Pushing ML Predictions Into DBMSs

In the past decade, many approaches have been suggested to execute ML workloads on a DBMS. However, most of them have looked at in-DBMS ML from a training perspective, whereas ML inference has been largely overlooked. We think that this is an important gap to fill for two main reasons: (1) in the near future, every application will be infused with some sort of ML capability; (2) behind every web page, application, and enterprise there is a DBMS, whereby in-DBMS inference is an appealing solution both for efficiency (e.g., less data movement), performance (e.g., cross-optimizations between relational operators and ML) and governance. In this article, we study whether DBMSs are a good fit for prediction serving. We introduce a technique for translating trained ML pipelines containing both featurizers (e.g., one-hot encoding) and models (e.g., linear and tree-based models) into SQL queries, and we compare in-DBMS performance against popular ML frameworks such as Sklearn and ml.net. Our experiments show that, when pushed inside a DBMS, trained ML pipelines can have performance comparable to ML frameworks in several scenarios, while they perform quite poorly on text featurization and over (even simple) neural networks.

Exploring the ATR-CHK1 pathway in the response of doxorubicin-induced DNA damages in acute lymphoblastic leukemia cells

Doxorubicin (Dox) is one of the most commonly used anthracyclines for the treatment of solid and hematological tumors such as B-/T cell acute lymphoblastic leukemia (ALL). Dox compromises topoisomerase II enzyme functionality, thus inducing structural damages during DNA replication and causes direct damages intercalating into DNA double helix. Eukaryotic cells respond to DNA damages by activating the ATM-CHK2 and/or ATR-CHK1 pathway, whose function is to regulate cell cycle progression, to promote damage repair, and to control apoptosis. We evaluated the efficacy of a new drug schedule combining Dox and specific ATR (VE-821) or CHK1 (prexasertib, PX) inhibitors in the treatment of human B-/T cell precursor ALL cell lines and primary ALL leukemic cells. We found that ALL cell lines respond to Dox activating the G2/M cell cycle checkpoint. Exposure of Dox-pretreated ALL cell lines to VE-821 or PX enhanced Dox cytotoxic effect. This phenomenon was associated with the abrogation of the G2/M cell cycle checkpoint with changes in the expression pCDK1 and cyclin B1, and cell entry in mitosis, followed by the induction of apoptosis. Indeed, the inhibition of the G2/M checkpoint led to a significant increment of normal and aberrant mitotic cells, including those showing tripolar spindles, metaphases with lagging chromosomes, and massive chromosomes fragmentation. In conclusion, we found that the ATR-CHK1 pathway is involved in the response to Dox-induced DNA damages and we demonstrated that our new in vitro drug schedule that combines Dox followed by ATR/CHK1 inhibitors can increase Dox cytotoxicity against ALL cells, while using lower drug doses. • Doxorubicin activates the G2/M cell cycle checkpoint in acute lymphoblastic leukemia (ALL) cells. • ALL cells respond to doxorubicin-induced DNA damages by activating the ATR-CHK1 pathway. • The inhibition of the ATR-CHK1 pathway synergizes with doxorubicin in the induction of cytotoxicity in ALL cells. • The inhibition of ATR-CHK1 pathway induces aberrant chromosome segregation and mitotic spindle defects in doxorubicin-pretreated ALL cells.

A41 FONTAN ASSOCIATED LIVER DISEASE: THE ROLE OF TRANSIENT ELASTOGRAPHY IN CHILDREN AND ADOLESCENTS

Background

Non-invasive assessment of Fontan Associated Liver Disease (FALD) is of interest, but studies have yielded inconsistent results about the correlation of severity of disease with laboratory values and imaging. Transient elastography (TE) is a non-invasive imaging modality used commonly for liver stiffness measurement (LSM) and in Fontan patients it is hypothesized to reflect not only liver fibrosis but also venous congestion.

Purpose

To better define the potential role of TE for non-invasive assessment of the severity of FALD.

Method

This was a retrospective study conducted on patients’ medical records at CHU Sainte-Justine Hospital. Patients less than 18 years of age with FALD who had at undergone at least one LSM by TE between 1998-2021 were included. The relationship between LSM and liver function tests, hepatic ultrasound findings (including a cirrhosis score), cardiac catheterization results and histological fibrosis scores were analyzed. The impact of interventions during cardiac catherization on LSM were also studied.

Result(s)

A total of 54 patients (36 boys and 18 girls) with FALD were studied. Median age at Fontan surgery was 4.6 years (IQR 4.0 ─ 5.4 years). Higher LSM values significantly correlated with longer time from Fontan, higher total and direct bilirubin and GGT levels, higher INR, longer APTT, lower Factor V, and lower absolute lymphocyte count. Greater LSM was also significantly associated with the presence of heterogenous parenchymal echogenicity, irregular liver contours and greater ultrasonographic cirrhosis scores. Higher TE values were significantly correlated with higher wedged hepatic venous pressure and Fontan pressure. After catherization interventions that addressed stenoses, there was a statistically significant reduction in mean LSM (24.9±3.63 kPa vs 15.8±4.6 kPa, p=0.005). After closure of significant pulmonary collaterals, mean LSM tended to increase, but this difference did not reach statistical significance (19.1±1.9 kPa vs 24.6±3.5 kPa, p=0.2). At liver biopsy, significant direct correlation was found between LSM and the grade of sinusoidal fibrosis and LSM. TE with values >20 kPa were found to have higher grades of sinusoidal fibrosis, while values <20kPa had higher grades of sinusoidal dilatation.

Conclusion(s)

This study showed that TE allows to identify patients with higher cholestatic parameters, more severe liver fibrosis at biopsy and sonographic signs suggestive of cirrhosis. Moreover, it confirmed that liver congestion significantly contributes to LSM values. Interestingly, catheter interventions addressing pulmonary stenoses led to the improvement of TE measurements, giving hope for the reduction of hepatic venous congestion in these patients, which might have an effect on their FALD. Finally, the LSM threshold of 20 kPa could be useful clinically as a value above which fibrosis is likely to be significant, while if below could indicate a greater contribution from hepatic congestion.

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Disclosure of Interest

None Declared

circPVT1 and PVT1/AKT3 show a role in cell proliferation, apoptosis, and tumor subtype-definition in small cell lung cancer

Small cell lung cancer (SCLC) is treated as a homogeneous disease, although the expression of NEUROD1, ASCL1, POU2F3, and YAP1 identifies distinct molecular subtypes. The MYC oncogene, amplified in SCLC, was recently shown to act as a lineage-specific factor to associate subtypes with histological classes. Indeed, MYC-driven SCLCs show a distinct metabolic profile and drug sensitivity. To disentangle their molecular features, we focused on the co-amplified PVT1, frequently overexpressed and originating circular (circRNA) and chimeric RNAs. We analyzed hsa_circ_0001821 (circPVT1) and PVT1/AKT3 (chimPVT1) as examples of such transcripts, respectively, to unveil their tumorigenic contribution to SCLC. In detail, circPVT1 activated a pro-proliferative and anti-apoptotic program when over-expressed in lung cells, and knockdown of chimPVT1 induced a decrease in cell growth and an increase of apoptosis in SCLC in vitro. Moreover, the investigated PVT1 transcripts underlined a functional connection between MYC and YAP1/POU2F3, suggesting that they contribute to the transcriptional landscape associated with MYC amplification. In conclusion, we have uncovered a functional role of circular and chimeric PVT1 transcripts in SCLC; these entities may prove useful as novel biomarkers in MYC-amplified tumors.

A Framework to Evaluate the Quality of Integrated Datasets

Evaluation is a bottleneck in data integration processes: it is performed by domain experts through manual onerous data inspections. This task is particularly heavy in real business scenarios, where the large amount of data makes checking all integrated tuples infeasible. Our idea is to address this issue by providing the experts with an unsupervised measure, based on word frequencies, which quantifies how much a dataset is representative of another dataset, giving an indication of how good is the integration process. The paper motivates and introduces the measure and provides extensive experimental evaluations, that show the effectiveness and the efficiency of the approach.

Abstract 5788: Genomic and transcriptomic profiles of DNA damage response genes in acute myeloid leukemia

The DNA damage response (DDR) pathway is frequently deregulated in cancer and it represent an attractive therapeutic opportunity. In acute myeloid leukemia (AML), different mechanisms of DDR deregulation have been identified, but a systematic investigation on DDR alterations is missing. To understand how the DDR pathways contribute to leukemogenesis, we studied the gene expression and mutational profiles of 274 DDR genes by analysing 539 AML cases profiled by whole genome (WGS) and RNA sequencing. WGS data were used to identify mutations in genes of the DDR and in a panel of genes known to be mutated in AML (n=73). Transcriptomic data were analysed through unsupervised clustering, differential expression and enrichment analysis. We detected 150 single nucleotide variants (SNVs) in 130 patients (24%, average 0.3 SNVs/case). Genes mutated in more than 1% of cases were ATM, BLM, BRCA2, POLG and POLQ. The most frequently altered pathway was the homologous recombination/Fanconi Anemia (HR) pathway (29%), followed by the genes that coordinates the DDR pathway (20%). We detected a trend toward mutual exclusivity between mutations in TP53 and mutations in genes of HR pathway or the genes that coordinates the DDR pathway (adj-p &lt;0.02). To further investigate the interplay between TP53 mutations and the HR pathway, we analysed the expression profiles of HR genes in 539 patients. We identified two groups of patients having higher (HR-high) or lower (HR-low) expression levels of HR genes. A panel of 5 genes was able to discriminate patients between the two groups (BRCA1, RAD54B, RMI2, UBE2T and XRCC2; AUC=0.9). Enrichment analysis on differentially expressed genes and gene set enrichment analysis showed that the cell cycle pathway, together with the G2/M transition/mitotic phase, E2F targets and the fatty acid metabolism pathways were upregulated in HR-high patients, while the pRB, EZH2, RPS14 and HOXA9 pathways were downregulated. Moreover, we observed that AML expressing CBFB-MYH1, RUNX1-RUNXT1 or carrying RAD21 mutations had higher chances to express lower levels of HR genes (HR-low), while patients with STAG2, SRSF2, U2AF1, FLT3-ITD alterations had higher chances of having higher expression of HR genes (p&lt;0.05). NPM1-mutated cases without FLT3-ITD clustered within the HR-low profile (adj-p&lt;0.05), while TP53 mutated cases tended to cluster in the HR-high group, although statistical significance was not reached. In conclusion, our data showed the presence of alterations in the DDR pathway that might be the reflection of driver events in AML. Functional studies will elucidate the functional impact of these alterations. The results suggested the presence of a therapeutic window that might be exploited with DDR inhibitors in molecularly-defined subgroups of patients.

Supported by the Torsten Haferlach-Leukämiediagnostik-Stiftung and AIRC IG 2019 (project 23810).

Citation Format: Antonella Padella, Stephan Hutter, Wencke Walter, Constance Baer, Irene Azzali, Andrea Ghelli Luserna Di Rorà, Martina Ghetti, Lorenzo Ledda, Matteo Paganelli, Claudia Haferlach, Wolfgang Kern, Giorgia Simonetti, Giovanni Martinelli, Torsten Haferlach. Genomic and transcriptomic profiles of DNA damage response genes in acute myeloid leukemia [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5788.

Abstract 1555: circPVT1 and linear PVT1 isoforms regulate cell growth, metabolic and DNA damage response related gene signatures in acute myeloid leukemia

Non-coding (nc)RNAs, including circular (circ)RNAs, contribute to tumor development and progression. Several ncRNAs were shown to affect the onset, prognosis, and treatment of acute myeloid leukemia (AML) in the past years. The human Plasmacytoma Variant Translocation 1 (PVT1) gene maps on the long arm of chromosome 8 (8q24), in the same genomic region hosting MYC and encoding for 83 linear (PVT1, lncipedia.org) and 26 high-confidence circular isoforms (circPVT1, www.circbase.org). The most common isoform of circPVT1 is a product of back-splicing of 410 nt and contains the whole exon 2 of PVT1 in a closed loop-like structure (hsa_circ_0001821). The study aims to investigate the role of PVT1 isoforms and circPVT1 in AML. Firstly, we focused on the various PVT1 isoforms and their differential expression in leukemia. Fourteen out of the 83 linear isoforms are expressed in the hematopoietic tissues (lymph node and white blood cells, www.noncode.org), and 6 of them were detectable in AML cell lines, including the t(8;21) KASUMI-1 and the NPM1-mutated OCI-AML3 models, together with circPVT1. We designed two antisense-oligonucleotides (ASOs), mapping on common exonic region and targeting the linear isoforms expressed in OCI-AML3 and KASUMI-1 cells, and one ASO spanning the junction region of circPVT1. ASOs-mediated knockdown (KD) showed a relevant decrease of PVT1 signals, especially by ASO combination, and circPVT1 level using the specific ASO in both cell lines, under normoxia and hypoxia (1% O2). The downregulation led to a significant decrease in cell growth, but, interestingly, only circPVT1-KD induced apoptosis under both conditions in OCI-AML3. To further investigate the biological consequences of circPVT1-KD, we performed RNAseq assays. Data analysis was performed by pseudo alignment of paired-end reads to the human transcriptome, then counted with the Kallisto tool. Differential expression analysis of single isoforms was performed with the Sleuth tool on normalized transcript per million. We identified a core of 644 and 838 commonly regulated genes by circPVT1 in both cell lines under normoxia and hypoxia, respectively. Pathway analysis (performed by EnrichR) revealed that these genes are involved not only in the RNA regulatory pathways, as expected according to circRNA functions, but also in metabolic (e.g., KDM3A, GPI, NFKBA, RBM3, XBP1) and DNA damage response (e.g., PIDD1, MUC1, BCLAF1, BABAM2) pathways, opening a new scenario for synthetic lethality approaches. In conclusion, our findings show that silencing of circPVT1 or the predominantly expressed PVT1 isoforms dampens leukemia cell growth, indicating a role in AML pathogenesis, and suggest that targeting them may have therapeutic potentials in AML.

Citation Format: Martina Ghetti, Antonella Padella, Eugenio Fonzi, Lorenzo Ledda, Andrea Ghelli Lusernadi Rorà, Matteo Paganelli, Doron Tolomeo, Clelia Tiziana Storlazzi, Giovanni Martinelli, Giorgia Simonetti. circPVT1 and linear PVT1 isoforms regulate cell growth, metabolic and DNA damage response related gene signatures in acute myeloid leukemia [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1555.

Mechanical dispersion of left ventricle and left atrial reservoir strain are both superior to global longitudinal strain to predict exercise capacity in heart failure with preserved ejection fraction

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Fundação Adib Jatene

Background/Introduction: 

Peak oxygen uptake (peak VO2) measures cardiovascular fitness and is a valuable diagnostic and prognostic marker in patients with heart failure with preserved ejection fraction (HFpEF). Measurement of peak VO2, however, requires specialized equipment and expert supervision, limiting its routine use by practicing clinicians. 

Strain curves obtained by speckle tracking echocardiography (STE) can provide different parameters of myocardial mechanics such as the Global Longitudinal Strain (GLS), which is the most robust STE feature for clinical practice. 

Notwithstanding, there is conflicting data on whether the GLS is associated with peak VO2 in HFpEF subjects.

Moreover, few studies have addressed the relationship between  peak VO2 and other interesting deformation parameters such as the left atrial (LA) reservoir strain or the left ventricular mechanical dispersion (MD).

Purpose

The present study aimed to examine the utility of the myocardial mechanics as assessed by STE in predicting peak VO2 in patients with HFpEF. 

Methods

From an ongoing prospective cohort of 189 subjects, we sampled subjects with different HFpEF stages. All patients underwent cardiopulmonary exercise testing (CPX) and a 2D-STE (LV GLS, MD, LA reservoir strain, LA conduit strain, and LA contraction strain) obtained by a blinded examinator. The missing data was handled by complete case analysis approach. We excluded subjects who had atrial fibrillation/flutter, severe COPD, STE with poor tracking quality, CPX with respiratory exchange rate (RER) &lt; 1. 

The Spearman"s correlation was calculated, and the 95% CI were estimated.

Finally, an estimative of the STE features importance to predict peak VO2 &lt; 20mL/Kg/min was done using the function "xgb.importance()" from machine learning model XGBoost in R software. XGBoost is a variant of Gradient Boosting Method that uses ensembles of decision trees. 

Results

We obtained 74 subjects (23 without evidence of heart disease, 23 with pre-heart failure and 28 with HFpEF). The MD presented the highest correlation with peak VO2 (Rho=-0.48; p-value &lt; 0.001) followed by LA reservoir strain (Rho = 0.40; p-value &lt; 0.001), LA conduit strain (Rho= –0.36; p-value &lt; 0.001) and LA contraction (Rho= –0.30 p-value &lt; 0.004) as shown in Figure 1. However, no correlation was found between GLS and peak VO2 (Rho= –0.07 p-value &lt; 0.5) (Figure 2A). 

The feature importance score (Figure 2B) showed the MD as the best relative contribution for VO2 prediction (gain= 0.34) superior to LA reservoir strain (gain = 0.25).  GLS presented contribution (gain = 20) superior to LA conduit strain (gain =10) and LA contraction strain (gain = 0.08).

Conclusion

Left ventricular mechanical dispersion and left atrial reservoir strain obtained with STE were better predictors of peak VO2 than GLS in patients with different HFpEF stages and may be helpful in risk stratification and diagnosis. Abstract Figure 1  Abstract Figure 2

The impact of isometric handgrip testing in left atrial reservoir function

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Fundação Adib Jatene

Background

Speckle tracking echocardiography (STE) allows accurate quantification of left atrial (LA) strain, thus allowing assessment of all phases of LA function (reservoir, conduit and contraction). Alterations in LA strain occur before changes in LA volumes, enabling early detection of LA dysfunction. In particular, the peak of LA strain during the reservoir phase (LASr) seems to be of prognostic value in heart failure.

LASr is essential to pool enough blood volume to fill the LV during the subsequent diastole. The main determinants of LA reservoir function include blood volume arriving from the right ventricle, LA relaxation, and LA compliance. Still, changes in atrioventricular plane movement during the ventricular systole have been considered an additional factor influencing LASr. The relative contribution of left ventricular afterload to LASr, however, has yet to be clearly defined.

Purpose

We aimed to study the LA function during changes in LV afterload induced by the handgrip maneuver in subjects without heart disease, applying LASr and strain curve shape analysis.

Material and Methods

We studied 31 subjects (47 ± 15 years) without evidence of heart disease. A comprehensive 2D echocardiography was performed. We recorded 3 beat clips with standard STE views of LV and LA in baseline conditions and then during pressure overload-induced by left handgrip (42 ± 8 kg) combined with simultaneous pneumatic constriction of the right arm and both lower limbs. The LV GLS and LASr were calculated offline by a blinded examinator using commercially available software.

Furthermore, we extracted the raw data of the strain curves and post-processed these signals using custom software. The global curves were split into different cardiac cycle phases using the valve opening and closure times(Figure 1). Quadratic functions estimated strain curves during the ejection phase due to the acceleration involved in the phenomenon. Quadratic function linear coefficients, a component of strain rate, were used to assess the shape of deformation curves.

Results

The handgrip maneuver caused mild reductions in LV strain: GLS baseline –19.07 % (±0.27) vs GLS handgrip -18.58% (±0.26) p = 0.02 (Figure 2A and C). Conversely, the LASr did not present significant changes: LASr baseline 33.82% (±0.84) vs LASr handgrip 32.96% (±0.85)  p= 0.18 (Figure 2B and C).

For the analysis of the shape of strain curves, we obtained data from 29 subjects. We found significant differences in LV ejection linear coefficient (ELC): LV ELC baseline –158.30 (±8.52) vs LV ELC handgrip –144.62 (±8.02) p = 0.02. For LA reservoir linear coefficient (RLC), we also found significant differences: LA RLC baseline 240.30 (±17.19) vs LA RLC handgrip 212.61 (±15.62) p = 0.03 (Figure 2D).

Conclusion(s)

The left atrial reservoir function is affected by changes in LV afterload induced by the handgrip maneuver. Our data suggest that LV pressure overload mainly impact the shape of LA strain curve rather than LASr. Abstract Figure 1  Abstract Figure 2

A219 EARLY PREDICTORS OF UNFAVORABLE OUTCOME IN NORTH AMERICAN INDIAN CHILDHOOD CIRRHOSIS

Background

North American Indian Childhood Cirrhosis (NAIC) has only been described in the Cree-Ojibway First Nations of Northern Quebec. NAIC presents with transient neonatal jaundice and progresses to biliary cirrhosis often requiring liver transplantation (LT) in childhood. Only 30 patients have been described to date and risk factors associated with an earlier progression to LT have not yet been identified. Moreover, NAIC patients seem to experience more fractures than other cholestatic patients, but this has not been confirmed.

Aims

With this study, we aimed to identify predictors at 6 months from presentation that might suggest progression to end-stage liver disease as well as evaluate bone health in affected patients.

Methods

The records of all NAIC patients diagnosed between 2000–2020 were reviewed. Subjects were split into 2 groups based on whether they had undergone LT or not (No_LT) before age 18. Recorded complications included: hepatic encephalopathy (HE), variceal bleeding (VB), ascites, spontaneous bacterial peritonitis (SBP), bacteremia, and pulmonary shunts. Laboratory data (alanine aminotransferase, ALT; total bilirubin, TB) were collected at presentation and follow-up. Bone mineral density (BMD) of the lumbar spine (Z-scores) and number of fractures were compared between groups. NAIC patients were then compared to cohorts with other chronic cholestatic diseases such as biliary atresia (BA, n=24) and Alagille syndrome (AS, n=11).

Results

A total of 14 patients (M=9, F=5) were diagnosed with NAIC. Average age at presentation was 2.1 months (IQR 1–16.9 months), with 3 patients older than 18 months. Overall, 6 patients were transplanted (avg 8.6±1.7 years), one was listed for LT but died waiting, and 7 remained in a state of compensated cirrhosis. All complications were only observed in the LT group except for VB which also occurred in 2 patients of the No_LT group. Between presentation and 6 months, ALT and TB levels increased more in the LT vs No_LT group (p=ns). There was a greater variation of ALT/TB levels in the LT group (p=0.0047) even once the 3 patients with late referral were excluded (p=0.0381). No patient in the No_LT group had fractures, while 3 did in the LT group. BMD was lower in the LT group vs No_LT group (-2.2±1.2 vs. -1.1±1.3, p=ns). NAIC patients had lower BMD (-1.7±1.3) than those with AS (0.7±0.9, p=0.003) or BA (-0.9±1.4, p=ns) and had a higher prevalence of fractures (21.4% vs. 12.5% for BA and 18.2% for AS patients).

Conclusions

In patients with NAIC, variation of ALT/TB levels at 6 months from presentation may be used as an early predictor of unfavorable outcome and progression towards end-stage liver disease. Patients who evolved to LT had more complications, higher prevalence of fractures and lower BMD values. Compared to children with BA or AS, NAIC patients had poorer bone health.

Funding Agencies

None

The SMART-ALPPS Protocol: Strategy to Minimize ALPPS Risks by Targeting Invasiveness

BACKGROUND

The range of procedures with documented feasibility by laparoscopic approach is widening in the setting of liver resections. Many technical limits have been overcome in the attempt to reduce the biological impact of major procedures [1-8]. Similarly, associated liver partition and portal vein ligation for staged hepatectomy (ALPPS)-which could be assumed as the paradigm of maxi-invasiveness-has recently been proposed in a minimally invasive fashion to reduce the impact of this procedure [9-12]. Technical insights to perform laparoscopic ALPPS are provided.

METHODS

Perioperative and intraoperative tips for laparoscopic ALPPS are provided within a SMART (Strategy to Minimize ALPPS Risks by Targeting invasiveness) protocol. Stage 1: After volumetric and functional assessment, partial liver transection is performed, keeping intact both the hilum and the caval plane (to prevent adhesions), therefore avoiding portal ligation. No inert material is left inside the abdominal cavity at the end of procedure to keep the liver surfaces apart. Radiologic portography with portal vein embolization is scheduled on postoperative day (POD) 1. Liver volume (pre-PVE: 29%; post-PVE: 52%) and liver function measured through a Technetium-99 hepatobiliary scintigraphy [13] (pre-PVE: 2.15%/min/sqm; post-PVE: 3.67%/min/sqm) of the future remnant liver are reassessed within 10 days to verify whether size and function are adequate. Stage 2: After 2 weeks from the first stage, laparoscopic right hepatectomy is performed following an anterior approach.

RESULTS

No conversion to open was required. Operative time was 100 and 300 minutes for stage 1 and 2, respectively. Intraoperative blood loss was 50 and 300 ml for the two procedures. Postoperative course was uneventful; patient was discharged on POD 6 of the second operation.

CONCLUSIONS

The implementation of a perioperative protocol to prevent the risk of liver failure by both assessing volume and function of FLR and targeting the invasiveness of the surgical procedure may allow to minimize and control risks of a maximally invasive procedure, such as ALPPS.

Occupational low-level exposure to hard metals: cobalt and tungsten biomonitoring as an effective tool to evaluate the effectiveness of industrial hygiene interventions for risk management

Purpose: The aim of the study was to assess the exposure to Cobalt (Co) and Tungsten (W) in a group of hard metal tool sharpeners through a combined approach of air and biological monitoring, and to evaluate the effectiveness of a control and improvement intervention carried out in collaboration with the medical officers of the local Health Protection Agency, by biomonitoring.Methods: We enrolled 132 workers from 17 companies of the province of Brescia, northern Italy. The study was performed in two phases: (1) an environmental and biomonitoring survey to assess the workers' exposure to Co and W at their usual working conditions; (2) a further biomonitoring survey 3 months after the enforcement of a control and improvement intervention, to assess its effectiveness.Results: Workers were found to be exposed to low concentration of airborne dust containing Co and W but after the intervention we recorded a significant decrease of the urinary concentrations of both Co and W. The extent of the decrease was correlated to the number of preventive industrial hygiene interventions that were carried out.Conclusions: Biological monitoring of Co and W in the hard metal tools manufacturing industry is a sensitive and effective method to evaluate the effectiveness of prevention practices.

Theory of Relativity for Posterosuperior Segments of the Liver

BACKGROUND

The accessibility to posterosuperior segments of the liver has traditionally constituted a restrain to adopt the laparoscopic approach in this setting. To overcome this challenge, multiple approaches have been reported in literature. Total transabdominal approach has been previously described for this purpose, even though the rationale to standardly adopt it and a technical depiction of how to achieve an optimal mobilization has never been specifically addressed.

METHODS

Total transabdominal purely laparoscopic approach to posterosuperior segments of the liver is presented, with detailed emphasis to the rotational motions targeted in laparoscopy. A literature review is presented to summarize all other possible accesses to posterosuperior area of the liver. The institutional series for the laparoscopic approach to Sg 7, Sg 6+7, and Sg8 is retrospectively described.

RESULTS

Three rotational motions of the liver are specifically addressed in a video presentation and described for the laparoscopic total-transabdominal approach; the local institutional series using this approach is presented. Other miscellaneous approaches identified from literature encompassing variations in operative position, transabdominal, transthoracic, and combined approaches are described.

CONCLUSIONS

Complete mobilization of the ligaments of the liver leads to a rotation of the transection line in front of the operator's view, allowing to achieve a safe total trans-abdominal laparoscopic approach to the posterosuperior ligaments of the liver, without compromising the vascular inflow control, the possibility to convert to open approach, nor requiring potentially harmful decubitus.

Biological monitoring of exposure to polycyclic aromatic hydrocarbons and to metallic elements in Italian Navy workers operating near the industrial area in Taranto (South Italy)

OBJECTIVES

To assess, by means of biological monitoring, exposure to polycyclic aromatic hydrocarbons (PAHs) and to metallic elements in Italian Navy workers operating near the industrial area in Taranto, and thereby estimate the health risk.

METHODS

A total of 450 workers in the Italian Navy were examined; they had office type jobs, and 150 of them worked near the industrial area in Taranto (exposed group), 150 in Taranto but far from this area (internal control group) and 150 in Brindisi (external control group). The recruited workers were administered a questionnaire inquiring about current and previous working activities, personal medical history, lifestyle and dietary habits, and their residence location. Then they collected a urine sample for the determination of 1-hydroxypyrene, 2-naphthol, cotinine and the metallic elements As, Cd, Co, Cr, Mn, Ni, Pb, Cu, Zn and Hg. The latter were measured in 110 workers in each group. In addition, in some of the work sites of the three groups, environmental samplings were carried out to determine PAHs and the 10 metallic elements, also taking into account the wind direction.

RESULTS

Airborne benzo(a)pyrene concentrations at the different sampling sites ranged from 0.02 to 0.06 ng/m3 and naphthalene between <25 and 65.3 ng/m3, regardless of the wind direction. Among the metallic elements, As, Cd, Co, Cr, Hg, Pb, Cu and Zn were present at concentrations below or just above the limit of detection (LOD). Mn and Ni were slightly higher in the work sites of the exposed group. The urinary concentrations of 1-hydroxypyrene, 2-naphthol and the single metallic elements were not higher in the exposed workers group than in the other 2 groups. Smokers had significantly higher urinary 1-hydroxypyrene and 2-naphthol concentrations, whereas cigarette smoking did not condition a higher urinary elimination of metallic elements in the three groups with the exception of Cd and Pb. Moreover, residence location conditioned Mn, Hg and As urinary excretion, consumption of shellfish and/or crustaceans in the 72 hours before urine collection conditioned As elimination, and consumption of legumes in the 72 hours before urine collection conditioned Ni elimination.

CONCLUSIONS

This research did not find a higher urinary excretion of 1-hydroxypyrene, 2-naphthol and As, Cd, Co, Cr, Mn, Ni, Pb, Cu, Zn and Hg in the exposed workers group as compared to the internal control group working far from the industrial area of Taranto, nor in the group working in another city far away from Taranto, Brindisi. Therefore, it indicated that workers in the Italian Navy operating near the industrial area in Taranto were not exposed to a greater risk attributable to exposure to PAHs and metallic elements than the two control groups.

Education and Training in Global Occupational Health and Safety: A Perspective on New Pathways to Sustainable Development

The institution of specific Occupational Health and Safety (OHS) training programs open to international trainees from developing countries in some European, American and Asian universities is now a well-established reality. Courses and seminars that focus particularly on this subject, widely varying in approach and duration, have been held for years at these universities; these academic institutions have combined their potential to attract students from developing countries with the scheduling of interesting lectures and training activities, depending on the availability of funds sufficient to cover travel and lodging costs. Interdisciplinarity is the key to the entire program and is its main strength, as the trainees have the opportunity to condense the technical notions and methodological aspects of different disciplines (occupational health, industrial hygiene, safety management, ergonomics) in one course. We firmly believe that these programs are a precious instrument for the training of occupational health professionals from low-income countries, as they are able to address their choices correctly, hopefully achieving the goal of reducing the human costs of development.

Composition of Metallic Elements and Size Distribution of Fine and Ultrafine Particles in a Steelmaking Factory

Background: The characteristics of aerosol, in particular particle size and chemical composition, can have an impact on human health. Particle size distribution and chemical composition is a necessary parameter in occupational exposure assessment conducted in order to understand possible health effects. The aim of this study was to characterize workplace airborne particulate matter in a metallurgical setting by synergistically using two different approaches; Methodology: Analysis of inhalable fraction concentrations through traditional sampling equipment and ultrafine particles (UFP) concentrations and size distribution was conducted by an Electric Low-Pressure Impactor (ELPI+™). The determination of metallic elements (ME) in particles was carried out by inductively coupled plasma mass spectrometry; Results: Inhalable fraction and ME concentrations were below the limits set by Italian legislation and the American Conference of Governmental Industrial Hygienists (ACGIH, 2017). The median of UFP was between 4.00 × 10⁴ and 2.92 × 10⁵ particles/cm³. ME concentrations determined in the particles collected by ELPI show differences in size range distribution; Conclusions: The adopted synergistic approach enabled a qualitative and quantitative assessment of the particles in steelmaking factories. The results could lead to a better knowledge of occupational exposure characterization, in turn affording a better understanding of occupational health issues due to metal fumes exposure.

Tips and Tricks for a Laparoscopic Approach to Paracaval Liver Segments

BACKGROUND

A dramatic spread of laparoscopic liver surgery has been experienced over the last years. The approach to paracaval liver segments 1 and 9 is still poorly described in literature, mainly due to its technical demands.

OBJECTIVE

The aim of this article was to introduce a safe and effective approach to paracaval liver segments through laparoscopy.

METHODS

A minimally invasive approach to resection of Segments 1 and 9 is presented, and an operative set-up is depicted. A step-by-step technique describing the inferior vena cava (IVC) with left and right hepatic venous junction exposure, segmental pedicle isolation, and parenchymal transection is shown through a video document.

RESULTS

Postoperative courses were uneventful, and patients were discharged on postoperative day 3.

DISCUSSION

The approach to paracaval liver segments requires accurate preoperative case selection, technical, surgical, and anesthesiological expertise in laparoscopic liver surgery, and adequate instrumentary.

CONCLUSION

Paracaval segments of the liver can be approached safely through laparoscopy by teams with extensive expertise in the field of laparoscopic liver surgery; however, suspected malignant infiltration of the IVC or unclear preoperative anatomy still contraindicate this approach.

Complications of Blind Placement Technique in 980 Subcutaneous Infusion Ports

Purpose

Subcutaneous Infusion Ports (SIPs) for prolonged venous access are useful tools for drug administration in a wide range of chronic diseases. An extensive use of these devices has to be balanced against the potential complications worsening the length and the quality of life of frequently compromised patients. The aim of the present study is the prospective evaluation of early and late complications of the technique for the blind placement of totally implantable devices for prolonged venous access.

Methods

Between April 1, 1991 and September 30, 1999, 980 SIPs were implanted in 967 patients. Thirteen patients received 2 SIPs. The surgical procedure, the catheter through peel-away technique after infraclavicular approach to the right or left subclavian vein, was performed without intraoperative fluoroscopy (blind placement technique) in the operating room under local anaesthesia. A postoperative chest radiography to rule out any procedure-related complications and to check the position of the catheter tip was obtained in all cases. For the purpose of the study, intraoperative complications as well as all SIP-related complications were recorded during the follow-up period and classified as major and minor complications.

Results

The study population consisted of 524 males/443 females, with a mean age of 56.3 ± 11.4 years (range 19–85 years). Primary diagnosis was malignancy in 916 patients (94.7%), acquired immunodeficiency syndrome (AIDS) in 44 patients (4.5%), and short gut syndrome secondary to subtotal small bowel resection in 2 cases (0.2%), others in 5 cases (0.5%). Perioperative complications were recorded in 12.9% of the 980 insertion procedures, including 77 cases of arterial puncture (7.8%) of the subclavian artery, 1 case of hemoptysis (without clinical and radiological evidence of pneumothorax) (0.1%), 23 cases of pneumothorax (2.3%), 20 of which (86.9%) required chest drainage, 10 cases of unsuccessful progression of the J-wire after the venepuncture (1%), 16 cases of catheter malposition (1.6%). As for the follow-up, 919 patients (95.0%) who had received 942 SIPs turned out to be suitable for long-term analysis, while 48 patients (5.0%) were excluded due to missing data. Seventy-seven SIPs (8.2%) were removed during the follow-up period, 13 of which received a second SIP. Long-term complications were recorded in 9.5% of the 942 SIPs, including mechanical complications (2.9%), infections (4.4%) and venous thrombosis (1.2%). Minor and major complication rates were 7.3% and 2.2% respectively. The overall incidence of SIP-related complications was 22.1%, including 44 major complications (4.5%) and 173 minor complications (17.6%).

Conclusions

Given the low rate of major complications, SIPs should be considered safe and effective devices, representing the first choice approach for prolonged venous access. Blind placement technique performed by full-trained operators yields adequate success rate to be suggested as a routine procedure.

Free copper in serum: An analytical challenge and its possible applications

Copper (Cu), as an essential metal, plays a crucial role in biochemical reactions and in physiological regulations. Cu in plasma is mostly bound to proteins; about 65-90% of Cu is tightly binds with caeruloplasmin and the rest of Cu is loosely binds with albumin and transcuprein. A small but significant relatively "free" fraction, probably complexed with amino acids, is present at around 5% of the total concentration. We developed and validated a new method for direct measurement of free Cu in serum by ultrafiltration with AMICON^®Ultra 100K device and determination with AAS. Also, we checked that there is no trace of albumin in the ultrafiltrates and we demonstrated the ultrafiltration of a known concentration of Cu added in artificial serum without albumin and, on the contrary, the retention of the Cu in artificial serum with albumin. The ultrafiltration procedure and the instrumental determination showed a good repeatability and a very low limit of detection (1μg/L). The method was applied to 30 healthy subjects, the mean value of the total Cu (994.8μg/L) is included in the normal range for healthy people and the values of free Cu (23.6μg/L) corresponding to 2.37% of the Cu total. The determination of free Cu by this simple and cheap method may be useful to measure the most bioavailable Cu fraction possibly implicated in neuro-degenerative and oxidative-stress related diseases.

[Reference values: from guidance values to the exposome.]

OBJECTIVES

The correspondence between biomarkers and the complex interaction of toxics with the human organism has been fully described years ago by the American National Research Council which developed a precious diagram.

METHODS

This model is still valid in describing the new methodologic agnostic or "omic" approaches to the science of exposure.

RESULTS

Reference values and exposome share indeed the search for internal dose biomarkers; adduttomics may be seen as an evolution of the target dose markers while epigenetics itself is a new way of exploring the world of early effect biomarkers.

[Exposome: from an intuition to a mandatory research field in occupational and enviromental medicine.]

OBJECTIVES

As Genomics aims at the collective characterization and quantification of genes, exposomics refers to the totality of lifetime environmental exposures, consisting in a novel approach to studying the role of the environment in human disease. The aim is to assess all human environmental and occupational exposures in order to better understand their contribution to human diseases. The "omics" revolution infact mostly regards the underlying method: scientific knowledge is expected to come from the analysis of increasingly extensive databases.

METHODS

The primary focus is on air pollution and water contaminants, but all the determinants of human exposure are conceptually part of the idea of exposome, including physical and psychological factors. Using 'omic' techniques the collected exposure data can be linked to biochemical and molecular changes in our body.

RESULTS

Since the first formulation of the idea itself of Exposome many efforts have been made to translate the concept into research, in particular two important studies have been started in Europe.

CONCLUSIONS

We herein suggest that Occupational Medicine could be a precious contributor to the growth of exposure science also in its omic side thanks to the methods and to the knowledges part of our background.

Risk due to exposure to metallic elements in a birdshot factory

The contribution of biological and environmental monitoring to the risk assessment of occupational exposure to lead (Pb), arsenic (As), and antimony (Sb) was studied in 18 workers at a birdshot factory (Exposed) and in 18 control workers (Controls) by the determination of both airborne Pb (PbA) and airborne As (AsA) only in the exposed workers and blood Pb (PbB), erythrocytic zinc protoporphyrin (ZPP), urinary Sb (SbU), and the urinary As species in exposed workers and controls. PbA (12-42 μg/m³) and AsA (1-4 μg/m³) were strongly correlated (r = .95). PbB, ZPP, and the sum of As³+As⁵+MMA were significantly higher in the exposed workers. As³ was higher than the limit of detection in 14 exposed workers and 1 control, As⁵ only in 1 exposed worker, SbU in all the exposed workers and in 4 controls. Monitoring for more metallic elements reveals a wider spectrum of exposures than can be achieved by lead surveillance alone and is preferable for characterizing occupational risk wherever possible.

A child with unresectable biliary rhabdomyosarcoma: 48-month disease-free survival after liver transplantation

We describe here a two-yr-old boy with biliary RMS successfully treated by chemotherapy and LT. The child presented with obstructive jaundice at 20 months of age. A mildly vascularized, non-calcified, partially cystic lesion was visualized in the left hepatic lobe. Solid infiltration of the common bile duct and of both left and right hepatic ducts was suspected. Liver biopsy suggested a botryoid-type embryonal RMS originating from the biliary tract. After extrahepatic spread of the tumor was excluded, a biliary drain was applied and neoadjuvant chemotherapy was started. After the treatment, although reduced in volume, the mass was still unresectable without aggressive surgery and gross residual disease. LT with a reduced segment II/III graft was performed four months after diagnosis. The patient received six cycles of adjuvant chemotherapy, and he is alive and recurrence-free 48 months post-transplantation. A posteriori, the transplant might have possibly been avoided with an aggressive resection with biliary reconstruction. Nevertheless, although the risk of the transplant has to be balanced against the chemoresponsiveness of the tumor, the four-yr disease-free survival of this patient suggests that, when coupled with effective chemotherapy, transplantation might be considered a potential treatment for unresectable biliary RMS.

Bariatric surgery in obesity: changes of glucose and lipid metabolism correlate with changes of fat mass

BACKGROUND AND AIM

Bariatric surgery induces significant weight loss and improves glucose metabolism in obese patients (BMI>35 kg/m(2)). Our aim was to compare restrictive (LAGB, laparoscopic gastric banding) and malabsorptive approaches (BIBP, biliary-intestinal bypass) on the loss of fat-free mass (FFM), fat mass (FM), and on changes of glucose and lipid metabolism.

METHODS AND RESULTS

Body composition (bio-impedance analysis, BIA), blood glucose (BG), insulin, triglycerides, total- and HDL-cholesterol, liver enzymes (AST and ALT) were measured at baseline and 1 year after surgery in patients undergoing LAGB, BIBP, and in diet-treated control patients. In the main study, with patients matched for initial BMI (43-55 kg/m(2), LAGB=24, BIBP=12, controls=6), decreases of BMI, FM, BG and cholesterol were greater in patients with BIBP than with LAGB (p<0.01), while decreases of FFM, insulin, HOMA-IR and triglycerides were similar. No effects on BMI, FM, FFM, BG, insulin, HOMA-IR or cholesterol were observed in the control patients. Decreases of BG, insulin, HOMA-IR, cholesterol and triglycerides correlated with FM but not with FFM decrease. Similar results were obtained in an additional study in patients with a different initial BMI (LAGB=25, BIBP=6, controls=24) and when considering all subjects together. A decrease of liver enzymes (ALT) was greater with LAGB than with BIBP, and HDL-cholesterol increased with LAGB and decreased with BIBP.

CONCLUSION

BMI, FM, BG and cholesterol decrease more with malabsorptive than with restrictive surgery, while FFM, insulin, HOMA-IR and triglycerides decrease in a similar way. FFM loss is of low entity. Changes of glucose and lipid metabolism are proportional to a decrease of fat mass but not of fat-free mass.

Effect of weight loss through laparoscopic gastric banding on blood pressure, plasma renin activity and aldosterone levels in morbid obesity

BACKGROUND AND AIMS

Several mechanisms are probably involved in obesity-related hypertension. This study was aimed to investigate the effect of significant weight loss on blood pressure and plasma renin activity (PRA) and aldosterone levels, other then on metabolic profile, in normotensive and hypertensive obese subjects.

METHODS AND RESULTS

Forty hypertensive and 55 normotensive obese subjects were studied under basal conditions and again 1 year after significant weight loss obtained through laparoscopic adjustable gastric banding (LAGB). Weight, waist circumference, blood glucose, insulin, electrolytes (Na and K), lipids and supine and upright PRA and aldosterone were evaluated. All parameters evaluated improved, except for total cholesterol, and electrolytes that did not change. Blood pressure decreased in hypertensive subjects, with a concordant decrease in PRA and supine aldosterone levels, not observed in normotensive patients.

CONCLUSION

Weight loss is associated with reduction of blood pressure and of PRA and aldosterone levels in obese hypertensive subjects.

Obese teenagers treated by Lap-Band System: The Italian experience

BACKGROUND

Little is known about obesity surgery in young and adolescent patients. The aim of this study is to evaluate results of laparoscopic adjustable gastric banding in obese teenagers.

METHODS

Patients < or = 19 years old selected from the database of the Italian Collaborative Study Group for Lap-Band were analyzed according to mortality, comorbidities, laparotomic conversion, intra- and postoperative complications, body mass index (BMI), and % excess weight loss (EWL) at different times of follow-up. Data were expressed as mean +/- SD.

RESULTS

Fifty-eight (1.5%) of 3813 patients who underwent operation with the Lap-Band System were < or = 19 years old: 47F/11M; mean age, 17.96 +/- 0.99 years (range, 15-19); mean BMI, 46.1 +/- 6.31 Kg/m2 (range, 34.9 - 69.25); mean % excess weight, 86.4 +/- 27.1 (range, 34 - 226.53). Sixteen (27.5%) of the 58 patients were superobese (BMI > or = 50). In 27/58 (46.5%) patients, 1 or more comorbidities were diagnosed. Mortality was absent. Laparotomic conversion was necessary in 1 patient with gastric perforation on the anterior wall. Overall postoperative complications occurred in 6/58 (10.3%). The band was removed in 6/58 (10.3%) patients for gastric erosion (3 patients), psychologic, intolerance (2 patients), and in the remaining patient was converted 2 years after surgery (BMI 31) to gastric bypass or gastric pouch dilatation. Patient follow-up at 1, 3, 5, and 7 years was 48/52 (92.3%), 37/42 (88.1%), 25/33 (75.7%), and 10/10, respectively. At these times, mean BMI was 35.9 +/- 8.4, 37.8 +/- 11.27, 34.9 +/- 12.2, and 29.7 +/- 5.2 Kg/m2. Mean %EWL at the same time was 45.6 +/- 29.6, 39.7 +/- 29.8, 43.7 +/- 38.1, and 55.6 +/- 29.2. Five/25 (20%) patients had < or = 25% EWL at 5 years follow-up, while none of the 10 patients subject to follow-up at 7 years had < or = 25% EWL.

CONCLUSIONS

Lap-Band System is an interesting option for teenagers suffering obesity and its related comorbidities, which deserves further investigation.

Chronic intestinal inflammation and seronegative spondyloarthropathy in children

BACKGROUND

Spondyloarthropathy in adults has been shown to be associated with either clinical or subclinical intestinal inflammation, however this association has rarely been described in children.

AIM

To report paediatric patients primarily referred to a paediatric gastroenterology centre for suspected inflammatory bowel disease and found to be affected by a seronegative spondyloarthropathy. Intestinal inflammatory lesions and rheumatological features have been described in them.

SUBJECTS

During a 18-month period, 129 children were referred because of symptoms and signs suggesting an inflammatory bowel disease; 31 of them (range age: 5-17 years) were selected because they also had signs of axial and/or peripheral arthropathy and form the basis of our study.

METHODS

The investigated patients underwent ileo-colonoscopy with biopsy and rheumatological assessment that also included X-ray and magnetic resonance imaging of the sacroiliac joints.

RESULTS

Only seven children had a classical inflammatory bowel disease (four had ulcerative colitis, three had Crohn's disease), 12 had an indeterminate colitis, 12 a lymphoid nodular hyperplasia of the distal ileum as main feature. In the latter two groups, endoscopy and histology revealed an intestinal inflammation of chronic type distinct from the classical pattern found in inflammatory bowel disease. All were HLA B27 negative and fulfilled the European Spondyloarthropathy Study Group criteria for spondyloarthropathy (except five children classified as undifferentiated spondyloarthropathy).

CONCLUSIONS

In a group of children primarily investigated for suspected inflammatory bowel disease and also presenting a seronegative spondyloarthropathy we have described both intestinal and rheumatological features. The majority of them exhibited either an indeterminate colitis or a lymphoid nodular hyperplasia of the distal ileum as main feature. These patients may be a population at risk of developing a full inflammatory bowel disease phenotype.

Comparison between arthroscopy and arthrotomy in the treatment of shoulder instability

Anterior post-traumatic shoulder instability represents a common finding in orthopaedic surgery. The surgical treatment of this lesion is often indispensable for the normal social life of the patient and for the sports activity of the young. The Bankart procedure with capsular retensioning by arthrotomic access has for years been the gold standard. In the last 10 years arthroscopic accesses have gained more and more consent for the surgical treatment of such lesions, with results that have considerably improved in time. It is the purpose of this study to compare the results obtained in patients affected with anterior-inferior post-traumatic shoulder instability treated by Bankart surgery, arthrotomic and arthroscopic, with a minimum follow-up of 4 years.

The Italian Group for LAP-BAND: predictive value of initial body mass index for weight loss after 5 years of follow-up

BACKGROUND

Laparoscopic of the LAP-BAND System placement stage of obesity is a safe operation, but its indication in terms of stage of obesity is controversial. The aim of this study was to evaluate the 5 years stage of obesity results for weight loss in patients with varying preoperative ranges of body mass index (BMI).

METHODS

Data were obtained from the Italian Collaborative Study Group for LAP-BAND System (GILB) registry. Detailed information was collected on a specifically created database (MS Access 2000) for patients operated on in Italy from January 1996 to 2003. Patients operated on between January 1996 and December 1997 were allocated to four groups according to preoperative BMI range: 30-39.9 kg/m(2) (group A), 40-49.9 kg/m(2) (group B), 50-59.9 kg/m(2) (group C), and =60 kg/m(2) (group D) percent estimated weight loss respectively. Postoperative complications, mortality, BMI, BMI loss, and (%EWL) were considered in each group. Data are expressed as mean +/- SD, except as otherwise indicated. Statistical analysis was done by means of Fisher's exact test, and p < 0.05 was considered significant.

RESULTS

After 5 years from LAP-BAND System surgery, 573 of 3,562 patients were eligible for the study. One hundred fifty-five of 573 (27.0%) were lost to follow-up, 24 of 418 (5.7%) underwent band removal due to complications (gastric pouch dilation, band erosion), eight of 418 (1.9%) were converted to other bariatric procedures, five of 418 (1.2%) died of causes not related to the operation or the band, and 381 of 573 (66.5%) were available for follow-up. Based on 96, 214, 64, and seven patients their preoperative BMI, Were allocated to groups A, B, C, and D, respectively. At time of follow-up mean BMI was 27.5 +/- 5.2 in group A, 31.6 +/- 4.7 in group B, 37.6 +/- 17.3 in group C, and 41.4 +/- 6.9 kg/m(2) in group D. Mean BMI loss was 9.8 +/- 5.4, 12.9 +/- 5.2, 15.8 +/- 8.1, and 23.2 +/- 4.9 kg/m(2), respectively, in groups A, B, C, and D. Mean %EWL at the same time was 54.6 +/- 32.3 in group A, 54.1 +/- 17.2 in group B, 51.6 +/- 35 in group C, and 59.l +/- 17.1 in group D.

CONCLUSION

Initial BMI in this series did not correlate with %EWL 5 years after the operation. In fact %EWL was almost the same in each group, independent of preoperative weight. Initial BMI was an accurate indicator of the results obtained 5 years after LAP-BAND in group C (50-59.9 kg/m(2)) and D (=60 kg/m(2)) patients, who remained morbidly obese despite their %EWL.

Italian Group for Lap-Band System: results of multicenter study on patients with BMI < or =35 kg/m2

BACKGROUND

The Lap-Band System is the most common bariatric operation world-wide. Current selection criteria do not include patients with BMI < or = 35. We report the Italian multicentre experience with BMI < or = 35 kg/m(2) over the last 5 years.

PATIENTS AND METHODS

Data were obtained from 27 centres involved in the Italian Collaborative Study Group for Lap-Band System. Detailed information was collected on a specially created electronic data sheet (MS Access 2000) on patients operated in Italy since January 1996. Items regarding patients with BMI < or = 35 were selected. Data were expressed as mean +/- SD except as otherwise indicated.

RESULTS

225 (6.8%) out of 3,319 Lap-Band patients were recruited from the data-base. 15 patients, previously submitted to another bariatric procedure (BIB =14; VBG= 1) were excluded. 210 patients were eligible for study (34M/176F, mean age 38.19+/-11.8, range 17-66 years, mean BMI 33.9+/-1.1, range 25.1-35 kg/m(2), mean excess weight 29.5+/-7.1, range 8-41). 199 comorbidities were diagnosed preoperatively in 55/210 patients (26.2%). 1 patient (0.4%) (35 F) died 20 months postoperatively from sepsis following perforation of dilated gastric pouch. There were no conversions to laparotomy. Postoperative complications presented in 17/210 patients (8.1%). Follow-up was obtained at 6, 12, 24, 36, 48 and 60 months. At these time periods, mean BMI was 31.1+/-2.15, 29.7+/-2.19, 28.7+/-3.8, 26.7+/-4.3, 27.9+/-3.2, and 28.2+/-0.9 kg/m(2) respectively. Co-morbidities completely resolved 1 year postoperatively in 49/55 patients (89.1%). At 60 months follow-up, only 1 patient (0.4%) has a BMI >30.

CONCLUSIONS

Although surgical indications for BMI < or = 35 remain questionable, the Lap-Band in this study demonstrated that all but 1 patient achieved normal weight, and most lost their co-morbidities with a very low mortality rate.

Ultrasound measurement of visceral and subcutaneous fat in morbidly obese patients before and after laparoscopic adjustable gastric banding: comparison with computerized tomography and with anthropometric measurements

BACKGROUND

There are now a variety of methods to assess body fat distribution, anthropometric (waist circumference and waist/hip W/H ratio), computed tomography (CT), and ultrasound (US) measurements, with CT considered as the reference method. Bariatric surgery leads to a significant and usually durable weight loss in morbidly obese patients; when assessing its results, it is of interest to measure changes of total fat tissue and of body fat distribution.

METHODS

In this study, we compared anthropometric, US, and CT measurements of body fat distribution under basal conditions and 1 year after laparoscopic adjustable gastric banding (LAGB); 120 morbidly obese patients were considered at baseline, and 40 patients were re-evaluated 1 year after LAGB.

RESULTS

Thickness of visceral and subcutaneous fat measured through CT and US methods was superimposable both under basal conditions and 1 year after LAGB, and the highest correlation was found between CT and US data on visceral fat, followed by CT and US data on subcutaneous fat; a fair correlation was also found between CT and US data on visceral fat and waist circumference.

CONCLUSION

We suggest that evaluation of body fat distribution is accomplished by US instead of CT measurement, because of its lower cost and low exposure risk. Waist circumference stands as a reasonable surrogate of both methods, while W/H ratio is poorly correlated with other measures of body fat distribution.

Randomized comparison of isoflurane and sevoflurane for laparoscopic gastric banding in morbidly obese patients

STUDY OBJECTIVE

To compare the efficacy and recovery profile of sevoflurane and isoflurane as the main anesthetics for morbidly obese patients.

DESIGN

Randomized, blinded study.

SETTING

Inpatients.

PATIENTS

30 ASA physical status II and III obese patients [body mass index (BMI) > 35 kg/m(2)] undergoing laparoscopic gastric banding for morbid obesity.

INTERVENTIONS

After standard intravenous induction of general anesthesia and tracheal intubation, anesthesia was maintained with either sevoflurane or isoflurane as the main anesthetics. The end-tidal concentrations of the volatile drugs were adjusted to maintain systolic arterial blood pressure within +/-20% from baseline values. When the surgeon started the skin suture, the end-tidal concentration of the inhalational drug was reduced to 0.5 minimum alveolar concentration in both groups. At the last skin suture, the inhalational drug was discontinued and the vaporizator was removed to allow blinded evaluation of the emergence times.

MEASUREMENTS AND MAIN RESULTS

No differences in anesthetic exposure, hemodynamic parameters, incidence of untoward events, or postoperative pain relief were reported between the two groups. Extubation, emergence, and response times were shorter after sevoflurane [6 min (3-15 min), 8 min (5-18 min), and 12 (6-25 min)] than isoflurane [10 min (6-26 min), 14 min (6-21 min), and 21 min (14-41 min)] (p = 0.001, p = 0.03, and p = 0.0005, respectively). The median time for postanesthesia care unit discharge was 15 minutes (25th-75th percentiles: 10-18 min) after sevoflurane and 27 minutes (25th-75th percentiles: 20-30 min) after isoflurane (p = 0.0005).

CONCLUSIONS

Sevoflurane provides a safe and effective intraoperative control of cardiovascular homeostasis in morbidly obese patients undergoing laparoscopic gastric banding, with the advantage of a faster recovery and earlier discharge from the postanesthesia care unit than isoflurane.

Thirty months experience with laparoscopic adjustable gastric banding

INTRODUCTION

Since June 1996 we performed laparoscopic adjustable silicone gastric banding (LASGB), because of low invasivity, absence of malabsorption, reversibility, and postoperative regulation.

MATERIALS AND METHODS

Criteria included body mass index (BMI) >40 or >35 with serious obesity-related conditions. 154 patients underwent LASGB. BMI ranged from 35 to 65.7 (mean 43.7+/-6.2).

RESULTS

The laparoscopic procedure was successfully completed in 150 patients (97.4%). One patient was converted to the laparotomic procedure because of hepatomegaly; 4 patients had to be converted for gastric laceration during the laparoscopic approach. In one of these patients, the band was removed 7 days later for sepsis, followed by an uneventful postoperative course. The mean length of postoperative hospitalization was 2.3+/-0.9 days. Per cent of excess weight loss was 42.5+/-22.4 after 1 year.

CONCLUSIONS

LASGB was feasible and effective.

Impact of minimally invasive surgery on adrenalectomy for incidental tumors: comparison with laparotomic technique

BACKGROUND

To compare laparoscopic and laparotomic techniques for the excision of incidental adrenal tumors.

MATERIALS AND METHODS

Twenty patients with silent adrenal tumor underwent adrenalectomy or tumor excision through the laparotomic (LPT Group: 12 cases) or laparoscopic (LPS Group: 8 cases) approach. LPT Group and LPS Group were comparatively analyzed in terms of age, gender, Body Mass Index (BMI), concomitant diseases, previous upper abdominal surgery, tumor side and size, type of operation (excision vs adrenalectomy), associated procedures, and pathology. The two groups were then compared for intra/postoperative complications, length of operation, and postoperative ileus, pain, hospitalization. Comparisons were performed also adjusting for variables (BMI, depression, tumor size) unhomogeneously distributed between the two groups.

RESULTS

LPT Group and LPS Group were comparable when evaluated for age, gender, BMI, concomitant diseases (except for depression), previous upper abdominal surgery, tumor side, type of operation, associated procedures, and pathology. Tumor size (LPKT > LPS, p = 0.03) and depression (LPT < LPS, p = 0.04) turned out to be differently distribution between the two groups, and were then considered, as well as the BMI (p = 0.08), in the covariance analysis. Postoperative ileus (LPT vs LPS: 3.5 +/- 0.2 days vs 2.3 +/- 0.2 days, p = 0.006), pain (LPT vs LPS: 3.0 +/- 0.3 days vs 1.7 +/- 0.2 days, p = 0.012), and hospitalization (LPT vs LPS: 7.9 +/- 1.0 days vs 3.5 +/- 0.4 days, p = 0.0002) were statistically shorter in the LPS Group; the length of operation, even if shorter in the LPS Group (LPT vs LPS: 2.9 +/- 0.3 hours vs 2.5 +/- 0.3 hours), did not reach statistical significance (p = 0.12). Results were confirmed by covariance analysis.

CONCLUSIONS

Laparoscopy seems a safe and effective approach which permits adrenal surgery with lower surgical stress than laparotomic technique.

Conservative management of cocaine-packet ingestion: experience in Milan, the main Italian smuggling center of South American cocaine

OBJECTIVE

To assess retrospectively the effectiveness and the safety of the conservative medical management of asymptomatic cocaine body-packers.

DESIGN

Case series collected during twelve years (1980-1992).

SETTING

Milan Airports Health Center. Department of Surgery and Intensive Care Unit of San Raffaele Hospital-University of Milan.

PARTICIPANTS

189 suspected cocaine body packers (143 male, 53 female), aged between 18-53 years, were brought to our observation by customs after disembarking at the Milan International Airports of Malpensa and Linate. 61 subjects (32%) turned to be carriers of packets containing cocaine (ovules).

INTERVENTIONS

Medical conservative treatment, based on close clinical observation and light solid diet, free assumption of liquids and oily laxatives. Plain abdominal X-ray and ultrasound were performed for the diagnosis of cocaine packet ingestion and then repeated up to the complete evacuation of all ovules. Two laparotomies with surgical removal of ovules in symptomatic patients (bowel obstruction and acute cocaine intoxication due to the intraluminal rupture).

MEASURES

Physical examination with neurological assessment every 8 hours and vital signs (including blood pressure, heart frequency and temperature) every 4 hours to detect complications (acute cocaine intoxication, bowel obstruction or perforation) secondary to cocaine packet ingestion. Structural features of the containers, cocaine amount per ovule, and rate and indications for surgical treatment have been reviewed.

RESULTS

Evacuation period lasted from 3 to 6 days. Ingested containers varied from 52 to 117 with a mean of 88 +/- 13 ovules for each body packer. Total amount of recovered 95% pure cocaine hydrochloride was 41 kilograms. Signs of cocaine toxicity and bowel obstruction requiring emergency laparotomy occurred in two cases (3.3%). Both patients recovered uneventfully.

CONCLUSIONS

Conservative management during spontaneous evacuation of the containers is the first choice approach to the body-packet ingestion. Close clinical observation allows an early detection of the patients with complications requiring emergency surgical treatment.

[Intestinal occlusion in cocaine-packet ingestion]

During the last decade, the increase of drug traffic and close customs' control have led smugglers to attempt various methods to pass through customs undetected. One method is the ingestion of large numbers of drug-filled packets (usually containing cocaine), together with anticholinergics inhibiting intestinal peristalsis, by a smuggler, called "body-packer" or "mule". The up-to-date approach to cocaine-packet ingestion is conservative medical management during the spontaneous evacuation of the "ovules". Emergency surgical treatment should be reserved for the complications of cocaine-packet ingestion ("body packer syndrome"), which are bowel obstruction due to clustering of the containers and intraluminal rupture of the "ovules" with massive drug transmucous absorption (acute cocaine intoxication). We describe a case of cocaine-packet ingestion in a 19 year old man who was asymptomatic at admission and thus conservatively treated. During the spontaneous evacuation of ovules, clinical and radiological signs of bowel obstruction appeared and the patient underwent emergency laparotomy with removal of 21 containers, two of them clustered in the distal ileum, causing the occlusion. This case gave reasons for a discussion on the specific features of bowel obstruction in cocaine packet ingestion. The bowel obstruction of cocaine-packet ingestion should be carefully considered and promptly treated because of the potentially lethal consequences (death rate of 56% of cases) of transmucous absorption of cocaine contained in "ovules". In fact, while opioid intoxication can be fought with specific antagonists towards opioid receptors (naloxone), the lack of a specific antidote makes cocaine poisoning particularly dangerous.(ABSTRACT TRUNCATED AT 250 WORDS)

[Is the surgical treatment of spontaneous bacterial peritonitis still up-to-date?]

We describe a case of spontaneous bacterial peritonitis in a 53 year old man affected by cryptogenic micro-macronodular cirrhosis, portal hypertention, splenomegaly and hypersplenism, who was admitted with hepatic failure and septic shock and successfully treated with antibiotics (combination of clindamycin and netilmycin), surgical abdominal drainage and splenectomy. This case gave reason for a literature review and an update on the therapeutic options in these high risk patients, especially concerning the role of surgery. Spontaneous Bacterial Peritonitis (SBP) is defined as a bacterial infection of ascitic fluid in the absence of any septic focus. It is a typical life-threatening complication of hepatic cirrhosis with ascites. Mortality is very high and ranges from 75% to 97% of patients, due to septic shock and hepatic failure (hepatorenal syndrome, hepatic encephalopathy, gastrointestinal bleeding). Infection with a single organism is found in most cases. Gram negative bacilli are present in about 70% of cases and E. coli (less frequently Klebsiella, Serratia, Pseudomonas) is principally found. Gram positive cocchi comprise an additional 30% of cases. Anaerobic and microaerophilic organisms seem to be rare causes of SBP (2.7-6%); this finding is probably due to the intrinsic bacteriostatic activity of ascites, which contains high oxygen tension (70 mmHg) and is an inhospitable environment for bacteroides and Clostridia. The prevalent isolation of enteric organism suggest that the gut is the most frequent source of infection, even if the pathogenetic mechanism is not yet well known. The right treatment depends on differentiating primary (SBP) from secondary peritonitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Fat absorption and gastroenteric pH profile in postsurgical pancreatic insufficiency: role of the association of H2-receptor antagonists with pancreatic enzymes

The complete control of steatorrhea in post-surgical exocrine pancreatic insufficiency is difficult. The aim of this study was to evaluate the effect of the association of ranitidine with pancrelipase om fecal fat excretion in patients who had undergone a pancreatoduodenectomy with suppression of the exocrine pancreatic secretion by Neoprene injection. Ten patients were studied 1 year after surgery. Steatorrhea was measured as an integrated test of 3-day stools, while patients were kept on a diet of 100 g lipid/day, with their usual enzyme supplementation therapy (16,050 USP units of lipase/meal). A basal 24-h gastroenteric pH profile was also obtained. In the following month, patients had ranitidine (150 mg twice a day) in addition to pancrelipase. Then steatorrhea and gastroenteric pH were reassessed. Mean fecal fat was 26.9 (SD 13.7) g/day without ranitidine and 30.5 (SD 13.9) g/day during combined treatment. Body weight and nutritional parameters did not show any significant variation after ranitidine administration. Even in the absence of ranitidine, postprandial gastroenteric pH values were always > 4; the H2-receptor antagonist only reduced fasting gastric acidity. In conclusion, the gastroenteric pH and fecal fat determinations showed that ranitidine is not useful in patients with total postsurgical exocrine pancreatic insufficiency.

[Conservative elective surgery in kidney neoplasms]

After the good results of "necessary" conservative surgery in the treatment of kidney neoplasms (bilateral neoplasms, congenital, acquired or functional solitary kidney), conservative surgery itself has been employed as elective treatment in selected cases presenting without the overmentioned problems. The authors report two cases of elective conservative surgery in kidney neoplasm with good results after 18 and 24 months.

[Comparative study of 24-hour continuous gastric pH-measurements in healthy people and in patients with pancreatic neoplasms treated with duodeno-pancreatic head resection]

The Authors compare pH measurements taken over a 24-h period to monitor, using an original method, a sample group of 11 healthy subject and a series of patients suffering from gastroenteropancreatic diseases. The data obtained confirm the utility of the functional study of gastrointestinal secretion.