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.

Walking and disability after rehabilitation in patients with cerebellar stroke

AIM

Aim of this study is to verify if the presence of extracerebellar stroke lesions negatively affects walking and functional capacities recovery of patients with cerebellar stroke.

METHODS

This study was carried out on 43 patients. Patients' selection was made through CT and MRI scans. Neuroimaging data were used to divide patients into 2 groups: 1) a group composed of 20 patients with isolated cerebellar involvement (group C); (2) a group composed of 23 patients with cerebellar plus extracerebellar involvement (group C+E). Patients were assessed through trunk control test (TCT), Lindmark scale and Rankin scale at admission and at discharge. Before rehabilitation, there were no significant differences in disability, TCT and Lindmark scores between the 2 groups of patients.

RESULTS

After rehabilitation, Lindmark scale (P=0.022) and TCT (P=0.015) scores of group C were statistically higher than those of group C+E. Disability was greater in group C+E (P=0.036). In these patients disability was absent in 17.4% of subjects, moderate-slight in 47.8% and severe in 34.8%. In group C disability was absent in 40% of subjects, slight-moderate in 55% and severe in 5%. Effectiveness in walking was 79.1% in group C and 57% in group C+E. Efficiency in walking was 0.13 in C group and 0.07 in C+E subjects. Effectiveness (P=0.008) and efficiency (P=0.008) of group C were significantly greater than of group C+E.

CONCLUSIONS

The study shows that the rehabilitation prognosis of cerebellar stroke is affected by the presence of extracerebellar stroke lesions.

The silence of the ribosomal RNA genes

Over the past decade emerging evidence has indicated that epigenetic factors control and regulate nuclear processes. The genes encoding ribosomal RNA (rRNA) represent an ideal model to study how epigenetics and chromatin can modulate gene expression. The reason for this is that in each cell, the rRNA genes exist in two distinct types of chromatin structure: an 'open' one corresponding to transcriptionally active genes and a 'closed' one representing the silent genes. Recent studies indicate that an epigenetic network mediates the transcriptional state of rDNA. Interplay of DNA methylation, histone modification and chromatin-remodeling activities establishes silencing at the rDNA locus in higher eukaryotes as well as at the underdominant genes in hybrid cells. The aim of this review is to summarize current knowledge about the active and silent states of rRNA genes and of nucleolar organizing regions and to analyze the mechanisms involved in the establishment and inheritance of rDNA silencing.

[Prothrombotic gene mutations in women with recurrent abortions and intrauterine fetal death]

AIM

The factor V Leiden mutation (FVL) and the G20210 prothrombin gene mutation (FII G20210A) are well-established risk factors for venous thromboembolism. In the recent years many scientific reports have suggested that these defects are associated with an increased risk of intrauterine fetal death. The aim of our study was to investigate the prevalence of these molecular defects in subjects with history of unexplained pregnancy loss.

METHODS

One-hundred and fifty women, 99 with history of unexplained recurrent pregnancy loss (between the 13th and the 20th week of gestation) and 51 with history of unexplained fetal death (pregnancy loss after the 20th week of gestation) were studied for hereditary thrombophilia. Physiologic coagulation inhibitors (antithrombin III, protein C, protein S) were in the normal range.

RESULTS

The prevalence of FVL and FII G20210A mutations was compared in patients with recurrent pregnancy loss and in a control group of 115 healthy women, without history of pregnancy loss (6.1% and 8.1% for FVL and FII G20210A respectively vs 2.6% for both mutations in the control group, P=0.36 for FVL and P=0.13 for FII G20210A). FVL and FII G20210A mutations were significantly more prevalent in women with fetal death (19.6%, P=0.001 for both mutations).

CONCLUSIONS

Our data suggest that the screening for the FVL and FII G20210A mutations is useful in the setting of unexplained early and late pregnancy loss. Further studies are necessary in order to clarify the real impact of prothrombotic molecular defects on the pregnancy outcome and then to evaluate the appropriate therapeutic approach.

Causes of portal venous thrombosis in cirrhotic patients: the role of genetic and acquired factors

OBJECTIVE AND METHODS

We compared frequencies of three common prothrombotic mutations (factor V Leiden, the G20210A mutation of the prothrombin gene, and homozygosity for C677T methylenetetrahydrofolate reductase) in 219 cirrhotic patients, 43 with and 176 without portal vein thrombosis (PVT). The following variables were related to PVT: prothrombin levels, platelet count, Child-Pugh classification, previous abdominal surgery, number of decompensation events, size of varices, red markers on varices, and sclerotherapy. All patients were followed up for a mean period of 18 months (range 10-30).

RESULTS

Prothrombotic mutations were detected in 64 of the 219 cirrhotic patients (29.2%), at equal frequency in patients with or without PVT. At univariate analysis, PVT was associated with Child-Pugh classes B and C, signs of liver decompensation, large varices with red markings, sclerotherapy, and abdominal surgery. At multivariate analysis, PVT was associated with sclerotherapy [odds ratio (OR) 4.9, 95% confidence interval (CI) 2.2-11] and previous surgery (OR 2.8, 95% CI 1.2-6.3). The combination of the two acquired factors increased the risk of PVT, whereas the combination of local with genetic defects did not. Only a single patient with genetic thrombophilia and without PVT at inclusion developed the complication during follow-up, concomitantly with the development of hepatocellular carcinoma.

CONCLUSION

In cirrhotic patients prothrombotic mutations by themselves are not causative of PVT. Sclerotherapy and previous abdominal surgery favour the development of two-thirds of cases of PVT; in the remaining cases the pathogenesis remains elusive.

[Isolated resection of the caudate lobe in metastasis of colorectal cancer]

The presence of metastatic lesions confined to the caudate lobe (CL or segment I) is quite a rare event. Even more rare is the decision to perform an isolate CL resection. Segmental resection in the liver is justified by the evidence that primary and secondary lesions, in early stage, are confined to the originating segment, and therefore a segmentectomy can be considered for the CL as well. Anatomy of the CL was deeply studied through the years since the surgical approach to this liver segment requires a detailed knowledge of its surgical anatomy and only after 1985 the surgical technique for CL isolate resection was established. We report our experience with 1 case of isolate colo-rectal metastasis confined to the caudate lobe and describe the surgical technique employed.

[The painful hemiplegic shoulder: effects of exercises program according to Bobath]

AIM

To verify whether a shoulder exercises program according to Bobath reduced the shoulder pain in hemiplegic patients.

METHODS

We studied a total of 20 patients with pain shoulder. Ten patients are assigned to group R (submitted to rehabilitation) and ten to group R+E (submitted to rehabilitation and shoulder exercises program according to Bobath). Shoulder exercises program was self-performed by the patients after training in occupational rehabilitation unit. The assessment of patients was performed at admission to hospital, at discharge and three months after discharge. Shoulder pain (VAS), shoulder range of motion, disability (FIM), motor function (Fugl-Meyer scale) and spasticity (Ashworth scale) of paretic arm were evaluated in all patients.

RESULTS

VAS was similar in both groups at admission and decreased in group R+E at discharge without reaching significant differences (p=0.253). On the contrary, VAS and Shoulder range of motion improved statistically in group R+E (p=0.0001, p<0.04 respectively) after three months. The others variables measured did not change.

CONCLUSIONS

This study showed that a shoulder exercises program according to Bobath reduces shoulder pain of patients with hemiplegia if it is performed daily and for a long period of time.

IL-10 haplotypes as possible predictors of spontaneous clearance of HCV infection

BACKGROUND

In hepatitis C virus infection an inappropriate ratio of pro-inflammatory and anti-inflammatory cytokines may either determine different outcomes of the infection or affect the benefit of antiviral treatment. Given that polymorphisms in regulatory regions of cytokine genes influence cytokine production, we determined frequency of polymorphisms of IL-10, IFNgamma, and TNFalpha genes in HCV-infected patients and healthy controls, and investigated their association with either ongoing or cleared HCV infection, or with response to treatment.

METHODS

Genomic DNA from 270 patients and 145 controls sharing the same ethnic background was studied by polymerase chain reaction, restriction enzyme digestion, direct sequencing, and microsatellite analysis.

RESULTS

The IL-10 ATA haplotype was more frequent in patients with spontaneous HCV RNA clearance (36.0%) than in patients with persistent infection (23%) (p=0.009, p corrected = 0.036). Neither TNF -308 and -238 polymorphisms nor IFNgamma alleles variability were associated with different HCV outcome. However, the combination of ATA homozygous state and IFNgamma 119 allele was more frequent in patients with spontaneous HCV clearance than in patients with ongoing disease (p=0.012; p corrected = 0.048). We could not confirm the reported effect of genetic influence on the response to treatment.

CONCLUSIONS

Our findings indicate that heterogeneity in the promoter region of the IL-10 gene has a role in determining a spontaneous favourable outcome of HCV infection.

[Benign hilar stenosis mimicking Klatskin tumor]

Preoperative diagnosis of hilar carcinoma (Klatskin tumor) is usually done according to the only clinical and imaging findings. However, in 5-15% of patients operated with this diagnosis, hilar stenosis is an inflammatory pseudo-tumoral benign one. We reported the case of a patient who underwent resection of common bile duct for suspicion of hilar carcinoma in whom, despite clinical and imaging findings highly suggestive of malignancy, pathologic examination revealed aspecific cholangitis. After a review of the literature, we conclude that resection of common bile duct is mandatory to exclude malignancy and allows excellent biliary drainage. Associated major hepatectomy should ideally be indicated, due to its higher risks, after pathological confirmation of cholangiocarcinoma, if necessary by frozen section.

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.

Resection and transplantation: evaluation of surgical perspectives in HIV positive patients affected by end-stage liver disease

PURPOSE

The aim of this study was to evaluate the opportunity of surgical treatment in terms of liver resection or liver transplantation in HIV positive patients affected by an end stage liver disease that referred to our liver unit.

METHODS

Among 1350 outpatients who referred to our liver unit from January 2002 to September 2003, thirty-two (2,4%) were HIV positive. The routes of transmission of the viral infection, the related co-infections and the underlying liver disease were recorded. The therapeutic pathway was analysed. The kind and the duration of the surgical procedures were assessed.

RESULTS

Fourteen (44%) of these thirty-two patients were not suitable for surgical treatment. Surgery was planned in 9 of 32 HIV positive patients (28%). Four patients (12%) were submitted to liver resection and OLT was performed in five patients (15%). Hepatocellular Carcinoma was present in 4 (44%) of the HIV positive patients considered for surgery.

CONCLUSIONS

In conclusion in our centre the 28% of HIV positive out patients had the opportunity to receive a surgical treatment. The candidate to this surgery is mostly young, HCV and/or HBV coinfected and affected by HCC in 44% of cases.

[Disability and rehabilitation outcome in hemiplegia with global aphasia and neglect]

PURPOSE

Global aphasia and neglect are considered to be the neuropsychological disorders mostly affecting the hemiplegia outcome. The aim of this study is to examine which of the two disorders is making worse the recovery from hemiplegia.

METHODS

The study was conduced on 45 patients suffering from hemiplegia: 15 subject with global aphasia, 15 with neglect and 15 without neuropsychological disorders (control group). All patients were subject to rehabilitation treatment. Before and after rehabilitation, the assessment of patients was made using neuropsychological tests, Fugl-Meyer scale and Functional Independence Measure (FIM). At admission, all patients were not self-sufficient.

RESULTS

At the end of the rehabilitation period the recovery of motor function was poor in both groups. The damage on limbs motion was severe in 93.4% and marked in 6.6% of both patients with global aphasia and neglect. At discharge, the FIM motor score of patients with global aphasia (44.6 +/- 13) was higher than in those with neglect (37.2 +/- 10) and was not statistically different from control group (51.2 +/- 18) (p = 0.493). The FIM motor score of patients with neglect was significantly lower than control group (p = 0.036). In patients with global aphasia effectiveness was 35.5% and efficiency 0.40 while in patients with neglect effectiveness was 18% and efficiency 0.22. The final disability was lower in patients subject to global aphasia than neglect.

CONCLUSIONS

The study showed that neglect limits the recovery from stroke more than global aphasia.e.

Sentinel node in gastric cancer surgery

Sentinel Node (SN) biopsy studies have been recently applied to gastric cancer. In this series, 40 selected patients operated for gastric adenocarcinoma located in the lesser curvature and/or anterior wall of the body and antrum, underwent an intraoperative dye lymphography. The lymphatic ducts and nodes were visualized and a SN was evidenced in all cases. This was removed and a frozen section examined. In all cases a radical D2-3 gastrectomy was performed and histology, molecular biology, RT-PCR research of micrometastases (CEA-mRNA), were determined on the specimens. Correlations between T and histological status of SN and regional nodes were done. In 16 cases the SN was negative and all the resected regional nodes were negative too. In 15 cases the SN node was positive and other nodes in other stations were found to be positive as well. In 2 cases the SN was negative but other nodes, in the same stations and in others, were positive (false negative = 5%). In 7 cases the SN was the only node in which metastases occurred, 3 demonstrated by conventional histology and 4 detected by RT-PCR. In these 7 cases the SN was the only involved node out of all resected nodes, thus demonstrating to be the real first node along the lymphatic routes from the tumour. This experience seems to confirm the existence of a Sentinel Node and that each gastric adenocarcinoma has its own lymphatic basin in which metastasis can occur. Although a prudent attitude towards the indications resulting from these observations is required, in selected cases a controlled and tailored lymphoadenectomy could be adopted.

[Work capacity of housewives with complete laceration of the rotator cuff]

OBJECTIVE

The aim of the this study is to evaluate the work capacity of housewives with full thickness tear of the rotatory cuff (FTTRC).

METHODS

Twenty-five subjects have been studied. The FTTRC was located un the right shoulder in 16 cases, in the left shoulder in 5 cases and was bilateral in 4 patients. All patients were female; the average age was 72.4 +/- 4 (range 62-81). The Assessments were made using the Constant Scale, the Groningen Activity Restriction Scale and the Simon's Test.

RESULTS

The result of this study confirmed that none of the housewives was able to carry out the houseworks quite independently and with no effort. 16% of the patients did the houseworks with great effort while 84% was helped in making some activities. Help is necessary for the usual housework and heavy domestic works (washing glasses, using vacuum cleaner to clean the floor). Patient's relatives provided help in 76.2% of cases while 23.8% were assisted by maid. Help was occasional in 33.3% of cases, continuous in 52.3% and full in 14.4% of patients. Disability resulting from FTTRC is heavier in subjects where electrical household appliances are not used (p < 0.05) and in subjects who feel deep pain (p < 0.05). The active movements of shoulder, local shoulder pain and level of use of upper limbs do not affect domestic works.

CONCLUSIONS

These study showed that FTTRC reduces work capacity of house wives. These disease is more preventing heavy domestic works.

[Genetic mutations, acquired coagulation system disorders and obstetric pathology. Personal experience]

BACKGROUND

To evaluate the incidence of thrombophilic disorders such as Factor II mutation, Leiden factor V and MTHFR genotype, and anti-phospholipid anti-bodies syndrome in women with or without pregnancy related problems.

METHODS

Sixty-three patients (group A) with pregnancy complications were included in the study and tested for Factor V mutation, Factor II mutation, 5-10 MTHFR reductase mutation and anti-phospholipid antibodies syndrome. The incidence of disorders was compared with thirty-six pregnancies without complications (control study, group B).

RESULTS

Hemostasis thrombophilic like disorders, were significantly high (p=0.001 vs group B). Nobody in both groups was homozygous for Leiden mutation or prothrombin mutation (Factor II). The prevalence of Factor V mutation in heterozygosis was significantly (p=0.01) higher in group A in comparison with group B. The MTHFR mutation in homozygosis was found in 21.4% of group A while in the control group it was 11%. Factor II mutation in heterozygosis and anti-phospholipid antibodies were found only in group A.

CONCLUSIONS

It is important to evaluate the hemocoagulation patterns in women with a history of complicated pregnancies.

Molecular mechanisms mediating methylation-dependent silencing of ribosomal gene transcription

Epigenetic control mechanisms silence about half of ribosomal RNA genes (rDNA) in metabolically active cells. In the mouse, 40% of rDNA repeats are methylated and can be activated by 5-azacytidine treatment. In exploring the effect of methylation on rDNA transcription, we found that methylation of a single CpG dinucleotide within the upstream control element of the rDNA promoter (at -133) abrogates rDNA transcription both in transfection experiments and in in vitro assays using chromatin templates. Chromatin immunoprecipitation assays demonstrate that methylation of the cytosine at -133 inhibits binding of the transcription factor UBF to nucleosomal rDNA, thereby preventing initiation complex formation. Thus, methylation may be a mechanism to inactivate rDNA genes and propagate transcriptional silencing through cell division.

A randomized trial of amantadine and interferon versus interferon alone as initial treatment for chronic hepatitis C

The aim of this study was to compare, in an open-label study, the efficacy and safety of a combination of interferon (IFN) and amantadine (AMA) with that of IFN alone in previously untreated patients with chronic hepatitis C. A total of 200 patients were randomized to 6 MU of IFN-alpha2a 3 times per week, with 200 mg of AMA daily (n = 99) or to an identical dose of interferon alpha2a (n = 101). Patients were treated for 12 months and observed for 6 months' posttreatment. At the completion of treatment, 28.7% of patients in the monotherapy group and 45.5% in the combination group had a virologic response (P =.014). At 6 months' posttreatment, a sustained virologic response was observed in 16.8% (95% CI: 9-23) of patients with IFN alone versus 29.3% (95% CI: 19-37) of patients who were treated with combination therapy (P =.036). In each of the 2 treatments, genotype was the only predictive parameter for a sustained response. At the logistic regression analysis, therapy and genotype were the only 2 parameters with an independent predictive value. In the combination group, at examination of month 3, hepatitis C virus (HCV)-RNA status had a 97.6% (95% CI: 93-102) positive predictive value and a 50% (95% CI: 37-63) negative predictive value for a sustained virologic clearance. A substantial proportion of naïve patients with chronic hepatitis C have an end-of-treatment and end-of-follow-up virologic and biochemical response to a combination of IFN and AMA. This new treatment appears safe and well tolerated.

[Experience of 10 years with the surgical treatment of lung cancer in elderly patients]

The surgical treatment of lung cancer in elderly patients is correlated with a lot of complications that in most cases are cardiopulmonary type; for this reason, in past times these patients were left out of the surgical treatment. Today, the progress of surgical, diagnostic and anesthetic techniques permit to execute pulmonary resections in patients older than 70 years too. The aim of this study is to evaluate postoperative complications and long-term and long-term survival in patients under and over the age 70. Between January 1990 and June 2000 we have assessed 172 patients with lung neoplasm. We have divided patients in two groups: those younger than 70 years of age (group 1, n = 119) and those older than 70 years of age (group 2, n = 53). Postoperative mortality for group 2 was 7.5% and for group 5.1%. The overall postoperative complication rate for group 2 was 30.2% and for group 1 10.9%. Within group 1 main complications have been of surgical type (61.5%) while in group 2 medical type (cardiopulmonary), with higher frequency in patients ASA 3 or ASA 4. The mortality at 12 months for non-neoplastic causes was 10.2% for group 2 and 2.5% for group 1. On the contrary, the mortality at 12 months for neoplastic causes was 8.2% for group 2 and 6.7% for group 1. We haven't noticed an important correlation between the extension of the resection and the recurrence of disease. The survival at 3 years was 46.5% for group 1 and 41% for group 2 and associated with neoplastic causes.