Giuseppe R. Nigri, MD, PhD, FACS Assistant Professor of Surgery Sapienza University of Rome Dept. of Surgery, St. Andrea Hospital, 5EST Via di Grottarossa 1035-1039, 00189 Rome, Italy FAX: (+39)0697252860 e-mail: giuseppe.nigri@uniroma1.it url: http://w3.uniroma1.it/nigri
Giuseppe R. Nigri, MD, PhD, FACS Assistant Professor of Surgery Sapienza University of Rome Dept. of Surgery, St. Andrea Hospital, 5EST Via di Grottarossa 1035-1039, 00189 Rome, Italy FAX: (+39)0697252860 e-mail: giuseppe.nigri@uniroma1.it url: http://w3.uniroma1.it/nigri
PLACE OF BIRTH: Philadelphia, PA - USA
EDUCATION University/Medical School "Sapienza" University, Rome, Italy - MD 1992 (magna cum laude)
ACADEMIC TITLES 2004- Assistant Professor of Surgery, Sapienza University, 2nd School of Medicine, Rome, Italy. Attending Surgeon, St. Andrea University Hospital, Rome, Italy 1999-2003 Clinical and Research Fellow in Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
RESIDENCY AND PH.D. Resident in General Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts and North Shore Medical Center, Salem, Massachusetts, (General Surgery rotation) - Partners HealthCare Doctoral thesis - "Photobiology in Experimental Surgery", Department of Surgical Sciences, Sapienza University, School of Medicine, Rome, Italy Residency in General Surgery (magna cum laude), La Sapienza University, School of Medicine
CLINICAL/RESEARCH EXPERIENCE & FELLOWSHIPS 2006 (July-Aug) Visiting Surgeon, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA 2005 (July-Aug) Visiting Surgeon, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA 2004 (Nov-Dec) Clinical Observer, Department of Surgery and Department of Pathology (Genetics and Molecular Biology), Memorial Sloan Kettering Cancer Center, Cornell University, New York, NY, USA 1999-2003 Clinical and Research Fellow in Surgery and Vascular Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA 1990 Research associate, Department of Anatomy, Medical University of Ohio (former Medical College of Ohio) Toledo, OH, USA 1989 Research associate, Department of Anatomy, Medical University of Ohio (former Medical College of Ohio) Toledo, OH, USA 1988-1992 Research Associate and Visiting Physician, Department of Anatomy and "Pietro M. Motta" Electron Microscopy Lab., Sapienza University
AWARDS Harvard Medical School’s nominee for the Doris Duke Clinical Scientist Award Best resident award (Photodynamic Therapy/Oncology session), 22nd Annual Meeting of American Society for Laser Medicine and Surgery, Atlanta, April 2002 Recipient of the US Air Force Grant for the 22nd Annual Meeting of the American Society for Laser Medicine and Surgery Italian Society for Surgery "E. Ruggieri" Award Best Overall Basic Science Paper Award, 21st Annual Meeting of American Society for Laser Medicine and Surgery, New Orleans, April 2001 Academy of Medicine of Rome Award
LICENSURES & CERTIFICATIONS USMLE - ECFMG Certification, United States Medical Licensure Examination/Educational Commission for Foreign Medical Graduates, Philadelphia, PA - USA Medical licence (temporary), Massachusetts Board of Registration in Medicine, Commonwealth of Massachusetts, USA Fully registered medical practitioner (#6070750), General Medical Council, UK Specialist registration, General Medical Council, UK Basic Life Support Certification (BLS). American Heart Association. Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Course I: December 7th, 2000; Course 2: June 21st, 2002) ATLS Instructor - Advanced Trauma Life Support Certification for Physicians - Provider Course I: October 2-3, 2000; Course II: June 19-20th, 2002, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. On that occasion, Dr. Nigri was selected as ATLS potential instructor Advanced Cardiac Life Support (ACLS). Department of Surgery, Massachusetts General Hospital, Harvard Medical School, June 21st , 2002, Boston, Massachusetts Italian Full Medical Licence Board Certified in General Surgery (Italy)
MGH Laser Safety Certification Course. MGH Laser Safety Committee, Department of Surgery, MGH Laser Center and Wellman Laboratories of Photomedicine. Massachusetts General Hospital, Harvard Medical School, November 18th, 2000, Boston, Massachusetts MGH Basic Radiation Protection Certification for Research and Hospital Personnel. The Radiation and Safety Office of Massachusetts General Hospital, Harvard Medical School, March 6th, 2000, Boston, Massachusetts MGH Animal Surgical Research Training Certification. Subcommittee on Research Animal Care (S.R.A.C.) and Office of Laboratory Animal Resources (O.L.A.R.). Massachusetts General Hospital (Charlestown Facility), Harvard Medical School, July 1999, Boston, Massachusetts MGH Human-subject Protection Education Certification. Partners Healthcare System. IRB training certification. Partners Human Research Committee HIPPA Compliance, Memorial Sloan Kettering Cancer Center, New York, NY, USA (Hccs) Child Abuse and Maltreatment Course - "Recognizing and Reporting Child Abuse, Maltreatment, and Neglect - New York State" - Medical Society of the State of New York (Provider #10608 - Certificate MSSNY6259) - October 13, 2007 Infection Control: A Training Program For Healthcare Professionals. Medical Society of the State of New York (Provider # TPO2013 Certificate # MSSNY6762) April 2, 2008 Biomedical Course in the Responsible Conduct of Research Curriculum - CITI Collaborative Institutional Training Initiative. Office if Research Education, University of Miami. May 14, 2008 Miscellaneous: Medic First Aid Instructor (BLS basic and BLS for Professionals - Instructor # 40424), Emergency First Response Instructor + Care for Children w/AED, DAN Oxygen First Aid Instructor (# 24600), PADI Instructor/MSDT(# 920705).
MILITARY SERVICE Army, Medical Corps, Liutenent (1995-1997)
MEDIA MGH Hotline, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. 06/07/2001:" July 6, 2001 Going global: MGH medicine featured on Italian TV "... RAI is very well known in Italy and throughout Europe," explains Giuseppe Nigri, MD, of MGH Surgery (shown above with camera crew). "Much of its programming ... ". MGH Hotline, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. 04/26/2002: "Giuseppe R. Nigri, MD, PhD of MGH Surgery, has been recognized by the American Society for Laser Medicine and Surgery for submitting the best resident research paper in the…". MGH Hotline, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. 06/04/2001: "Giuseppe R. Nigri, MD, of MGH Surgery, has been recognized by the American Society for Laser Medicine and Surgery for submitting the best overall science paper…". "Super Quark", RAI UNO (trailer, MPEG VIDEO), 08/21/2001. Scientific TV show, broadcast on Italian National TV and filmed at Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. MGH Wellman Laboratories of Photomedicine - Media relations: Wellman news - "Giuseppe R. Nigri, MD, PhD, of MGH Surgery, has been recognized by the American Society for Laser Medicine and Surgery for submitting the best resident research paper in the specialty of Photodynamic Therapy/Oncology at the organization's annual meeting" MGH Website – Division of Vascular Surgery, Department of Surgery – Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts Brigham and Women's Hospital: Anesthesia Records, Academic Activities and Achievements, , Harvard Medical School, Boston, Massachusetts Ministero degli Esteri (Italian Foreign Minister): Da Vinci Database - Italian Researchers Abroad - Giuseppe R. Nigri, M.D., Ph.D, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston - MA, USA
INVENTIONS/DISCLOSURES Nigri G., LaMuraglia G.: Complement inhibition enables photodynamic therapy in vein grafts. MGH Corporate Sponsored Research and Licensing. Massachusetts General Hospital, Harvard Medical School, February 2002, Boston, Massachusetts. Nigri G., LaMuraglia G.: Adjustable retractor for microsurgery. MGH Corporate Sponsored Research and Licensing. Massachusetts General Hospital, Harvard Medical School, November 2001, Boston, Massachusetts. LaMuraglia G.M., Nigri G.R., Kossodo S.: Modulation of photodynamic therapy in vein grafts. MGH Corporate Sponsored Research and Licensing. Massachusetts General Hospital, Harvard Medical School, June 2001, Boston, Massachusetts. LaMuraglia G.M., Nigri G.R., Kossodo S.: Sterilization of prosthetic vascular graft by shock waves. MGH Corporate Sponsored Research and Licensing. Massachusetts General Hospital, Harvard Medical School, November 2000, Boston, Massachusetts.
MISCELLANEOUS Member of the Editorial Board of World Journal of Surgical Oncology (UK) Member of the Editorial Board of Patient Safety in Surgery (USA) Member of the Editorial Advisory Board of the Open Surgical Oncology Journal (USA) Associate Editor of Journal of Medical Science Research (USA) Associate Editor of Journal of Medical Case Reports (UK) Associate Editor of BMC Research Notes (UK) Member of the Simulation Center Committee - Association for Surgical Eucation (USA) Member of the Scientific Committes of the XXXVI World Congress(2008) of International College of Surgeons Member of the Organizing Committee/Preliminary Faculty of the EuroAmerican MultiSpecialty Summit IV, Laparoscopy and Minimally Invasive Surgery, Society of Laparoendoscopic Surgeons, February 11-14, 2009, Orlando, Florida, USA Member of the Board on Teaching & Training Standards, Sapienza University, II School of Medicine Institutional Rapresentative, Italian Society for University Surgeons Institutional Rapresentative, Association for Academic Surgery (USA)
PROFESSIONAL MEMBERSHIPS American Medical Association (USA) American College of Surgeons, Fellow (USA) American Society of Colon and Rectal Surgeons (USA) American Society of General Surgeons (resident member, 2002) Association for Academic Surgery (USA) – Istitutional Rapresentative (2005-2008) Association for Surgical Education (USA) CIMIT - Center for the Integration of Medicine and Innovative Technology, (USA) International College of Surgeons, Fellow (2003-2007) Italian Society for Surgery (ITA) Italian Society of University Surgeons (ITA) - Istitutional Rapresentative Massachusetts Medical Society (USA) New York Academy of Sciences (2001-2002 - USA) Society of Laparoendoscopic Surgeons (USA)
Abstract: Laparoscopic adrenalectomy is now regarded as the procedure of choice for most adrenal glands presenting surgical pathology. The primary adrenal-specific contraindication to laparoscopic adrenalectomy today is the presence of a large adrenal mass with evidence of local infiltration or venous invasion. We used our multicentre experience to compare the transperitoneal (TLA) and retroperitoneal (RLA) minimally invasive approaches. In our study we found statistically significant differences between RLA and TLA in terms of duration of surgery (148 minuti vs. 112; p < 0.005), intra-operative blood loss (439 cc vs 333 p < 0.005; p < 0.005) and time of first oral intake (1.2 +/- 0.5 days vs 1.8 +/- 1.08 days; p < 0.005). The RLA approach is preferable in cases of previous abdominal surgery, but its learning curve is extremely steep. TLA access needs a less demanding learning curve and tends to be faster than RLA, where the working area is penalised by limited manoeuvring space. There is no clear preference between TLA and RLA in the literature. However, the experience of the surgeon still remains the most important variable when choosing between the two approaches.
Abstract: We report a case of a 36-year-old man who was admitted to the Emergency Department with right flank pain. The clinical presentation was suggestive of renal colic. However, a computed tomography scan showed the presence of a foreign body in the inferior duodenal flexure. Upper gastrointestinal endoscopy demonstrated a 6.5-cm wooden toothpick deeply embedded in the duodenal wall; this was removed via endoscopy. The peri-duodenal inflammatory reaction had encased the right ureter, resulting in hydronephrosis. The patient did well and was discharged on post-operative day 7. He did not recall toothpick ingestion. When evaluating patients with acute abdominal pain, foreign body ingestion should be considered. In patients with a history of toothpick ingestion, immediate diagnosis with endoscopic management should be performed.
Abstract: ABSTRACT: INTRODUCTION: Lipoma is the most frequent benign tumor of the soft tissue. This lesion is often asymptomatic except in cases of enormous masses compressing nervous-vascular structures. Although the diagnosis is mostly clinical, imaging tools are useful to confirm the adipose nature of the lesion and to define its anatomic border. Sometimes, lipomas may be the result of a previous trauma, such as in this patient. CASE PRESENTATION: A 45-year-old man presented at our institution with a giant hard firm mass in the upper external quadrant of the right buttock disclosed after a weight loss diet. Subsequent magnetic resonance imaging showed a giant adipose mass developed beneath the large gluteal muscle and among the fibers of the medium and small gluteal muscles. When questioned on his medical history, the patient reported a blunt trauma of the lower back 14 years earlier. He underwent surgery and histological examination confirmed a giant lipoma. CONCLUSION: Lipomas might result from a previous trauma. It is hypothesized that the trigger mechanism is activated by cytokine and growth factors released after the trauma. We herein present an exceptional case of a giant post-traumatic lipoma which caused a painful compression on the right sciatic nerve.
Abstract: Cavernous hemangiomas are rare, benign, non-functioning neoplastic lesions that often involve liver and skin. Hemangiomas of the adrenal gland are very uncommon, and usually found accidentally in otherwise asymptomatic patients. This paper reports the only case of a large cavernous hemangioma removed with transperitoneal laparoscopic adrenalectomy and reviews the literature.
Abstract: Hepatic resection is today the treatment of choice for cirrhotic patients affected by hepatocellular carcinoma (HCC). Short term results are now definitely satisfactory, with a mortality rate in the referral centers lower than 5%. However, long term results are affected by a high recurrence rate, between 50% and 100%, due to the underlying cirrhosis. Notwithstanding the high recurrence rate, the hepatic resection guarantees a five years survival between 40% and 60%, comparable to the one offered by liver transplantation. The aim of this paper is to review the results of studies on resected cirrhotic patients affected by HCC.
Abstract: Since 2001 we have conducted a prospective randomised study of right laparoscopic-assisted hemicolectomy vs open right hemicolectomy for right colon cancer in order to assess the differences in intraoperative and postoperative results as well as oncological clearance. Thirty-three patients with right colon cancer received laparoscopic-assisted right hemicolectomy (LRH) and were compared with 33 patients who underwent open right hemicolectomy (ORH). We analysed morbidity and mortality, number of postoperative days of starving, postoperative days tolerating a liquid diet and a soft diet, duration of postoperative ileus, as well as the distance of the resection margin from the tumour (< 5 cm or >5 cm), and the number of lymph nodes found in the resected specimen. We also compared the length of operative time, blood loss, and any associated surgery. Morbidity occurred in 1 patient undergoing LRH (3.0%) as against 4 patients (12.1%) in the ORH group (p < 0.05). Postoperative ileus lasted 3.15 days (range: 3-5 days) in the LRH group vs 3.0 days (range: 1-4 days) in the ORH group. Median operative time was 251 min (range: 130-360 min) in the LRH group vs 222.9 min (range: 135-360 min) in the ORH group, while blood loss amounted to a median of 135 mi (range: 100-300 ml; SD +/- 42.9 mi) in the LRH group vs. 404.1 ml (range: 250-1000 ml; SD +/- 159.3 ml) in the ORH group (p <0.05). The distance of the resection margin from the tumour was more than 5 cm in both groups. In the LRH group a median of 12.7 lymph nodes were removed (range: 9-31; SD +/- 4.5) vs. 18 lymph nodes in the ORH group (range: 8-29; SD +/- 3.9) (p < 0.05). Associated surgery was performed in 15.1% of cases in both groups. In our experience LRH presents a statistically significant advantage in terms of morbidity and blood loss compared to ORH. Equivalent oncological clearance was obtained, fulfilling the stated criteria of 5 cm free resection margins and number of lymph nodes resected, though we removed fewer lymph nodes in LRH compared to ORH (p < 0.05).
Abstract: Amyand's hernia is defined as an inguinal hernia within the hernial sac containing the appendix. It is a rare disease, reported in 1% of cases of inguinal hernia repair. The appendix can be complicated by acute appendicitis in 0.13% of cases. This disease is often very difficult to diagnose, and most of the time it can be confused with an incarcerated or strangulated inguinal hernia. Often, it requires an emergent surgical treatment. This article describes the case of a 82-year-old female who was admitted for an intestinal obstruction and a bulge in the right inguinal region. An abdominal computed tomography scan showed dilated small bowel loops with multiple air/liquid levels and one loop herniating into the right inguinal canal. The patient underwent a laparotomy that showed the presence of an acute appendicitis and a necrotized ileal loop protruding into the right inguinal canal. The patient underwent an appendectomy and small bowel resection and she was discharged on postoperative day 10. Amyand's hernia can be a challenge for the surgeon. Its treatment depends on the grade of inflammation of the appendix. In fact, it can range from the simple repair of the abdominal defect with a prosthetic mesh, to appendectomy, small bowel resection and repair of the abdominal wall defect without a mesh.
Abstract: The aim of the present study was to investigate the expression of a number of angiogenic factors such as VEGF, VEGF-C, TGF-alpha and apoptosis in an attempt to relate these biological markers to TNM staging, lymph-node status and prognosis. Angiogenic factors and apoptosis were studied immunohistochemically in 72 gastric cancer cases. The search for micrometastases was performed with an immunohistochemical technique in 20 NO cases. Apoptosis determination was assessed with the TUNEL assay. The chi2 test according to Pearson was used for statistical analysis. The apoptotic index was related to both stage and prognosis: high expression cases showed an earlier stage (p < 0.02) and a better prognosis (p < 0.05). The determination of high neovessel density was related to poorer 5-year survival (p < 0.05). Only the expression of VEGF-C correlated inversely with prognosis (p < 0.05). The presence of micrometastases was unrelated to any of the biological markers studied. Our results partly confirm those reported in the literature. The present study revealed a number of biological markers that may be helpful for identifying particular subgroups of patients. More investigation with similar techniques in large prospective series is needed as a support to clinical practice.
Abstract: Exposure to light-at-night, including disturbance of the circadian rhythm, possibly mediated via the melatonin synthesis and clock genes, has been suggested as a contributing cause of breast cancer. Persons who engage in nightshift work may exhibit altered nighttime melatonin levels and reproductive hormone profiles that could increase the risk of hormone-related diseases, including breast cancer. Several studies have been conducted worldwide recently to investigate the effects of factors that can disrupt circadian rhythm and alter normal nocturnal production of melatonin and reproductive hormones of relevance to breast cancer etiology. We selected 5 international study, published on well known journals and based on large numbers of subjects, and we evaluated them in order to define a state of the art of this topic. Comparing these studies we conclude that nurses who frequently attend night shifts should undergo strict and periodical breast cancer screening, since the risk is significantly increased in this population.
Abstract: Aneurysms of the splenic artery are the most common splanchnic aneurysms. Aneurysms of a splenic artery with an anomalous origin from the superior mesenteric artery are however rare, with eight previously reported cases. Their indications for treatment are superposable to those of aneurysms affecting an orthotopic artery. Methods of treatment of this condition include endovascular, minimally invasive techniques and surgical resection. We report one more case of aneurysm of an aberrant splenic artery, treated with surgical resection, and preservation of the spleen.
Abstract: BACKGROUND: Gastrointestinal stromal tumors (GIST) of the stomach are the most frequent followed by those of the intestinal tract, while colon and rectum represent rare sites. GIST of the anal canal are extremely rare. They have been studied along with GIST of the rectum, as a single entity, and along with them they represent 5% of GIST. GIST arising from the anal canal account for only 2%-8% of the anorectal GIST. Thus anal GIST must be considered an exceptional case. CASE PRESENTATION: A 78-year-old man was referred to our Institution for an anal mass, in absence of any symptom. The patient was treated by local excision. An histological diagnosis of a low grade GIST was made. No further treatment was necessary. No local recurrence of distant metastases were found at follow-up. CONCLUSION: At the moment, only ten cases of c-kit positive anal GIST are reported in the literature. These few data are not sufficient to establish a widely accepted approach for this neoplasia.We recommend to perform an initial local excision, to define the risk of aggressive behavior and the resection margins and proceed to a more aggressive treatment, if the GIST belongs to high or very high risk group. The role of adjuvant therapy is still uncertain. Although inhibitors of tyrosine-kinase receptor needs further studies before their routine use, their role in case of distant or local recurrence has been accepted. Patients' close follow up is mandatory to disclose as soon as possible local recurrences or metastases.
Abstract: The tumor, node, metastasis (TNM) system has become the principal method for assessing the extent of disease, determining prognosis in gastric cancer patients, and affecting the therapy strategies. The extent of lymph node metastasis is the most important prognostic factor. The aim of this study was to compare the N-classifications of the 4th and the 5th-6th TNM editions and to evaluate retrospectively the prognostic value of the 2002 TNM edition. We evaluated 344 patients who underwent curative total or subtotal gastrectomy. Nodal involvement was detected in 221 (64%) patients. Median follow-up period was 76 months. Thirty per cent of the old N1 patients were reclassified as pN2 (18.5%) and pN3 (11.3%). Eighty-eight per cent of the old N2 patients were reclassified as pN1 (75%) and pN3 (13.7%). In reclassifying the patients, statistically significant changes were reported between 1987 and 2002 TNM stage grouping, mainly in stage IIIB and IV. The 5-year survival rate per stage group did not statistically differ between the 4th and the 5th-6th editions, although a diminutive trend was registered in the IIIA stage. pTNM stage, nodal numerical stage, nodal topographical stage, and depth of tumor invasion resulted in significantly independent prognostic factors. Our data confirm the simplicity and easy application of the new stadiation and the better prognostic stratification of the N-stage. The pN3 group showed a worse prognosis independent of location. On the other hand, prognostic value of pN1 and pN2 stage is lower, probably depending on lymph node location. In multivariate analysis, the difference between old and new TNM staging is low. Hence, we suggest comparing lymph node location and number in larger series. In our series, in pT1 tumors, neither pN2 nor pN3 involvement was found. Hence, in our opinion, for correct N-staging, 10 lymph nodes in early gastric cancer and at least 16 in the other pT-stages seem sufficient for a real pN0 stadiation.
Abstract: The TNM system has become the principal method for assessing the extent of disease, determining prognosis in gastric cancer patients, and influencing therapeutic strategies. The extent of lymph node metastases is the most important prognostic factor. The aim of the study was to compare the 4th and 6th TNM edition N-classifications and to retrospectively evaluate the prognostic value of the 2002 TNM edition. We evaluated 344 patients who underwent curative total or subtotal gastrectomy. Our data confirm the simplicity and easy application of the new staging and the better prognostic stratification of the N-stage. In multivariate analysis the difference between the old and new TNM staging is minimal. We therefore suggest comparing lymph node location and number in larger series. For the purposes of correct N-staging, 10 lymph nodes in early gastric cancer and at least 16 in the other pT stages seem sufficient to achieve effective pNO staging.
Abstract: BACKGROUND/AIMS: Evaluation of the short- and long-term outcome of liver resections for HCC in cirrhotic patients. METHODOLOGY: A retrospective analysis was performed on 106 consecutive cirrhotic patients with HCC resected between June 1974 and September 2002. Univariate and multivariate analyses were performed on several clinicopathological variables to analyze factors affecting the long-term outcome and intrahepatic recurrence. RESULTS: Overall mortality and morbidity were 10.7% and 26% respectively. These rates significantly decreased in the last years: from 1997 to 2002 no hospital mortality has been recorded. After a median follow-up of 19 months (interquartile range: 10-36), tumor recurrence appeared in 25 patients (23.5%). The 1-, 3-, and 5-year overall survival rates were 86.6%, 70.3%, and 60.6%, respectively. The 1-, 3-, and 5-year disease-free survival rates were 86.3%, 58.1%, and 40.7%. Univariate analysis showed that viral etiology of cirrhosis (p=0.03), presence of multiple nodules (p=0.02) and vascular invasion (p=0.05) are related to a worse long-term survival. Multivariate analysis showed that only the viral etiology of cirrhosis and the presence of multiple nodules were significant independent prognostic factors. CONCLUSIONS: Results after hepatic resection for HCC in cirrhotic patients can be improved by using a limited surgical approach. The viral etiology of cirrhosis, the presence of multiple nodules and vascular invasion negatively affected recurrence rate and long-term survival.
Abstract: BACKGROUND: Biliary cystadenoma is a rare benign neoplasm, which is often misdiagnosed for a hepatic abscess or a hydatid cyst that tends to recur and is at risk for progression to malignant neoplasm. CASE PRESENTATION: This case describes a 30-year-old woman admitted to our institution in an emergency setting. The patient was originally misdiagnosed as affected by a hepatic hydatid cyst at another hospital, and then emergently treated at our Institution for severe abdominal pain. Histologic evaluation of the cyst showed that it was a biliary cystadenoma and, therefore, the patient underwent a hepatic resection in order to completely remove the lesion. CONCLUSION: Complete excision of any suspicious hepatic cystic lesion remains the best method for diagnosis and treatment of cystadenoma. Incomplete excision of most biliary cystadenoma results in a higher rate of recurrence and the risk of malignant transformation. We report this case to elucidate the clinical presentation, preoperative evaluation, and surgical treatment of these rare lesions.
Abstract: BACKGROUND: Hepatocellular adenomas are the most common benign liver tumors. They are usually related to oral contraceptive intake. CASE PRESENTATION: This case describes a 58-year-old woman admitted to our institution for a hepatic mass incidentally discovered during a routine examination. The patient, who was never on oral contraceptives, was asymptomatic upon admission. She underwent a thorough diagnostic evaluation and then a hepatic right trisegmentectomy. The histologic evaluation of the mass showed that it was a hepatocellular adenoma with areas of bone marrow metaplasia. CONCLUSION: Bone marrow metaplasia has rarely been found associated to liver tumors. The presence of marrow-derived hepatic progenitor cells might be the source of both adenoma hepatocytes and bone marrow differentiated cells. To our knowledge, this is only the second case in the English literature in which areas of bone marrow metaplasia were found in a hepatocellular adenoma.
Abstract: Gastroesophageal junction (GEJ) neoplasms have become more common over the past decade. Like mediastinal and abdominal lymph nodes and other gastric tumors, GEJ tumors spread to the retroperitoneal nodes. The TNM staging system does not consider this pattern and does not clinically distinguish GEJ tumors from gastric and esophageal cancers. The aim of the study is to compare the old and new TNM staging systems to assess whether the new TNM classifies lymph node involvement in these tumors as a prognostic factor. From January 1983 to December 1995, 438 patients underwent curative gastric resections for cancer at the Department of Surgery "P. Valdoni" of the University of Rome "La Sapienza". Sixty-two had GEJ type II and III tumors according to the Siewert classification system. The old pN1 and new pN1 survival rates (P < 0.05) were statistically different; the old pN2 and new pN2 survival rates (P = 0.483) were not. The multivariate analysis of significant statistical prognostic factors showed that the pTNM staging in type II and type III GEJ tumors is the most important prognostic factor (P < 0.001), followed by the old pN and new pN (P < 0.001) and the pT (P < 0.005). Gender, age, Lauren type, and tumor location according to Siewert (II vs III) were not independently significant prognostic factors. This study concludes that the numbers and locations of metastatic lymph nodes are important prognostic factors that should be included in the next TNM edition.
Abstract: Aim of the study was to evaluate the surgical strategy for the treatment of the hilar cholangiocarcinoma, focusing on the clinicopathological factors influencing the outcome. Between January 2001 and December 2003 23 patients out of 33 underwent surgery for hilar cholangiocarcinoma. All patients underwent resection of the extrahepatic biliary duct. This was the only treatment in patients with Bismuth-Corlette type I cholangiocarcinoma, or in patients not suitable for hepatic resection. In the other cases, resection of extrahepatic bile duct was associated to right or left hepatectomy. The univariate and multivariate analysis evaluated multiple clinicopathological factors in order to assess long term survival. Major hepatic resection was carried out in 19 (82%) patients. Hepatic resection extended to the segment 4 was performed in 5 patients. Also, left hepatectomy was carried out in 14 patients, while resection of the caudate lobe in 7 (30%) patients. No hospital mortality was recorded, while the overall morbidity was 43%. The 1 year survival rate was 63.2%, and the median survival rate 19 months. Recurrencies showed up in 12 patients (52%). Among the other factors, low level of albumin (p = 0.006), positive resection margins (p = 0.003) and T (p = 0.02) mostly affected the long term survival. Surgery is the gold standard for achieving curative treatment of hilar cholangiocarcinoma. The bile duct resection, along with hepatic resection, the best option to increase long term survival of these patients. The univariate and multivariate analysis showed that low albumin levels, positive resection margins and T are the most important factors influencing long term survival.
Abstract: OBJECTIVE: Migration of vascular smooth muscle cells (SMCs) into the subintimal space, and their proliferation and resultant deposition of extracellular matrix are key processes in the development of intimal hyperplasia, leading to vascular recurrent stenosis. The purpose of this study was to investigate the effects of clinically administered doses of gamma-radiation on SMCs and extracellular matrix proteins in vitro, to better understand how it impinges on cellular and extracellular components of recurrent stenosis. METHODS: The effects of gamma-irradiation (10, 20 Gy) on SMC migration into three-dimensional collagen matrix gels was quantitated by calibrated light microscopy, and the release of metalloproteinases into conditioned media was investigated with an enzyme-linked immunosorbent assay and zymography. Collagen production was assayed with [(3)H]-proline incorporation, and SMC phenotype changes with confocal microscopy with a fluorescent alpha-actin antibody. The effect of gamma-irradiation on extracellular matrix was investigated by quantitating untreated SMC proliferation ((3)H-thymidine incorporation) on irradiated endothelial cell-derived matrix and by assessing structural collagen matrix changes with sodium dodecylsulfate polyacrylamide gel electrophoresis. All groups were compared with nonirradiated control groups. RESULTS: SMC vertical migration was significantly decreased by gamma-irradiation (48% and 55%, respectively; P <.0001). Irradiation did not generate measurable matrix protein crosslinks, nor did it alter the production of metalloproteinases or collagen synthesis. However, gamma-irradiation decreased the ability of extracellular matrix to induce nonirradiated SMC proliferation (15% reduction; P =.0028). Moreover, gamma-irradiation reversed the secretory phenotype of cultured SMCs to a contractile type. CONCLUSIONS: The gamma-irradiation-induced reduction of cellular migration, changes in SMC phenotype, and functional activity of matrix-bound factors, and no measurable effects on the production of extracellular matrix proteins, may in part explain the diverse effects of gamma-irradiation on the restenotic response.
Abstract: OBJECTIVE: Photodynamic therapy (PDT) inhibits post-interventional stenosis in balloon-injured arteries, but causes thrombosis when applied to vein grafts. This may result from added free radicals produced during the hypoxia-reperfusion injury of vein graft implantation. The purposes of this study were to determine whether a free radical scavenger could inhibit vein graft thrombosis, enabling PDT to inhibit intimal hyperplasia; and to investigate the role of neutrophils, also a source of radicals, in this setting. METHODS: Jugular vein bypass grafts of the common carotid artery were performed in rats. PDT was administered in situ to the vein graft and artery in the presence or absence of deferoxamine (DFX), an OH- scavenger. RESULTS: PDT alone induced thrombosis in all untreated vein grafts. DFX administration or inhibition of neutrophil adhesion to the graft prevented PDT-induced vein graft thrombosis. Moreover, DFX given together with PDT significantly decreased vein graft intimal hyperplasia (0.010 mm2 +/- 0.005 mm2; P<.002) as compared with DFX alone (0.113 mm2 +/- 0.009 mm2) or untreated control animals (0.112 +/- 0.007 mm2). CONCLUSIONS: OH- radicals and neutrophils both have key roles in PDT-induced vein graft thrombosis. By inhibiting free radical production or neutrophil adhesion to the graft, adequate PDT can be administered for successful inhibition of vein graft intimal hyperplasia.
Abstract: Photodynamic therapy (PDT) is based on a photochemical reaction using a photosensitizer and light to produce reactive oxygen species that have biological effects. Although its application in some fields is largely based on thrombosis, in the vascular setting thrombosis must be prevented. In this study we examined the effects of PDT on the changes in activity of thrombomodulin (TM) and tissue factor (TF) as important regulators of the coagulation process of endothelial cells. Human umbilical vein endothelial cells were treated with PDT (chloro-aluminum-sulfonated phthalocyanine, lambda = 630 nm) at different light-energy doses, and TM and TF levels were measured using fluorescence spectroscopy. Microparticles (MP) were analyzed using flow cytometry analysis. PDT alters the thrombogenic state of endothelial cells by causing decreased expression of TM and increased expression of functional TF in a light-energy dose-dependent way. PDT-treated endothelial cells shed large numbers of MP containing high levels of TF. TF functionality of PDT-treated cells, measured by a Factor Xa-generating assay, was high. TF was located mostly intracellularly and in MP. The disturbed anticoagulant balance described in this study may explain the occurrence of thrombosis induced by PDT and, if not contained, dispute the suitability of PDT as an adjuvant modality to treat vascular restenosis.
Abstract: Although the standard approach for inflow to the brachial artery is directly from the subclavian or the carotid artery, unusual scenarios exist when this direct route is not accessible. We present a case of a patient after right radical mastectomy and radiation therapy for breast cancer with severe ischemic symptoms of the dominant right upper extremity. Angiography revealed an occluded right subclavian artery with a paucity of distal collaterals across the right shoulder. A reversed vein graft was constructed from the right common carotid artery to the right brachial artery and was tunneled with a retrohumeral approach to avoid the previously operated and irradiated field. The patient has remained asymptomatic with a patent graft at 2 years.
Abstract: Restenosis results from intimal hyperplasia and constrictive remodeling following cardiovascular interventions. Photodynamic therapy (PDT) has been shown to inhibit intimal hyperplasia in vivo by preventing neointimal repopulation of the treated vessel. This study was undertaken in an attempt to further dissect the mechanisms by which PDT acts on secreted and extracellular matrix proteins to inhibit migration of cultured human vascular cells. PDT of three-dimensional collagen gels inhibited invasive human smooth muscle cell (SMC) migration, whereas cell-derived matrix metalloproteinase production remained unaltered. Additionally, PDT generated cross-links in the collagen gels, a result substantiated in an ex vivo model whereby PDT rendered the treated vessels resistant to pepsin digestion and inhibited invasive migration of SMC and fibroblasts. These data support the premise that by inducing matrix protein cross-links, rendering the vessel resistant to degradation, in vivo PDT inhibits repopulation of the vessel and therefore intimal hyperplasia.
Abstract: One of the major drawbacks to therapeutic cardiovascular intervention is intimal hyperplasia and constrictive remodeling, which result in vascular restenosis. Neointimal hyperplasia is characterized by proliferation and migration of smooth muscle cells. These cells also produce new extracellular matrix, leading to narrowing of vessels. Photodynamic therapy (PDT) represents one of the most promising approaches to the inhibition of intimal hyperplasia. PDT requires the interaction among 3 factors: a source of light, usually a laser, a photosensitizer and oxygen. When the inert photosensitizer absorbs light of a specific wavelength, it is activated to an excited triplet state, generating reactive oxygen species. These free radicals are able to induce apoptosis of the smooth muscle cells that had absorbed the photosensitizer; they also induce changes in the extracellular matrix, reducing cell migration. Because of continued success of PDT in inhibiting intimal hyperplasia in experimental animal models, it is now being tested in clinical trials for vascular diseases. PDT offers many advantages to the surgeon since it can act on numerous factors responsible for vascular lesions. In the future PDT could be used in helping to overcome the inherent failures associated to vascular reconstruction. This treatment modality is emerging as an encouraging therapeutic option, either alone or as an adjunct to conventional treatment. However, more detailed clinical investigation are necessary to determine its full potential.
Abstract: A series of 79 normal human hearts was studied focusing on the morphological characteristics of the papillary muscles of the right ventricle and their tendinous cords (chordae tendineae). The number, incidence, length and shape of the anterior, septal and posterior papillary muscles were observed. The tendinous cords attached to each papillary muscle were counted at their origin. The papillary muscles and the tendinous cords were measured in situ and after the removal of the right atrioventricular valve (tricuspid valve). The anterior and posterior papillary muscles (apm, ppm) were present in 100% of the cases. The septal papillary muscle (spm) was absent in 21.5% of the hearts. The apm presented 1 head in 81% and 2 heads in 19%; it was 19.16 mm in length. The spm was one-headed in 41.7% and presented two heads in 16.5%; the presence of a 3 and 4 heads appeared in 12.7% and 7.6% respectively; the spm was 5.59 mm in length. The ppm had 1 head in 25.4%, 2 heads in 46.8%, 3 heads in 21.5% and 4 heads in 6.3% of the cases; it was 11.53 mm in length. Tendinous cords (TC) varied as follows: from 1 to 11 TC originated in the apm (mean 4.74); from 1 to 8 TC originated in the ppm (mean 2.67) and from 1 to 5 TC originated in the spm (mean 1.77).
Abstract: BACKGROUND AND OBJECTIVE: Bacteria that cause infection of vascular prosthetic grafts produce an exopolysaccharide matrix known as biofilm. Growth in biofilms protects the bacteria from leukocytes, antibodies and antimicrobial drugs. Laser-generated shock waves (SW) can disrupt biofilms and increase drug penetration. This study investigates the possibility of increasing antibiotic delivery and sterilization of vascular prosthetic graft. STUDY DESIGN/MATERIALS AND METHODS: Strains of Staphylococcus epidermidis and S. aureus were isolated from infected prosthetic grafts obtained directly from patients. Dacron grafts were inoculated with the isolated bacteria, which were allowed to form adherent bacterial colonies. The colonized grafts underwent the following treatments: (a) antibiotic (vancomycin) alone; (b) antibiotic and SW (c) saline only; and (d) saline and SW. Six hours after treatment, the grafts were sonicated, the effluent was cultured and the colony forming units (CFU) were counted. RESULTS: CFU recovered from control grafts colonized by S. epidermidis were comparable: saline, 3.05 x 10(8) and saline+SW 3.31 x 10(8). The number of S. epidermidis CFU diminished to 7.61 x 10(6) after antibiotic treatment but the combined antibiotic+SW treatment synergistically decreased CFU number to 1.27 x 10(4) (P<0.001). S. aureus showed a higher susceptibility to the antibiotic: 2.26 x 10(6) CFU; antibiotic +SW treatment also had an incremental effect: 8.27 x 10(4) CFU (P<0.001). CONCLUSIONS: This study demonstrates that laser-generated shock waves have no effects alone, but can enhance the effectiveness of antibiotics against bacteria associated with prosthetic vascular graft biofilms, suggesting that this treatment may be of value as adjunctive therapy for prosthetic graft infections.
Abstract: Authors expose their experience with autotransfusion, made during several years in a general surgery university department. Discussion is made about ethic and economical aspect of the philosophy guiding the most general concept of blood sparing, and different methods of autotransfusion; attention is then focused on practical experience made during two years (1995-1997) when the program worked well. On the whole, in 94 patients, 172 blood units were collected plus 10 plasma units obtained by aferesis. No method-related complications are have been observed. Elements who corresponded to difficulties or obstacles to the fully application of the method have been critically analyzed. Authors propose finally guide-lines which want to be valid proposal to increase method use while respecting at the best ethics, economics, efficacy and efficiency that must guide our work.
Abstract: Photodynamic therapy (PDT) generates free radicals through the absorption of light by photosensitizers. PDT shows promise in the treatment of intimal hyperplasia, which contributes to restenosis, by completely eradicating cells in the vessel wall. This study investigates the mechanisms of PDT-induced cell death. PDT, using the photosensitizer chloroaluminum-sulfonated phthalocyanine (1 mg/kg) and laser light (lambda = 675 nm) 100 J/cm(2) was administered to rat carotid arteries after balloon injury-induced intimal hyperplasia. Apoptosis was determined by cell morphology with light microscopy and transmission electron microscopy, DNA cleavage by terminal dUTP nick-end labeling staining, and nucleosomal fragmentation (ladder pattern) by DNA agarose gel electrophoresis. Four hours after PDT, apoptosis was observed in vascular cells, as evidenced by terminal dUTP nick-end labeling staining and transmission electron microscopy. Within 24 hours no cells were present in the neointima and media. Immunofluorescence using an alpha-smooth muscle cell actin antibody confirmed the disappearance of all neointimal and medial cells within 24 hours. No inflammatory cell infiltrate was observed during this time frame. Apoptosis was sharply confined to the PDT treatment field. These data demonstrate that vascular PDT induces apoptosis as a mechanism of rapid, complete, and precise cell eradication in the artery wall. These findings and the lack of inflammatory reaction provide the basis for understanding and developing PDT for a successful clinical application in the treatment of hyperplastic conditions such as restenosis.
Abstract: BACKGROUND/AIMS: The pathological changes and the risk of developing cancer in the ileal pouch mucosa of patients who received restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) were studied. The presence or absence of remaining rectal mucosa below the IPAA in both patients with stapled and handsewn IPAA was also examined. MATERIALS AND METHODS: Endoscopy of the ileal pouch was performed on 38 patients at 4, 12, 18 and 36 months after restorative proctocolectomy with ileal pouch. Mucosal biopsy specimens were taken from the ileal reservoir in order to assess the histological incidence of inflammation. In 23 patients, biopsies were taken to perform cytometric DNA analysis. Clinical symptoms of pouchitis (over six evacuations in 24 hours, night-time evacuations, leakage of feces, bloody diarrhea, abdominal pain and fever) were recorded and correlated with the histological findings. Biopsies were also sampled below the ileo-anal anastomosis (IPAA) in order to identify residual rectal mucosa. RESULTS: Results of histological assessment showed various degrees of chronic inflammation increasing over time (from 42 to 60%) while the presence of both acute and chronic inflammation of the reservoir was less frequent (from 18 to 30%). Villous atrophy was present in 39-68% of patients and the grade of villous atrophy was correlated to the grade of inflammation. Clinical pouchitis was present in 3 to 8% of cases at the different controls and it was always associated with the highest grade of histological inflammation and severe villous atrophy. No significant alteration of the DNA cellular content was observed. Very low incidence of aneuploidy (0.7-1% Ex.R.) has been reported in three cases. However, we found dysplasia in only one patient who underwent surgical treatment for familial polyposis coli. IPAA evaluation showed no residual rectal mucosa in 40% of cases with stapled IPAA; in the remaining 60%, we found a small amount of rectal mucosa (maximum 1 cm). We did not find rectal mucosa after handsewn IPAA with mucosectomy. CONCLUSIONS: Patients treated with restorative proctocolectomy with IPAA showed a higher and increased incidence of inflammation during follow-up. No significant alteration of DNA cellular content nor dysplasia of the pouch mucosa were observed. In this study the chance of leaving rectal mucosa after stapled IPAA was about 60%.
Abstract: In order to evaluate the effects of potassium cristalloid cardioplegic solutions (CPS) on the endothelial morphology, human saphenous veins were studied by scanning electron microscopy after exposure to three CPS named MKP (magnesium-potassium-procaine cardioplegia), LK (low-potassium cardioplegia), and HKA (high-potassium-albumin cardioplegia) and to their main components. Vein rings, selected from the saphenous veins sampled for graft harvesting in 63 patients undergoing aorto-coronary bypass surgery, were exposed for 30, 60, and 120 minutes to the following buffered solutions: Krebs bicarbonate (as control); MKP cardioplegia; KCl (16.0 mmol/L); MgCl2(2).6H2O (16.0 mmol/L); Procaine (0.05 mmol/L); NaCl (92.5 mmol/L); LK cardioplegia; KCl (10.0 mmol/L); Mannitol (74.3 mmol/L); Glucose (27.7 mmol/L); HKA cardioplegia; KCl (30 mmol/L). Severe endothelial lesions, consisting of diffuse disendothelialization and diffuse signs of endothelial suffering, were induced by KCl (30 and 16 mmol/L) after 60-120 min, and by MKP cardioplegia and KCl (10 mmol/L) after 120 min. Moderate endothelial lesions, characterised by diffuse endothelial surface changes and focal cellular loss, were induced by KCl (30 and 16 mmol/L) after 30 min, MKP cardioplegia and KCl (10 mmol) 30-60 min, LK cardioplegia, HKA cardioplegia, and MgCl2.6H2O after 120 min. Slight endothelial lesions, consisting of diffuse endothelial bulging, or absence of significant endothelial changes, were found in samples otherwise treated. Our findings showed a significant damaging effect of CPS on the human saphenous vein endothelium in-vitro. The endothelial lesions seemed related to the presence of potassium and magnesium, and to prolongation of the time of exposure to the cardioplegic solutions.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: In order to study the initial development of myocardial ultrastructural changes owing to right atrium volume overload, myocytes have been studied in specimens taken from the right atrial wall and auricle of four children aged 1 to 6 years with ostium secundum atrial septal defect undergoing cardiac surgery. The younger patients (1 to 4-year-old children) we observed did not show diffuse and significant myocardial ultrastructural damages. The most significant myocardial changes were observed in the 2 older patients (six years old) as we found subcellular signs of myocardial hypertrophy such as an increased number of mitochondria, increased glycogen inclusions, areas of new sarcomerogenesis and nuclei lobulated and variably shaped. Focal degenerative changes, such as rupture of mitochondrial cristae and intercellular fibrosis were also noted. These changes may be considered as the initial features of myocardial hypertrophy because they were not as severe and diffuse as those usually seen in a marked functional failure.
