Search

Background: Pancreaticobiliary maljunctions (PBMs) are congenital anomalies of the junction between pancreatic and bile ducts, frequently associated with bile duct cyst (BDC). BDC is congenital biliary tree diseases that are characterized by distinctive dilatation types of the extra- and/or intrahepatic bile ducts. Todani’s types I and IVa, in which dilatation involves principally the main bile duct, are the most frequent. PBM induces pancreatic juice reflux into the biliary tract that is supposed to be one of the main factors of biliary cancer degeneration, although the diagnostic criteria of PBM that can be either morphological and/or functional are not well defined especially in Western series. Objective: The aim of this study was to assess the relative prevalence of PBM in BDC in a large European multicenter study, to analyze the characteristics of PBM and try to propose diagnostic criteria of PBMs based on morphological and/or functional criteria and define the positive, negative predictive values, sensibility and specificity of either criteria. Results: From 1975 to 2012, 263 patients with BDC were analyzed. Among them, 190 (72.2%) were considered to present PBM. Types I and IVa had a similar rate of PBM association. According to the “AFC classification,” 57.2% had a C–P type, 34.5% a P–C type and 8.3% a complex type (“anse-de-seau”). The median length of the common channel in patients with PBM was 15.8±6.8mm (range 5–40mm). The median intrabiliary amylase and lipase levels were 65,249 and 172,104UI/L, respectively. For the diagnostic of PBM, a common channel length of more than 8mm and an intrabiliary amylase level superior to 8000UI/L were associated with a predictive positive value and a specificity of more than 90%. Synchronous biliary cancer had an incidence of 8.7% in all patients with BDC and PBM 11.1% in adults. Compared to type IV, the type I BDC was associated with statistically more cancer patients in the presence of PBM. Conclusions: Characteristics of PBM associated with BDC in Western population are quite close to reported Eastern series. The results suggest considering both the intrabiliary value of amylase >8000UI/L and a length of a common channel >8mm as appropriate values for positive diagnosis of PBM.

Objective: To evaluate improvements in operative and long-term results following surgery for hilar cholangiocarcinoma. Design: Retrospective multicenter study including 17 Italian hepatobiliary surgery units. Patients: A total of 440 patients who underwent resection for hilar cholangiocarcinoma from January 1, 1992, through December 31, 2007. Main Outcome Measures: Postoperative mortality, morbidity, overall survival, and disease-free survival. Results: Postoperative mortality and morbidity after liver resection were 10.1% and 47.6%, respectively. At multivariate logistic regression, extent of resection (rightor right extended hepatectomy) and intraoperative blood transfusion were independent predictors of postoperative mortality (P =. 03 and P =. 006, respectively); in patients with jaundice, mortality was also higher without preoperative biliary drainage than with biliary drainage (14.3% vs 10.7%). During the study period, there was an increasingly aggressive approach, with more frequent caudate lobectomies, vascular resections, and resections for advanced tumors (T stage of 3 or greater and tumors with poor differentiation). Despite the aggressive approach, the blood transfusion rate decreased from 81.0% to 53.2%, and mortality slightly decreased from 13.6% to 10.8%. Median overall survival significantly increased from 16 to 30 months (P =. 05). At multivariate analysis, R1 resection, lymph node metastases, and T stage of 3 or greater independently predicted overall and disease-free survival. Conclusions: Surgery for hilar cholangiocarcinoma has improved with decreased operative risk despite a more aggressive surgical policy. Long-term survival after liver resection has also increased, despite the inclusion of cases with more advanced hilar cholangiocarcinoma. Preoperative biliary drainage was a safe strategy before right or right extended hepatectomy in patients with jaundice. Pathologic factors independently predicted overall and disease-free survival at multivariate analysis. Arch Surg. 2012; 147(1): 26-34

Hepatocarcinoma (HCC) is the fifth most common cancer, with more than one million fatalities occurring annually worldwide. Multiple risk factors are associated with HCC disease etiology, the highest incidence being in patients with chronic hepatitis B virus and hepatitis C virus, although other factors such as genetic makeup and environmental exposure are involved. Multiple genetic alterations including the activation of oncogenes and inactivation of tumor suppressor genes are required for malignancy in human cancers and are correlated with increased stages of carcinogenesis and further tumor progression. In this study of 21 HCC patients, we analyzed pRb2/p130, vascular endothelial growth factor (VEGF), p27((KIP1)), and proliferating cell nuclear antigen as potential HCC molecular biomarkers. In our sample set, we found that p27((KIP1)) was absent. Univariate survival analysis showed that proliferating cell nuclear antigen expression (diffuse staining50% of positive cells in tumor) was confirmed as a significant HCC prognostic biomarker for determining patient survival agreeing with previous studies (P = 0.0126, log-rank test). Lower pRb2/p130 expression was associated to a borderline P value of inverse correlation with tumor malignancy and to a positive correlation with respect to the time from HCC diagnosis (Spearman coefficient = 0.568; P0.05). Conversely, higher VEGF expression was associated with a poor survival (P = 0.0257, log-rank test). We demonstrate for the first time that pRb2/p130 is inversely correlated with VEGF expression and tumor aggressiveness (P0.05) in p27((KIP1))-negative HCC patients. pRb2/p130 and VEGF expression are independent from tumor staging, suggesting their possible role as independent prognostic molecular biomarkers in HCC. Furthermore, we have evidence that VEGF together with pRb2/p130 may act as new HCC biomarkers in a p27((KIP1))-independent manner. Additional studies with larger numbers of patient data would allow the use of multivariable techniques and would be able to further identify patients with poorer survival.

AIM. The properties of plasma cholinesterase (CHE) are partly undiscovered. Equally unknown are the correlations between changes in CHE and other blood variables during the acute phase response related to acute surgical and critical illness. METHODS. Data from 432 measurements of CHE and other variables performed in 92 patients were systematically evaluated and processed by regression analysis. RESULTS. There was a strong direct correlation between CHE and albumin (r=0.77, p

Papillary carcinoma of the gallbladder is less invasive, less frequently metastasizes and results in a longer survival than other gallbladder tumors. It is frequently associated with Anomalous Pancreatico-biliary junction (APBJ), a malformation that occurs most frequently in Japan. Consequently, most cases of papillary cancer have been reported in the Japanese literature, while the incidence of this neoplasm, and its association with APBJ, is still unknown in Western Countries.Seventy cases of gallbladder cancer, observed between January 1992 and December 2000, were retrospectively evaluated. All the histological sections and available cholangiograms were reviewed.Three cases of papillary carcinoma were found (4.2%); APBJ was detected in one of these. All patients underwent resection and are long-term survivors; one patient developed, three years later, a papillary cancer of the common bile duct and was treated by Whipple's procedure.This study provides evidence that papillary carcinoma is more rare in Western countries than in Japan and it is characterized by a longterm survival after surgical resection. Further studies and reports are necessaries to define if this different incidence can justify differences between Western and Japanese results after surgery for gallbladder cancer.

BACKGROUND/AIMS: It has been shown that hepatic pedicle clamping is a safe and effective technique to control bleeding during liver resection. A major drawback can be the induction of liver ischemia and splanchnic venous stasis. METHODOLOGY: This randomized controlled clinical trial compared continuous and intermittent hepatic pedicle clamping during resection of the cirrhotic liver in order to determine which technique is more effective in reducing operative blood loss and producing less ischemic injury. In 18 patients we performed continuous portal triad clamping during liver transection while in 17 patients we performed intermittent clamping. The two groups matched for extent of resection. Serial hepatic function tests were performed on postoperative day 1, 3 and 7. RESULTS: No significant difference was found between the two groups in terms of operative findings. Operative mortality was 5.7% (2 patients). Six patients (17.3%) had postoperative complications. There were no significant differences between the two groups with regard to postoperative liver function tests and coagulation profile. CONCLUSIONS: Continuous and intermittent clamping are both effective in reducing blood loss during hepatectomy in cirrhosis. The two techniques seem to be comparable in terms of ischemic injury. Our findings suggest that intermittent portal triad clamping may not be necessary. As this is contrary to the normal expectancy, additional studies may be needed.

Renal cell carcinoma is an aggressive tumor which is often advanced at the time of diagnosis; its distant spread can take a lymphatic route or, more often, a vascular route (renal vein and inferior vena cava), but tumor thrombosis of left portal vein extending into the round ligament (the umbilical vein) coming from this tumor, to our knowledge, has never been described. We report the case of a metastatic thrombosis of left portal vein and of the umbilical vein from renal cell carcinoma, developed 13 years after nephrectomy, which was successfully treated with left hepatectomy. The experience with hepatectomy for metastatic renal cell carcinoma has been rarely reported. Nevertheless radical hepatectomy is considered to be the only opportunity for curative treatment for selected patients with metastatic renal cell carcinoma.

The aim of the present study is to assess the nuclear DNA ploidy patterns, the fraction of cells in the various phases of the cell cycle as determined by flow cytometry and to evaluate Proliferative cell-nuclear antigen (PCNA) expression in order to examine the relationships between phase-two molecular factors, clinicopathological aspects and outcome of patients with cancers of the ampulla of Vater.Paraffin-embedded specimens from 18 cases of cancers of ampulla of Vater radically resected between 1985 and 1995 were analyzed by flow-cytometry and immunohistochemical staining with monoclonal antibody to the PCNA. The relationships between cell-proliferation kinetics, PCNA-positive cancer cells, clinicopathological findings and the clinical course were evaluated.Pathologist reports documented 17 papillary adenocarcinomas and one case of mucinous carcinoma. According to the TNM classification, 4 patients were in stage I, 7 in stage II and 7 in stage III. Locally advanced ampullary tumors (T3-T4) had a significantly worse prognosis (p = 0.01); survival at 3 and 5 years for stage I-II patients (11 cases) was 90% and 79% as compared to 42% and 42% for patients with stage III (8 cases), respectively (p = n.s.). Thirteen cancers (72%) were diploid and 5 (28%) aneuploid. Patients with aneuploid tumors were younger (mean age: 59 years) than patients with diploid tumors (mean age: 66 years; p = 0.04). No significant correlation was found between size of the tumor (T), lymphnodal status (N), grading (G) or aneuploidy. Difference in terms of survival between aneuploid and diploid patients was relevant (16 vs. 121 months) but, due to the small number of cases, was not statistically significant (p = n.s). The mean value of S-phase fraction (SPF) was 14.8%. PCNA positive rate significantly correlates with size of the tumor (T1-T2 vs. T3-T4; p = 0.03). Actuarial overall survival resulted in 70%, 63% and 31% at 1, 5 and 10 years, respectively. The high rate of diploidy (72%) supports the relative benign behavior of ampullary cancers.PCNA positive rate significantly correlates with size of the disease. Aneuploidy, although without significant prognostic value, correlates well with survival. Because of the wide range of all variables, more data are needed to establish the relationships between pathological factors, DNA ploidy and PCNA rate and their significance as molecular predictors of prognosis in ampulla of Vater cancers.

Nineteen patients with distal juxtapapillary choledochoduodenal fistula diagnosed by endoscopic retrograde cholangiopancreatography are reported. Eighty-four percent of the patients had undergone previous operations on the biliary tract. Fistula appears to be mostly secondary to common bile duct exploration with rigid probes or to a technical mistake in performing sphincteroplasty. Spontaneous fistula secondary to the passage of a stone into the duodenal lumen may also occur. Common duct stones were responsible for the symptoms in most cases (70%). Endoscopic sphincterotomy showed good results in cholecystectomized patients with stones. Surgery directed to the fistula or biliary by-pass are not recommended. Uncomplicated fistula probably does not require treatment.

Lymphoepithelial cyst of the pancreas (LCP) is a rare, benign cyst mimicking pseudocyst or cystic neoplasm. Literature describing LCP is limited to case or brief series reports, and the natural history of this condition is largely unknown. A literature review was carried out in order to elucidate the clinical, pathological and biochemical features of LCP. The aim of this study was to define diagnostic criteria and treatment.A Medline and Pubmed search was conducted by using the key-words "lymphoepithelial cyst" and "pancreas". The articles found were accurately examined and all details regarding clinical and pathological features were included in a data-base. Furthermore, a case recently observed in our unit was added to the review.Ninety-two cases of LCP were found in the worldwide literature, including the case that we observed. LCP occurs more frequently in males (M:F=5.5:1), its preferred site is the tail of the pancreas, and its size ranges between 2 and 10centimetres. Histologically, it is a true cyst delineated by a keratinizing squamous epithelium surrounded by lymphoid tissue. LCP is asymptomatic in the majority of cases and preoperative diagnosis is complicated by a lack of specific radiological features of the disease. An accurate preoperative diagnosis can only be made by obtaining cytological specimens and placing them in the hands of a pathologist who is familiar with the cytological appearances of the disease.LCP is a rare lesion worldwide, without any prevalence in different countries or in different ethnic groups. Understanding the features of LCP, making an accurate diagnosis and differentiating it from cystic neoplasm preoperatively is vital, as when it is diagnosed certainly, a conservative treatment is justified. Otherwise, radical surgery in the form of pancreatic resection is required to exclude the diagnosis of pancreatic cystic neoplasm.

Long term results of hepatic resection for metastases from colorectal cancer depend upon several factors which are related to both features of primary cancer and of metastases. The aim of this study was to evaluate prognostic factors that best correlate with long-term results.Fifty-eight hepatic resections were performed for colorectal cancer metastases. Long-term results were evaluated in relation to age of patients, features of primary tumor, features of metastases, section margin, number of intra-operative blood transfusions and execution of adjuvant chemotherapy.Overall 5-year survival rate was 17%. 5-year survival rate in patients with stage B primary tumor was 63%, in patients with late metachronous metastases it was 28%, in patients with section margin1 cm it was 33% and in patients who did not receive intra-operative transfusions it was 45%. Patients with a solitary metastasis or with metastases sized less than 4 cm and those who received adjuvant chemotherapy also showed a better survival than the others.Better results were observed in patients without nodal involvement of the primary tumor. Patients with a small solitary metachronous metastasis that appeared more than one year after the colorectal resection and resected with a section margin of more than 1 cm, also showed good results.

The "blind" insertion of the Veress needle for insufflation of the peritoneal cavity with subsequent closed placement of the first trocar during laparoscopic abdominal procedures can result in severe major vascular and visceral injuries. An open technique was proposed as an alternative method for insufflation in patients with abdominal scars to reduce the possibility of such complications. The aim of this article is to report the results of our experience with the routine use of open technique in laparoscopic surgery.Open technique was routinely used and prospectively evaluated in 330 patients who underwent laparoscopic procedures.Laparoscopic conversion was necessary in 25 out of 330 cases (7.6 percent): in 20 cases for unclear biliary anatomy during laparoscopic cholecystectomy, and in 5 cases for minor hemorrhage that could not be managed by laparoscopy. In the 305 procedures completed by laparoscopy, 11 patients (3.6 percent) had 13 postoperative complications. These complications were all of minor importance and were always unrelated to trocar insertion; in particular, no major vascular or visceral injuries were observed.Routine use of open technique for pneumoperitoneum represents the best prevention of most of the severe trocar-related complications that are potentially avoidable.

Hilar cholangiocarcinoma (HC) is a rare tumor which has to be distinguished by intrahepatic cholagiocarcinoma invading hepatic hilum because the former has better prognosis then the latter. Patients with HC are difficult to manage because many challenging issues remain in the treatment of this tumour regarding correct diagnosis and therapeutic strategy. HC is resectable in about 30% of cases, but operative risk is highly influenced by septic complications of preoperative biliary drainage and by the need of major liver resection associated with biliary resection. We report the results of 43 resected patients (28 M/15 F; mean age 60 years, range 33-78), accounting for 29% of 149 patients with HC. Symptomless jaundice was the most common clinical presentation (87%; 130 patients). Biliary stricture was classified according to the Bismuth-Corlette classification as type 1 in 3 patients (7%); type 2 in 12 patients (28%); type 3 in 28 patients (65%). Ten patients underwent preoperative right portal vein embolization. Main biliary confluence excision associated with major hepatectomy was performed in 40 patients (93%), with R0 resection rate by 77%. Postoperative mortality rate was 6.9% (3 patients). Morbidity rate was 52.5% (21 patients), being biliary fistula (38%) and liver failure (19%) the most frequent complications. Five-year overall and disease-free survival rate were 36.1% and 28.2, respectively. Surgical resection remains the only chance of cure for patients with HC. However, due to the complexity of surgery immediate results remain unsatisfactory with morbidity and mortality rates higher than those reported after liver resection for other malignancies. This is mainly related to septic complications, strictly linked to complications of preoperative biliary drainage. Selective biliary drainage, careful management of biliary drains, drainage of excluded ducts in case of cholangitis, bile culture guided antibiotic use and preoperative portal vein embolization are important factors to reduce the risk of cholangitis and of postoperative complications. Because of the significant perioperative risk, the demanding operative management and the rarity of this tumor, patients with HC should be referred to tertiary surgical centers.

Background & Aims: The aim of this study was to compare liver resection and radiofrequency ablation in patients with single hepatocellular carcinoma

Objective: The purpose of the study was to analyze clinical presentation, surgical management, and long-term outcome of patients suffering from biliary diverticulum, namely Todani type II congenital bile duct cyst (BDC). Background: The disease incidence ranges between 0.8% and 5% of all reported BDC cases with a lack of information about clinical presentation, management, and outcome. Methods: A multicenter European retrospective study was conducted by the French Surgical Association. The patients' medical records were included in a Web site database. Diagnostic imaging studies, operative and pathology reports underwent central revision. Results: Among 350 patients with congenital BDC, 19 type II were identified (5.4%), 17 in adults (89.5%) and 2 in children. The biliary diverticulum was located at the upper, middle, and lower part of the extrahepatic biliary tree in 11, 4, and 4 patients (58%, 21%, and 21%, respectively). Complicated presentation occurred in 6 patients (31.6%), including one case of synchronous carcinoma. Surgical techniques included diverticulum excision in all patients. Associated resection of the extrahepatic biliary tree was required in 11 cases (58%) and could be predicted by the presence of complicated clinical presentation. There was no mortality. Long-term outcome was excellent in 89.5% of patients (median follow-uptime: 52 months). Conclusions: According to the present largest Western series of Todani type II BDC, the type of clinical presentation rather than BDC location, was able to guide the extent of biliary resection. Excellent long-term outcome can be achieved in expert centers.

Importance The prognostic value of lymph node (LN) assessment after liver resection for hilar cholangiocarcinoma (HC) is still controversial, and the number of LNs required to be removed to obtain adequate staging is not well defined. Objectives To evaluate the LN status in patients after liver resection for HC and to clarify which prognostic factor (the number of positive LNs or the LN ratio [LNR]) was most accurate for staging and what minimum number of retrieved LNs was required for adequate staging. Design, Setting, and Participants Retrospective multicenter study of patients who underwent resection for HC between January 1, 1992, and December 31, 2007, at 8 hepatobiliary Italian centers. The last follow-up was assessed in July 2014. Main Outcome and Measures Differences in overall survival (OS) according to the LN status were analyzed. The OS results were defined as actual because all included patients completed a 5-year follow-up. Results One-hundred seventy-five patients with 1133 retrieved LNs were analyzed. The mean (SD) age of the cohort was 63 (10) years, and 42.9% (75 of 175) were female. The median number of LNs examined per patient was 6.5. Forty percent (70 of 175) had LN metastasis. An LNR exceeding 0.20 was associated with significantly lower 5-year OS than an LNR of 0.20 or less (10.6% vs 24.4%; odds ratio, 2.434; 95% CI, 1.020-5.810; P = .04). On multivariable analysis, the LNR was the only independent prognostic factor for OS but was influenced by the total number of retrieved LNs. The LNR was greater than 0.20 in all patients (30 of 30) with 1 to 4 retrieved LNs and in 52.5% (21 of 40) of patients with at least 5 retrieved LNs. Five-year OS in patients with 1 to 5 retrieved LNs was significantly lower than that in those with 6 to 7 retrieved LNs and those with at least 8 retrieved LNs (34.2%, 64.5%, and 62.7%, respectively; P = .047). Five-year OS did not significantly improve when the number of retrieved LNs was greater than 6. These results were confirmed in a receiver operating characteristic curve analysis performed among N0R0 patients, in whom 5 retrieved LNs was the most accurate cutoff to predict 5-year actual OS (area under the curve, 0.624; P = .004). Conclusions and Relevance An LNR exceeding 0.20 was the only independent prognostic factor for OS in N1 patients after liver resection for HC. However, the LNR was influenced by the total number of retrieved LNs, and removal of more than 5 LNs was the minimum number of LNs required for adequate staging.

Aim To compare clinical presentation, operative management and short- and long-term outcomes of congenital bile duct cysts (BDC) in adults with children. Methods Retrospective multi-institutional Association Francaise de Chirurgie study of Todani types I+IVB and IVA BDC. Results During the 37-year period to 2011, 33 centers included 314 patients (98 children; 216 adults). The adult population included more high-risk patients, with more active, more frequent prior treatment (47.7% vs 11.2%; p < 0.0001), more complicated presentation (50.5% vs 35.7%; p = 0.015), more synchronous biliary cancer (11.6% vs 0%; p = 0.0118) and more major surgery (23.6% vs 2%; p < 0.0001), but this latter feature was only true for type I+IVB BDC. Compared to children, the postoperative morbidity (48.1% vs 20.4%; p < 0.0001), the need for repeat procedures and the status at follow-up were worse in adults (27% vs 8.8%; p = 0.0009). However, severe postoperative morbidity and fair or poor status at follow-up were not statistically different for type IVA BDC, irrespective of patients' age. Synchronous cancer, prior HBP surgery and Todani type IVA BDC were independent predictive factors of poor or fair long-term outcome. Conclusion BDC is a more indolent disease in children compared to adults, except for Todani type IV-A BDC.

Background Pancreaticoduodenectomy represents the major treatment for pancreatic and periampullary neoplasms. Complications related to pancreaticojejunostomy are still the leading cause of morbidity and mortality. A solution proposed by some surgeons is the occlusion of main pancreatic duct by acrylic glue, avoiding pancreaticojejunostomy. Nevertheless, the consequences of this procedure on glucose metabolism are not well-defined. Methods We retrospectively analyzed a cohort of 50 patients who underwent pancreaticoduodenectomy and had metabolic assessments available. The metabolic evaluation included the following: body composition and clinical evaluation, an oral glucose tolerance test, and an hyperinsulinemic euglycemic clamp procedure. Results Twenty-three patients underwent pancreatic duct occlusion and were compared with 27 patients, well-matched controls, who underwent pancreaticojejunostomy. Pancreatic duct occlusion leads to a greater impairment in insulin secretion compared with classic pancreaticojeunostomy. Conclusion Pancreatic duct occlusion is associated with a greater reduction in insulin secretion but does not lead to meaningful differences in the management of patients with diabetes.

In the present study, the prognostic impact of factors involved in the apoptosis pathway were tested on 67 consecutive patients treated with surgical resection. Included in the study were all patients resected for pancreatic adenocarcinoma from 1988 to 2003. Expression analysis for p53, Bax, and Bcl-2 were performed by immunohistochemical staining. Apoptotic cells were identified by the TUNEL method. These data were correlated with survival. Sixty-seven tumor specimens were included in the study. A strong positive correlation was recorded between p53 overexpression and Bax expression levels (P < 0.001). By univariate analysis, overall survival seemed to be improved with Bcl-2 and Bax expression (respectively, P = 0.0379 and 0.0311). The median survival time in patients with low apoptotic index was better versus those with a high index (P = 0.0127). Lymph node involvement was the only clinico-pathologic parameter that significantly correlated with overall survival (P = 0.0202). By a multivariate Cox regression analysis, the only immunohistochemical parameter that influenced overall survival was the apoptotic index (P = 0.040). Tumor's overexpression of both Bax and Bcl-2 resulted the strongest independent prognostic factor (P = 0.013). This is the first study to report a statistically significant association of apoptosis to overall survival for pancreatic cancer patients treated with surgical resection. The contemporary overexpression of Bax and Bcl-2 represents the strongest prognostic factor.

BACKGROUND: We aimed to evaluate the feasibility and long-term results of 2-stage hepatectomy (TSH) in patients with bilobar colorectal liver metastases (CRLM). STUDY DESIGN: We performed a retrospective multicenter study including 4 Italian hepatobiliary surgery units. One hundred thirty patients were selected for TSH between 2002 and 2011. The primary endpoint was feasibility of TSH and analysis of factors associated with failure to complete the procedure. The secondary endpoint was the long-term survival analysis. RESULTS: Patients presented with synchronous CRLM in 80.8% of cases, with a mean number of 8.3 CRLM and with concomitant extrahepatic disease in 20.0% of cases. The rate of failure to complete TSH was 21.5% and tumor progression was the most frequent reason for failure (18.5% of cases). Primary tumor characteristics, type, number, and distribution of CRLM were not associated with significantly different risks of disease progression. Multivariable logistic regression analysis showed that tumor progression during prehepatectomy chemotherapy was the only independent risk factor for failure to complete TSH. The 5- and 10-year overall survival rates for patients who completed TSH were 32.1% and 24.1%, respectively, with a median survival of 43 months. Duration of prehepatectomy chemotherapy >= 6 cycles was found to be the only independent predictor of overall and disease-free survival. CONCLUSIONS: This study showed that selection of patients by response to prehepatectomy chemotherapy may be extremely important before planning TSH because tumor progression while receiving prehepatectomy chemotherapy was associated with significantly higher risk of failure to complete the second stage. For patients who completed the TSH strategy, long-term outcomes can be achieved with results similar to those observed after single-stage hepatectomy. (C) 2014 by the American College of Surgeons.

OBJECTIVE: The aim of this study was to determine the prognostic significance of the preoperatively assessed tumor doubling time (DT) in patients undergoing liver resection for mass-forming intrahepatic cholangiocarcinoma (IHC). METHODS: We evaluated 79 patients who underwent curative resection for IHC, and in whom the same imaging technique was preoperatively available in two consecutive occasions, to allow the calculation of the DT. The influence of DT and other clinical and pathological variables on tumor recurrence and patient survival was determined by the Kaplan-Meier method and uni- and multivariate analysis. RESULTS: Median overall survival was 40 months; 1-, 3-, and 5-year survival rates were 86.1, 55.1, and 35.1 %, respectively. Median disease-free survival was 17 months; 1-, 3-, and 5-year disease-free survival rates were 62.0, 29.1, and 23.3 %, respectively. At univariate analysis, DT

Numerous materials may be used for the cranial reconstruction, including autologous bone and different types of synthetic resins. During surgical procedures, cranial reconstruction has been performed in many different techniques, with or without fixation. To be ideal for cranioplasty, the material must be resistant to infections, radiolucent, thermally nonconductive, nonionizing and noncorrosive, stable, inert, aesthetically pleasing, protective (with biomechanical properties equal to those of the cranium), malleable and easily contoured, inexpensive, and readily available. However, no currently available materials satisfy all of these criteria. Thus, there has been a continuous search for materials capable of filling the defects of the calvarium not only for aesthetic reasons but also for protecting the skull against possible traumas and complications. 1 KRYPTONITE Bone Cement (Doctors Research Group, Oxford, CT) is a nontoxic product with adhesive, bioabsorbable, and osteoconductive properties; this cement requires mixing of 3 components: the first and the second components are fatty acids derived from castor oil (prepolymer and polyol), whereas the third component is calcium carbonate (Figs. 1A, B). Castor seed of the castor plant is the source of castor oil, which contains between 40% and 60% oil that is rich in triglycerides, mainly ricinolein. The seeds have a wide variety of uses: the Ebers Papyrus is an ancient Egyptian medical treatise believed to date from 1552 BC, translated in 1872 AC; it describes castor oil as a laxative. 2Y4 KRYPTONITE Bone Cement has received a CE mark for distribution in Europe and regulatory clearance in Canada and has been approved by Health Canada; and recently, this cement has been approved by the US Food and Drug Administration. We present 6 cases of cranial repair using the bioabsorbable calcified triglyceride KRYPTONITE Bone Cement with and without cranial fixation systems.

Pancreatic cancer is one of the most aggressive gastrointestinal cancer with less than 10% long-term survivors. The apoptotic pathway deregulation is a postulated mechanism of carcinogenesis of this tumour. The present study investigated the prognostic role of apoptosis and apoptosis-involved proteins in a series of surgically resected pancreatic cancer patients. All patients affected by pancreatic adenocarcinoma and treated with surgical resection from 1988 to 2003 were considered for the study. Patients' clinical data and pathological tumour features were recorded. Survivin and Cox-2 expression were evaluated by immunohistochemical staining. Apoptotic cells were identified using the TUNEL method. Tumour specimen of 67 resected patients was included in the study. By univariate analysis, survival was influenced by Survivin overexpression. The nuclear Survivin overexpression was associated with better prognosis (P = 0.0009), while its cytoplasmic overexpression resulted a negative prognostic factor (P = 0.0127). Also, the apoptotic index was a statistically significant prognostic factor in a univariate model (P = 0.0142). By a multivariate Cox regression analysis, both the nuclear (P = 0.002) and cytoplasmic (P = 0.040) Survivin overexpression maintained the prognostic statistical value. This is the first study reporting a statistical significant prognostic relevance of nuclear and cytoplasmic Survivin overexpression in pancreatic cancer. In particular, patients with high nuclear Survivin staining showed a longer survival, whereas patients with high cytoplasmic Survivin staining had a shorter overall survival.