Malignant insulinoma presenting as metastatic liver tumor. Case report and review of the literature

Insulin-secreting tumors are the commonest hormone-producing neoplasm of the gastrointestinal tract. They occur with an incidence of 4 cases per million per year. About 10% of them are metastatic and malignant insulinomas very rarely observed in children and in elderly. We report a rare case of very large malignant insulinoma in a 71-year-old woman admitted in our Oncological Institute on October 2005. She presented with fasting hypoglicemia (blood glucose 35 mg/dl) and high serum insulin levels (insulin 115.9 microU/ml). A computerized tomographic scan showed a pancreatic tail lesion of about 6 cm in max diameter and multiple liver metastases. A whole body scintiscan using 111In-DTPA-D-Phe1-octreotide was made and an increased uptake in the tail of the pancreas has been found. The patient was submitted to liver biopsy and the diagnosis of a metastatic insulin-secreting tumor was immunoistochemically confirmed. Due to the presence of some hypoglicemic episodes uncontrolled by medical treatment, on December 2005 the patient was admitted to surgical intervention with a body and tail pancreatic resection. Post-operatively the patient experienced again syncope with hypoglycemia and hyperinsulinemia. It was then decided to start a schedule of treatment with somatostatin analog (octreotide subcutaneously 500 microg three times a day) with a good control of blood glucose levels (101 mg/dl). A trans-arterial chemioembolization was planned but the patient died for pancreatic and cardiovascular complications before this treatment started.

Modified liver hanging maneuver during orthotopic liver transplantation with inferior vena cava preservation: results after 120 consecutive applications

The outflow venovenous anastomosis represent a crucial aspect during orthotopic liver transplantation (OLT) with inferior vena cava (IVC) preservation. The modified Belghiti liver hanging maneuver applied to the last phase of hepatectomy, lifting the liver, provides a better exposure of the suprahepatic region and allows easier orthogonal clamping of the three suprahepatic veins with a minimal portion of IVC occlusion. The outflow anastomosis constructed with a common cloacae of the three native suprahepatic veins is associated with a lower incidence of graft related venous outflow complications. The procedure planned in 120 consecutive OLT was achieved in 118 (99%). The outflow anastomosis was constructed on the common cloaca of the three hepatic veins in 111/120 cases (92.5%). No major complications were observed (bleeding during tunnel creation, graft outflow dysfunction, etc) except in one patient with acute Budd-Chiari, who successfully underwent retransplantation.

Cystic pancreatic neoplasms: 12-year surgical experience

Cystic pancreatic neoplasms have been increasingly diagnosed in the last years. Resection is recommended in most cases, but their management has not been standardized since an accurate nonoperative differentiation is often difficult. A retrospective review of 30 patients undergoing surgical resection for cystic pancreatic neoplasms between 1993 and 2005 was performed. Median age of the patients was 63 years and 63.5% were female. Twelve patients (40%) were asymptomatic. Twenty-nine had curative resections. Pathologic analysis revealed 13 serous cystadenomas, 9 mucinous cystadenomas, 3 mucinous cystadenocarcinomas, 4 intraductal papillary mucinous neoplasms and 1 solid pseudopapillary neoplasm. Overall mortality was 6.5% (2 patients). Postoperative complications occurred in 12 patients (41%). Pancreatic fistula occurred in 7 cases (24%). Reoperation was required in 2 patients (6.5%). Two patients operated for mucinous cystadenocarcinoma and invasive intraductal papillary mucinous neoplasms died of recurrence at 24 and 7 months postoperatively. Excluding another patient died from other cause, all others are currently alive with no evidence of disease. Diagnostic accuracy for cystic pancreatic neoplasms is still limited. Considering the good prognosis and acceptable morbidity and minimal mortality after surgical treatment in specialized centers, resection seems still justified in most cases.

The surgical treatment of ilio-femoral venous obstruction

METHODS

A series of 9 patients of a mean age of 48 years, operated on for compression of the ilio-femoral venous axis is reported. The cause of obstruction was external compression in 3 cases, a retroperitoneal sarcoma in 1 case, and an infrarenal aortic aneurysm in 2. Two patients presented with a Cockett's syndrome, 3 with a chronic ilio-femoral thrombosis, and one with a post-traumatic segmentary stenosis. Treatment consisted in a resection/Dacron grafting of 2 infrarenal aortic aneurysms, one femoro-caval bypass graft, 2 transpositions of the right common iliac artery in the left hypogastric artery for Cockett's syndrome, 3 Palma's operations for chronic thrombosis, and one internal jugular vein interposition for segmentary stenosis.

RESULTS

There were no postoperative deaths and no early thromboses of venous reconstructions performed. All the patients were relieved of symptoms during the follow-up period, whose mean length was 38 months.

CONCLUSION

The cause of venous obstruction and the presence of symptoms which are resistant to medical treatment are the main indications to ilio-femoral venous revascularization. The choice of the optimal treatment in each single case yields satisfactory results.

Pancreaticoduodenectomy for pancreatic metastatic melanoma

Isolated pancreatic metastatic melanoma is a rare occurrence. Even more rare is the surgical treatment of this lesion. However, considering the lack of effective systemic treatment and the decreasing morbidity and mortality rates of pancreatic resections in specialized centers, selected patients, especially if symptomatic, may be considered for surgical resection to achieve good palliation or improve survival. We performed a pancreaticoduodenectomy in a patient with a bleeding pancreatic metastasis from cutaneous melanoma excised 10 years before and reviewed the recent literature.

[Small bowel stromal tumors in a "meckelian" location. About a clinical observation]

The Meckels divetriculum has a prevalence of the 0.3-3%. It is surgically removed only when arise a complication or a neoplasia. The Meckels diverticulum tumors are unfrequent and observed in only the 0.5-3.2% of the Meckels diverticula. The 12% of these tumors are a GIST. We report a case of a gastrointestinal stromal tumor with neural immunophenotype, observed in a patient presenting a deep venous thrombosis perhaps with a paraneoplastic origin. We also report some observations about the state of the art about the GIST management and particularly of all of them arising in a Meckels diverticulum.

[Surgical treatment of lung metastasis: experience with 108 cases]

In this study the Author's analyze their experience (between September 1973 and December 2002) with 108 pulmonary resections for metastatic tumors to the lungs to evaluate prognostic factors and the impact on survival of extended metastasectomy. Overall mortality and major morbidity were 1.85% and 2.78%. The actuarial survivals at 5 and 10 years were respectively 46.6% and 39.9%. The best mean survivals are observed in patients with metastases from breast, colorectal, thyroid and urinary tract carcinomas, in cases with disease free interval > 12 months and in the patients who underwent sequentially surgery and chemotherapy. Patients with pulmonary metastases also potentially benefit from iterative pulmonary resection.

[Growth hormone secretion in heart failure]

Growth hormone is a pituitary polypeptide hormone regulating growth in paediatric age as well as inducing anabolic actions directly or IGF-I mediated in adult age. Particularly, in many animals GH and IGF-I receptors were observed in cardiac myocyte membrane. GH modifies left ventricle structure and function. As concerns spontaneous GH secretion, some data suggest that pituitary gland can have a compensatory role on endocrine response to heart failure. Heart failure stage was directly correlated to nocturnal GH levels. All GH spontaneous night secretion parameters as well as IGF-I levels showed a range between normal people and very high spontaneous secretion. Therefore in these patients there are either a GH peripheric resistance or a reduction of the activity of GH/IGF-I axis. Anyhow in our patients, GH 24 hour infusion was inducing a 5 fold increase in GH concentration and a 50% increase in basal IGF-I levels. Anker et al. suggested to evaluate nutritional state in heart failure patients, observing no differences in non-cachectic patients vs controls, while cachectic patients presented a typical GH resistance syndrome. Interestingly, cardiovascular effects of GH administration seem to be only marginally correlated to hemodynamic basal state. On the other hand basal hormonal setting of the patient seems to correlate to the GH-induced cardiovascular response. In fact, low basal IGF-I but high basal GH patients presented the worst endocrine and cardiovascular response to GH infusion. In literature there are controversial data about GH treatment in patients with chronic heart failure. The heterogeneity of the population could be the reason for this discrepancy. Besides very different IGF-I responses to GH have been reported. Therefore, as there is good clinical evidence that GH acute infusion can improve heart failure, it seems to be necessary firstly to evaluate the basal endocrine status of the patients. Particularly attention should be given to those patients that present a peripheric GH resistance. On the other hand, those patients with a reduced pituitary GH reserve are supposed to have very beneficial effects from GH treatment.

Preliminary observations on the effects of acute infusion of growth hormone on coronary vasculature and on myocardial function and energetics of an isolated and blood-perfused heart

Recent studies have shown that growth hormone (GH) deficiency may deteriorate post-ischemic myocardial reperfusion damage. Furthermore, GH has been reported to be a promising therapeutic option in the treatment of chronic myocardial dysfunction. However, the exact mechanisms of action of GH on the cardiovascular system, particularly in the acute setting, are still unclear. The aim of our study consisted of monitoring the acute effects of GH infusion on isolated blood-perfused rabbit heart according to dose-response pattern and during ischemic conditions to test its anti-ischemic property. Seven blood-donors perfused isolated hearts were used as experimental model. The mechanical and metabolic data of the isolated organs were continuously monitored. Under aerobic conditions, dose-response curves were initially tested after intracoronary infusion of GH at increasing dosages (1, 2, 3 mg/l). After a stabilization period, the effects of GH infusion (5 mg/kg) administered 30 minutes prior to acute global myocardial ischemia (30 minutes) were also investigated. At the doses tested, GH did not induce any changes either in the developed or in the diastolic pressures of the isolated organ. However, transient reduction of the coronary perfusion pressure was observed at the dosage of 3 mg/l. During the ischemia/reperfusion study, at the dosages used in this study, GH did not modify either the degree of stunning in the early reperfusion or the recovery of the developed pressure at the end of reperfusion. In addition, GH did not prevent either the increase of diastolic pressure during ischemia or the release of lactate and CPK during reperfusion. Tissue content of high-energy phosphates was also not changed by GH infusion. In our experimental model, acute GH infusion did not reduce the ischemic/reperfusion damage of the myocardium. However, GH transiently induced coronary vasodilation without modifying the myocardial contractility. Acute effects of GH appear, therefore, to predominantly relate to vascular dilation suggesting that the effects on myocardial contractility may require long-lasting intake being likely linked to enhancement of specific protein synthesis or gene expression of cardiac myocytes.

Transperitoneal approach for pericardial drainage

A variety of surgical approaches for pericardial drainage have been proposed. The choice of the best approach can be, therefore, oriented depending on the cause of the pericardial effusion. Recently a different approach, for neoplastic or post-traumatic pericardial effusion, has been proposed, in order to create a peritoneal-pericardial window avoiding the insertion of a tube. We report a case of late postoperative cardiac tamponade in a patient with a previous coronary surgery in which, due to extensive adhesion of the anterior wall a modified transperitoneal approach to the pericardium, was used.

Combined surgical approach for carotid and coronary stenosis. Sixty-four patients and review of literature

BACKGROUND

The proper role of combined carotid endarterectomy (CEA) and coronary bypass (CABG) is still controversial. We contribute to the discussion through the critical evaluation of 64 consecutive patients, whose data have been collected in a prospective way.

METHODS

Between 1990 and 1999, 64 patients presenting a critical coronary disease (unemendable by PTA) associated with severe carotid stenosis (= or >70% if symptomatic, = or >80% if asymptomatic), underwent combined CEA-CABG. Cardiological symptoms were evident in 90.6% of cases. Thirty-five patients (54.7%) had a three-vessel coronaropathy, 18 (28.1%) a two-vessel disease and 11 (17.2%) severe stenosis of the common trunk; furthermore 7 patients (10.9%) had a low ejection fraction (<50%). A positive neurologic history was present in 22 (44%) patients. Thirty-four patients (55%) had a carotid stenosis >90%; a significant disease of the contralateral carotid axis was observed in 53% of cases: stenosis >50% in 30 patients and thrombosis in 4. CEA was performed with somato-sensorial evoked potential monitoring.

RESULTS

The hospital mortality rate was 6.2% (4 patients). The cause of death was cardiac in 2 cases (1 early bypass thrombosis and 1 irreversible coronary spasm) and related to a multiorgan failure in 2. The neurologic morbidity rate was 0%.

CONCLUSIONS

Our data highlight that in these high-risk patients the combined approach dramatically reduces the stroke risk although the mortality rate is still higher than that observed after CEA or CABG.

[Neurinoma of the brachial plexus: 2 case reports]

Neurinomas, also referred to as neurilemmomas and schwannomas, are rare benign tumours of the peripheral nerves. A small percentage of these lesions arise from the brachial plexus. The Authors report two cases of schwannoma arising from the brachial plexus. Such lesions, usually asymptomatic, may cause sensitivity alterations or, less frequently, motor deficits in the involved arm. Tumour enucleation, avoiding damage to any of the nervous fascicles, is the treatment of choice.

A new method to assess the fluidodynamic behaviour of an angiographic contrast agent

PURPOSE

To propose a new method for the assessment of the fluidodynamic behaviour of angiographic contrast agents. The method enables measurement of the spatial distribution and time dependence of the contrast agent along a pseudo-vessel on images obtained with an X-ray image intensifier.

MATERIAL AND METHODS

A particular phantom was devised consisting of a plexiglas box with an insert into which a latex tube with a 0.4 cm in diameter was placed in order to simulate the tortuous flow of a blood vessel. The box, which is filled with water to simulate the thickness of a normal patient, is connected to an injection and pumping system which serve to keep the contrast agent flowing in the pseudo-vessel tube. The pseudo-vessel tube was filled with plain water in one case and with saline solution in another case to assess their different dilution capabilities. The phantom and the flow of contrast agent were imaged with a conventional X-ray image intensifier system and the images were stored in digital format during 35 second acquisitions at a speed of 4 frames per second; for any frame it is possible to measure the mathematical contrast in any position in the image. Further, a diagram showing the time dependence of the spatial distribution of the mathematical contrast is proposed. The X axis shows the spatial distribution of the mathematical contrast, whereas the Y axis shows its temporal variation with a gray level proportional to the mathematical contrast value. By building an horizontal profile of this diagram one can obtain the spatial distribution at a fixed time, while by building a vertical profile one can obtain the temporal variation at a fixed point. Several different contrast agents were so tested.

RESULTS

The proposed method allows different fluido-dynamic behaviour patterns of contrast agents and flowing media to be shown. Owing to the different chemical characteristics of water and saline solution these media have different dilution capabilities (higher for water) and this is well demonstrated by the diagram profiles obtained for each. The system has also allowed the detection of a particular behaviour of some contrast agents, whose spatial distribution was non uniform even in the last frames, thus showing a tendency to maintain their bolus-nature over time. An interesting feature which can be noticed in all the temporal profiles is the presence of a "pre-bolus", i.e. the contrast is higher at the very beginning of the flow, then decreases and after some time starts to increase again. Though the initial contrast value obviously depends on the iodine concentration employed, the method shows the contrast variation as a function of time is different for different contrast agents.

CONCLUSIONS

The method and the equipment proposed provide a good description of the fluidodynamic behaviour of different contrast agents, but do not constitute a reference method for testing haemodynamic behaviour which, "in vivo", is obviously affected by several other chemical and metabolic factors. However, the method allows evaluation of the contrast agents from a physical and fluidodynamic point of view, showing that the iodine content is not the only feature affecting their behaviour. The method can be used in quality control to test the constancy of the physical behaviour of different contrast agents.

[Use of abdominal wall retractor Laparo Tenser in gasless laparoscopic cholecystectomy]

High pressure CO2-peritoneum for laparoscopic surgery is not indicated in patients with impairment of cardiorespiratory and renal function and in high risk patients and in obesity. On the other site the uncontrolled abdominal insufflation and the blind insertion of the first trocar in patients with extended intraperitoneal adhesions, often cause bleeding and the intestinal loops dislocation, and can determine visceral lesions. In these patients gasless technique with an abdominal laparolifter can be employed. We report an experience of 36 patients undergoing laparoscopic cholecystectomy by a subcutaneous planar retractor. It was observed a good operative exposure in 83.3%; the surgery was safely performed in 88.8%. Two suprafascial hematoma related to the insertion of the needles of the Laparo Tenser occurred. A regular post-operative discharge was observed in 84.4%. These good results supports the extension of the laparoscopic approach for the cholecystectomy to complicated or to high risk patients.

Long-term results of coronary artery bypass grafting procedure in the presence of left ventricular dysfunction and hibernating myocardium

OBJECTIVE

Long-term left ventricular (LV) performance and patient outcome after coronary artery bypass grafting (CABG) procedure in the presence of depressed LV function and hibernating myocardium (HM) have been poorly determined. Therefore, we prospectively evaluated patients undergoing CABG with severe LV dysfunction and HM to elucidate postoperative prognosis.

METHODS

We enrolled 120 consecutive patients undergoing CABG with severe LV dysfunction and HM as assessed by dobutamine echocardiography and by rest-redistribution radionuclide (Thallium-201) study. Mean patient age was 60+/-9 years (range 31-77 years). Mean preoperative LVEF was 28%+/-9 (range 10-40%). All patients underwent echocardiographic study to assess LV recovery of function intraoperatively, prior to hospital discharge, at 3 months, at 1 year, and yearly during the follow-up. Univariate and multivariate analysis were performed to to evaluate predictors of postoperative survival.

RESULTS

There were 2 hospital (1.6%) and 15 late (12.5%) deaths, mainly for heart failure, leading to an actuarial survival of 80+/-6% and 60+/-9% at 5 and 8 years, respectively. LVEF significantly improved perioperatively (from 28+/-9% to 40+/-2%, P<0.01). Increase in LVEF, however, was gradually offset over the time (EF of 33+/-9%, 32+/-8%, and 30+/-9% at 3 months, and 12 months, and 8 years after surgery, respectively). Furthermore, patients who experienced limited LV functional recovery perioperatively had a more remarkable decline of LVEF thereafter, and suffered from recurrence of heart failure symptoms (freedom from heart failure 82+/-5% and 60+/-8% at 4 and 8 years respectively). Advanced preoperative NYHA Class, and age were independent risks factors for reduced postoperative survival. Preoperative angina and use of arterial conduits apparently did not influence patient morbidity and mortality at long term.

CONCLUSION

CABG procedure in the presence of HM enhances LV recovery of function and has a favourable prognosis. Functional benefit of the left ventricle, however, appears to be time-limited, despite remarkable improvement in patient functional capacity. Advanced preoperative heart failure, minimal perioperative improvement of LVEF, and age account for a poor long-term prognosis.