BACKGROUND/AIMS:To evaluate the impact of the traditional clamp-crush technique and a radiofrequency bipolar vessel sealing device (BVSD) for liver resection on operative blood loss, transfusion rate, duration of operation, length of hospitalization and morbidity.METHODOLOGY:From a database, 100 patients who underwent elective liver resection were retrospectively selected. In 40 patients parenchyma transection was performed by BSVD (LigaSure system) and 60 patients were operated using traditional clamp-crush technique (CC group).RESULTS:The two groups were well-matched for baseline and surgical characteristics. Peak of transaminases was significantly higher in the BSVD on postoperative days 1, 3 and 5 (minimum p = 0.02 vs. CC). There was no significant difference between CC group and BVSD group in median operation time (180 vs. 190 min), blood loss (600 vs. 700 mL), transfusion rate (48.0% vs. 60.5%), hepatic failure (3.2% vs. 2.5%), morbidity rate (26.6% vs. 27.5%), and hospital stay (13 vs. 12 days).CONCLUSIONS:Increased tissue damage in the BSVD group did not seem to correlate with organ dysfunction or postoperative morbidity. The two techniques appear equivalent in term of outcome and thus the choice of transection strategy remains according to the surgeon preference and experience.

Materials and methods From November 2005 to July 2008 we prospectively collected data from patients who underwent colorectal resection. The study group comprised 264 patients, divided in two groups according to age under 70 (group A) or over 70 years (group B). We analyzed comorbidities and ASA score; type of surgical procedure and diagnosis; surgical contamination wound class, incidence of SSIs and their characteristics.

Materials and methods We present the case of an 84-year-old woman, affected by essential thrombocythemia, monoclonal gammopathy and senile dementia, who was admitted in our Hospital for abdominal pain and high white blood cells levels. An abdominal CT scan showed splenic infarctual abscess and a broad-spectrum antibiotic therapy was arranged. Because of the unfavourable clinical evolution, a laparoscopic splenectomy was indicated.

Purpose In literature, few papers compare different hemostatic devices in laparoscopic adrenalectomy. This sequential cohort study analyzes the outcomes of laparoscopic adrenalectomy performed by different hemostatic instruments, to evaluate if any of them has any advantage over the other and as secondary endpoints, the impact of body mass index (BMI) and tumor size on the indication, and the outcome of laparoscopic adrenalectomy.Methods Forty-six patients, aged 54.6 +/- 46 years, underwent laparoscopic adrenalectomy over 5 years. Mean BMI was 27 +/- 4.8 kg/m(2). Twenty-four patients had a left tumor, and 22 had a right one. Patients were divided into two groups according to the hemostatic device: Ultracision was used in 26 patients, and Ligasure was used in 20. Groups were well matched for histology, tumor size and site, BMI, gender, and age.Results Mean operating time was 126.5 +/- 52 min, blood losses were 101 +/- 169 mm, conversion rate was 6.5%, morbidity was 26%, and hospitalization was 5.3 +/- 2.5 days. Groups did not differ for surgical time, blood losses, complications, and conversion rate; BMI and length of surgery were not related. Tumor side and size did not affect surgical time, regardless of the hemostatic tool. Patients submitted to left adrenalectomy bled more (p=0.007) and had more complications (p=0.016) than those undergone operation on the right side.Conclusions Obesity (BMI>30) and large masses do not contraindicate laparoscopic adrenalectomy. Left adrenalectomies bleed more and have a higher morbidity. Hemostatic device choice is up to surgeon's preference.

Background/Aims: A cell-mediated immunodeficiency is demonstrated to occur in advanced cancer patients. Lymphocytopenia predicts a poor prognosis, moreover, the surgical trauma can worsen the impaired immune surveillance and favor disease recurrence. This study investigates the effectiveness of preoperative interleukin-2 administration to improve lymphocyte counts' postoperative recovery in pancreatic cancer.Methodology: 31 patients with pancreatic cancer who underwent radical surgery were randomized according to 3 different groups. Group A: 9 patients treated with human recombinant IL-2 subcutaneously at 9 million IU/day for 3 days before surgery; group 13: 9 patients treated with IL-2 at 12 million IU/day for 3 days before surgery; group C: 13 patients treated with surgery alone. Assessment of total and T helper lymphocyte counts were studied at hospital admission and in 7th and 14th postoperative day.Results: Toxicity of IL-2 treatment was mild in all groups. Postoperative lymphocytopenia was observed in group A and C, without statistical differences, whereas group B had mean lymphocyte levels within the normal values in the postoperative period.Conclusions: This preliminary result suggests that preoperative subcutaneously IL-2 immunotherapy at 12 million IU for 3 consecutive days before surgery is able to abrogate the effects of the surgical trauma and recover a normal immunofunction in pancreatic cancer patients.

We report a case of a patient observed in emergency condition for recurrent episodes of massive obscure gastrointestinal bleeding that required surgical control. At laparotomy we found an ileal mass with the characteristics of a gastrointestinal stromal tumor (GIST) at histopathological analysis. GISTs should always be considered as a possible cause of obscure gastrointestinal bleeding, although they are often difficult to diagnose preoperatively. Laparotomy is sometimes the only way to obtain a diagnosis. Starting from this case, we reviewed the literature about GISTs, focusing our attention on their diagnosis and the possible surgical and nonsurgical therapies.

Several studies have shown that there is a paucity of immune cells within the stroma of pancreatic adenocarcinoma, a very aggressive cancer with a median survival of about 18 months. A 65-year-old man presented with jaundice. Abdominal ultrasound revealed intra- and extrahepatic bile duct dilatation and a 45-mm diameter hypoechoic solid mass within the pancreatic head; a computed tomography scan excluded vascular infiltration and metastatic lesions. The patient received immunotherapy consisting of 6,000,000 IU human recombinant interleukin-2 administered subcutaneously twice a day for 3 consecutive days. Thirty-six hours after the last dose, he underwent a pylorus-preserving pancreatoduodenectomy. Because of the presence of high-grade dysplasia detected by intraoperative histological examination of a distal section, a spleen preserving total pancreatectomy was performed. The postoperative course was uneventful. The patient died 32 months after surgery because of local recurrence. Histopathology showed G3 pancreatic ductal adenocarcinoma infiltrating the anterior and posterior peripancreatic tissue, duodenal wall and intrapancreatic common bile duct, with sarcoma-like foci and a component of intraductal tumor involving the common bile duct. In the distal pancreas, widespread foci of pancreatic intraepithelial neoplasia (PanI2-3) were found. The Ki-67 proliferation index was 16%. TNM staging was pT3 pN1 R1. Sections were immunostained for the T-lymphocyte marker CD3 and for the dendritic cell marker CD1a. Intratumoral infiltration was high for CD1a+ cells and mild for CD3+ cells. Preoperative immunotherapy with interleukin-2 may contribute to massive stromal infiltration of immune cells in pancreatic adenocarcinoma. This may prolong the survival even in the presence of negative prognostic factors (age >65 years, tumor diameter >20 mm, R1, tumor grade G3).

Background and aims Innate immunity cells play a crucial role in host anticancer defense: cancer patients with high levels of natural killer (NK) cells and eosinophils have a better prognosis. Recombinant interleukin-2 (rIL-2) immunotherapy stimulates innate immunity cells. This study aims to evaluate the toxicity of pre- and postoperative rIL-2 treatment and the effects on innate immunity both in peripheral blood and in cancer tissue of patients with resectable pancreatic adenocarcinoma. Materials and methods Seventeen patients received high dose rIL-2 preoperative subcutaneous administration and two low dose postoperative cycles. We evaluated NK cell and eosinophil count in blood and in pancreatic surgical specimens. Results Toxicity was moderate. In the early postoperative period, blood NK cells and eosinophils significantly increased compared to basal values ( p < 0.02). Histopathological analysis did not find significant intratumoral infiltration of NK cells nor of eosinophils. Conclusions Preoperative high dose rIL-2 administration is able to counteract surgery-induced deficiency of NK cells and eosinophils in peripheral blood in the early postoperative period, although it cannot overcome local mechanisms of immune tumor escape in cancer tissue. The amplification of innate immunity, induced by immunotherapy, may improve the control of metastatic cells spreading in the perioperative period.

BACKGROUND:There is evidence that cancer is immunogenic under certain situations. IL-2 is described to stimulate an effective antitumor immune response in vitro and in vivo. The ability of cancer patients to undergo surgical resection is still the most important prognostic factor for many solid tumors, including gastric adenocarcinoma. The host immune system may be further compromised by surgical procedures leading to a generalized state of immunodepression in the post-operative period. The aim of this randomized case-control study is to evaluate the effects of pre-operative low-dose IL-2 treatment on patients with gastric adenocarcinoma who undergo surgery.METHODS:Sixty-eight patients with gastric adenocarcinoma were enrolled in the study and randomized in two groups: 36 patients were pre-treated with IL-2 and 32 underwent surgery without any treatment. Total peripheral WBC, neutrophils, CD3(+) T, CD4(+) T, CD8(+) T and NK cells were obtained before and after surgery, at different times. Peritumoral infiltration was analyzed on all surgical specimens. Overall survival and relapse-free survival were studied with a median follow-up of 51 months.RESULTS:Low-dose IL-2 treatment resulted in an increase peritumoral lymphocytic and eosinophilic infiltrations and in a minor decrease in CD3(+) T and CD4(+) T cells after surgery (P < 0.05). A stepwise multivariate analysis revealed that overall survival and relapse-free survival were affected only by stage of tumor and age of patients.CONCLUSIONS:According to our data low-doses of IL-2 administered pre-operatively to patients with gastric cancer activate peripheral and peri-tumoral lymphocytes but did not affect prognosis.

Introduction. Blood loss and bile leakage are well-known risk factors for morbidity and mortality during liver resection. Bleeding usually occurs during parenchymal transection, and surgical technique should be considered an important factor in preventing intraoperative and postoperative complications. Objective. Many approaches and devices have been developed to limit bleeding and bile leakage. The aim of the present study was to determine whether a bipolar vessel sealing device allows a safe and careful liver transection without routine inflow occlusion, achieving a satisfactory hemostasis and bile stasis, thus reducing blood loss and bile leak and related complications. Patients and methods. A total of 50 consecutive patients (24 males, 26 females, with a mean age of 57 years) underwent major and minor hepatic resections using a bipolar vessel sealing device. A clamp crushing technique followed by energy application was used to perform the parenchymal transection. Inflow occlusion was used when necessary to control blood loss but not as a routine. No other devices were applied to achieve hemostasis. Results. The instrument was effective in 45 patients and failed to achieve hemostasis in 5 cases, all of whom had a cirrhotic liver. Median blood loss was 490ml (range 100–2500ml) and intraoperative blood transfusions were required in eight cases (16%). Mean operative time was 178min (range 50–315min). Inflow occlusion was necessary in 16 (32%) patients. The postoperative complication rate was 24%, with a postoperative hemorrhage in a cirrhotic patient. There was no clinical evidence of bile leak or procedure-related abdominal abscess. Conclusion. We conclude that the device is a useful tool in standard liver resection, achieving good hemostasis and bile stasis in patients with normal liver parenchyma, but its use should be avoided in cirrhotic patients.

BACKGROUND Laparoscopic splenectomy (LS) is considered the gold standard for the treatment of hematologic disease of the spleen. Intraoperative bleeding is the main complication and main cause of conversion during LS. In this paper, we present our experience with 112 LS procedures, comparing two different techniques and instruments for spleen dissection and hilar vascular control. METHODS We have performed a total of 112 LS procedures in 9 years in two affiliated university hospitals. There were 48 males and 64 females (median age, 32.8 years). Indications were as follows: idiopathic thrombocytopenic purpura (ITP) in 42 patients, hereditary spherocitosis in 28, 6 with beta-talassemia, 1 with hemolitic anemia, 27 with lymphoma, 2 with leukemia, 3 with splenic cysts, and 3 PPT cases. Associated procedures were present in 25 cases (17 cholecystectomy and 4 liver/lymphnodal biopsies + lysis of adhesions). Patients were divided in two groups according to the method of dissection and hilar section (group 1, endostapler + monopolar coagulation with 38 patients; group 2, the Ligasure Vessel Sealing System (Valleylab, Boulder, CO) with 74 patients). RESULTS Groups were well matched according to age, indications, spleen sizes, and procedures associated. Conversion rates (10 cases, 9%; 5 in each group), postoperative hospital stay (median 4 days in each group), and intra- and postoperative complications were similar in the 2 groups without any mortality in each group, while intraoperative blood loss (loss of 100 mL in 55 patients in group 2, 78%; and in 21 patients in group 1, 52%), transfusion rates (8 patients in group 1 versus 4 patients in group 2), and operative mean time (150 minutes in group 1 versus 125 minutes in group 2) were minor in the Ligasure Vessel Sealing System group, with a statistical significance. CONCLUSIONS The approach to spleen dissection and hilum section was safe and efficacy in each case, otherwise the use of Ligasure results in a gain of time. Furthermore the average intraoperative bleeding and average transfusion rates of this series were lower in group 2.

We report a case of the contemporaneous presence of two histologically different pancreatic neoplasms, one renal cancer and one embryogenic duodenal anomaly in a single patient. A 66-year-old man underwent ultrasound examination because of urinary disorders; a solid neoformation within the inferior pole of the left kidney was observed. Computed tomography confirmed the renal lesion, but also a heterogeneous mass within the pancreatic head appeared without bile ducts dilatation. Abdominal magnetic resonance revealed a multiloculated cystic component of the pancreatic mass. A second CT scan confirmed the renal and biliary findings, but it revealed a modest enlargement of the pancreatic asymptomatic mass. A resection of the left kidney inferior pole and a pylorus-preserving pancreaticoduodenectomy were performed. Histopathologic analysis of the surgical specimen revealed mild differentiated papillary renal carcinoma, intraductal papillary mucinous adenoma of the pancreatic head, foci of intraepithelial pancreatic neoplasm and pancreatic heterotopy of duodenal muscular and submucosal layers. The coexistence of several primaries and anomalies in one patient led us to suppose a genetic predisposition to different lesions, even in the absence of known familial genetic syndromes. The study of such cases may help to improve the investigation of molecular correlations and etiological factors of different solid tumors. Nowadays, surgery is the only effective cure.

In December 2000, the Italian Registry of Laparoscopic Surgery of the Spleen (IRLSS) was formally launched under the auspices of the Italian Society for Endoscopic Surgery and New Technologies (SICE). The aim of this multicentre study was to analyse various aspects of the treatment that are still under discussion, such as the extension of the laparoscopic indications in cases of malignancy, independently of the associated splenomegaly, patient selection and operative techniques. A retrospective review of 379 patients undergoing laparoscopic splenectomy for haematological diseases from February 1, 1993, to September 15, 2005, was conducted. Data were collected from the 18 italian centres participating in the IRLSS. The mean length of surgery was 140 minutes (range: 25-420). Conversion was necessary in 25 cases (6.6%), and at least one accessory spleen was found in 30 patients (8%). The mean spleen weight was 1200 g (range: 85-4500). Perioperative death occurred in two cases (0.5%). There were no complications in 312 patients (82.3%), with a mean hospital stay of 5.5 days (range: 2-30). Morbidity occurred in 67 patients (17.8%), mainly consisting in transient fever (n = 22), pleural effusions (n = 16), and actual or suspected haemorrhage (n = 14), requiring re-intervention in 7 patients. This first study carried out on the IRLSS data shows that laparoscopic splenectomy may constitute the gold standard for haematological diseases with a normal-sized spleen. The low morbidity and mortality rates suggest that laparoscopic splenectomy can be successfully proposed also for splenomegaly in haematological malignancies.

BACKGROUND/AIMS Tumor infiltrating lymphocytes (TILs), recognized as a tumor-host reaction, have been linked to prognosis in various tumors, with a clear positive correlation between the density of the lymphoid infiltrate at the advancing margin of the tumor and the prognosis of the patients. TILs are somewhat activated by tumor associated antigens and by IL-2 endogenous release. The aim of this study is to verify if subcutaneously administered IL-2 is able to enhance TILs in gastric cancer patients and is able to influence the prognosis of the patients. METHODOLOGY We enrolled 39 consecutive patients with gastric adenocarcinoma. Patients were randomized to be treated with surgery alone (control group, 20 patients) or with surgery plus preoperative IL-2 (Interleukin-2) administration (treated group, 19 patients). Total lymphocytes, CD4 and CD4/CD8 were evaluated pre- and postoperatively. Peritumoral stromal reaction, neutrophils, lymphocytes and eosinophils infiltration in tumor histology were evaluated as well as survival curves and compared between the groups. RESULTS IL-2 treatment was safe and well tolerated, and in the IL-2 treated group a significant increase over the baseline pretreatment values of the total lymphocyte, CD4 and CD4/CD8 on both the 14th and 50th postoperative days was observed (p < 0.05). Peritumoral stromal reaction, neutrophils and eosinophils infiltration did not shown any statistical difference between the two groups. Otherwise we observed a statistically significant difference in the peri- and intratumoral lymphocytes infiltration between IL-2 treated and control patients (p = 0.000026). Median overall and disease-free survivals were longer, even if not significantly, in the IL-2 group than in the control arm (p = 0.089 and p = 0.09 respectively). CONCLUSIONS Our data shows that IL-2 seems to be able to induce substantial changes in the inflammatory infiltration of the neoplasm, improving the host activity toward the tumor and enhancing the TILs phenomenon in gastric cancer patients. This feature seems to improve the prognosis of the patients.

Thrombosis of the portal system is a potentially life-threatening complication after splenectomy. The reported incidence is low (≅1%), however may be underestimated due to difficult in making the diagnosis. The factors associated with its development and the clinical outcome are poorly characterized. The aim of this study was to assess the incidence, risk factors, treatment, and outcome in series of consecutive cases.

Background/aims Optimal management of gastrointestinal carcinoid neoplasms that metastasize to the liver is controversial. Although operative resection seems to be the most effective approach to metastatic disease, hepatic metastases are usually multicentric and often non-resectable. We investigated the effectiveness of several forms of palliative tumor cytoreduction followed by administration of somatostatin analogues in advanced carcinoid neoplasms. Methods We reviewed our experience with 34 patients with gastrointestinal carcinoid neoplasms. Eighteen patients had metastases and 14 had hormonal symptoms. Twenty-two patients underwent radical surgery, ten with multiple liver metastases were treated with a combination of debulking (resection, radiofrequency ablation, chemoembolization), followed by medical treatment with long-acting octreotide and eventually by radiolabelled somatostatin analogues, and two patients with intractable disease received only biotherapies. Results The six patients with metastatic disease who underwent radical curative liver resection had a median survival of 52 months, compared with a median survival of 48 months in the ten patients who underwent palliative debulking. Symptomatic improvement was observed in all the patients after debulking procedures. The two patients who underwent only medical treatment died after 9 and 18 months. Conclusions Aggressive tumor debulking should be performed in patients with liver metastases already at diagnosis even when complete resection is not feasible because the combination of cytoreductive procedures followed by biotherapies may provide good long-term survival and achieves symptom control in most patients with advanced disease.

Blood loss, a well-known risk factor for morbidity and mortality during liver resection, occurs during parenchymal transection, so many approaches and devices have been developed to limit bleeding. Surgical technique is an important factor in preventing intraoperative and postoperative complications. The aim of the present study was to determine whether the bipolar vessel sealing device allows a safe and careful liver transection, achieving a satisfactory hemostasis thus reducing blood loss and related complications.

BACKGROUND:Laparoscopic splenectomy (LS) is becoming the gold standard for the treatment of hematological disease in children. Intraoperative bleeding is the main complication and main cause of conversion during LS. We present the use of the LigaSure Vessel Sealing System for achieving a safe vascular control, compared with previous techniques.METHODS:LigaSure is an energy-based device which works by applying a precise amount of bipolar energy and pressure to the tissue, thus achieving a permanent seal. We have performed a total of 15 LS in children during 6 years, on 6 males and 9 females with a median age of 11 years (range 5-17). Seven children had hereditary spherocytosis, 4 thrombocytopenic idiopatic purpura (ITP), 3 beta talassemia, and 1 hemolytic anemia. Patients were divided into two groups according to the method of dissection: group 1 ultrasonic coagulation+endostapler (8 pts); group 2 LigaSure (7 pts). We employed a 4 trocars technique with right semilateral position.RESULTS:The groups were well-matched for age, gender, weight, indication and spleen size. Fourteen LS were completed with one conversion (7%) because of hilar bleeding due to accidental injury with endostapler. Median operative time of the series was 140 min (range 90-205), significantly shorter in the group 2 (130 min versus 155 min, P<0.05), as well as median blood loss (group 1, 180 ml versus group 2, 70 ml, P<0.05). There was no mortality, with one postoperative complication (7%) (pulmonary atelectasis). The median postoperative hospital stay was 4 days (range 2-5) without differences between groups.CONCLUSIONS:Each method of dissection seems to be safe and effective. Otherwise LigaSure results in a reduction of operating time and blood loss.