibitor (TKI) of both HER2 and EGFR (epidermal growth factor receptor) pathways, has an antitumor activity translated into progression-free survival benefit in HER2-positive metastatic patients previously treated with a taxane, an anthracycline, and trastuzumab. Despite these advances, ~25% of patients with HER2-positive breast cancer experience recurrence in the adjuvant setting, while in the metastatic setting, median survival time is 25 months. In this review, we discuss the safety, efficacy, and limitations of the trastuzumab emtansine (T-DM1) conjugate in the treatment of HER2-positive metastatic breast cancer. We also highlight Phase III randomized trials, currently underway, using either the T-DM1 conjugate or various combinations of monoclonal antibodies and TKIs. Moreover, in contrast with all these agents developed on the basis of "central dogma" of simplified reductionist transcription and single gene-phenotype linear relationship, we summarize the emerging, amazing era of next-generation, transcriptional circuitry and intracellular signaling network-based drugs guided by the latest advances in genome science and dynamics of network biology.

A patient presenting with acute abdomen due to metastatic small bowel melanoma: a case report

Introduction

Malignant tumors of the small bowel are rare. Melanoma of the small intestine is in most cases metastatic from a primary skin lesion. Perforation of small bowel melanoma is an extremely rare entity. To the best of our knowledge this is the fifth case published to date.

Case presentation

We report a rare case of acute abdomen due to perforated metastatic small bowel melanoma in a 38-year-old Caucasian man.

Conclusions

In the majority of cases small bowel melanoma represents metastasis from cutaneous sites. Although rare, the possibility of abdominal metastatic melanoma presenting with the clinical picture of acute abdomen must be always considered by the operating surgeon in patients with a history of primary cutaneous malignant lesion.