Bowel obstruction by sigmoid strangulation as complication after laparoscopic adjustable gastric banding.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) has been widely performed in the past, however, given its limited weight loss compared to some other procedures, this technique is less often used. Furthermore, a number of complications leading to band removal have been reported in the past few years. METHODS: We present a late acute bowel obstruction by sigmoid strangulation in a female patient with the LAGB performed 15 years ago. RESULTS: The laparoscopic exploration displayed a post-LAGB intestinal strangulation of the sigmoid loop which was caused by the connecting tube. Since the bowel was still viable, the tube was cut and the obstruction has been successfully resolved. The patient was discharged three days after the surgery. CONCLUSION: Although less often performed, knowledge of LAGB complications can be of importance. We believe that, the present strangulation of the sigmoid by the LAGB tubing is the world's first ever case reported. Nevertheless, when it is still proposed to selected patients, an adequate length of the intra-abdominal tubing could reduce the risk of loop formation and prevent this kind of obstruction by internal hernia.

Pain control in thoracic oncology.

This review of pain management in lung cancer is based on the presentation of four cases of thoracic oncology patients with pain at various stages of their disease. The approach will be multidisciplinary, involving a thoracic oncologist, radiologist, thoracic and orthopaedic spine surgeon, radiation therapist, pain medicine specialist, and palliative care specialist. This multispecialty approach to the management of different painful presentations in thoracic oncology will demonstrate the complexity of each case and the improved patient outcomes which result from the involvement of different disciplines working in concert.In the USA, Europe and other countries, palliative care specialists often become rapidly involved in the management of these patients, coordinating social care and providing psychological support.Thoracic and orthopaedic spine subspecialists provide surgical methods to control tumour invasion, and improve quality of life and preservation of function in settings of even diffuse metastatic disease. Similarly, thoracic oncology and radiation therapists utilise both therapeutic and palliative chemotherapeutic and radiation therapy regimens to prolong and improve quality of life.The pain medicine specialist can, in addition to medication management, offer a variety of interventional approaches including unique drug delivery systems such as epidural analgesia, regional anaesthesia techniques, and intrathecal pumps, as well as neuromodulation techniques and neurolytic or neuroablative procedures.In the USA, these specialists complete an additional fellowship year in pain medicine following the completion of an anaesthesiology, physical medicine and rehabilitation, neurology or psychiatry residency. These programmes are accredited by the Accreditation Council for Graduate Medical Education, or ACGME (www.acgme.org).

Correlating tumor metabolic progression index measured by serial FDG PET-CT, apparent diffusion coefficient measured by magnetic resonance imaging (MRI) and blood genomics to patient's outcome in advanced colorectal cancer: the CORIOLAN study.

BACKGROUND: Metastatic colorectal cancer (mCRC) may present various behaviours that define different courses of tumor evolution. There is presently no available tool designed to assess tumor aggressiveness, despite the fact that this is considered to have a major impact on patient outcome. METHODS/DESIGN: CORIOLAN is a single-arm prospective interventional non-therapeutic study aiming mainly to assess the natural tumor metabolic progression index (TMPI) measured by serial FDG PET-CT without any intercurrent antitumor therapy as a prognostic factor for overall survival (OS) in patients with mCRC.Secondary objectives of the study aim to test the TMPI as a prognostic marker for progression-free survival (PFS), to assess the prognostic value of baseline tumor FDG uptake on PFS and OS, to compare TMPI to classical clinico-biological assessment of prognosis, and to test the prognostic value on OS and PFS of MRI-based apparent diffusion coefficient (ADC) and variation of vADC using voxel-based diffusion maps.Additionally, this study intends to identify genomic and epigenetic factors that correlate with progression of tumors and the OS of patients with mCRC. Consequently, this analysis will provide information about the signaling pathways that determine the natural and therapy-free course of the disease. Finally, it would be of great interest to investigate whether in a population of patients with mCRC, for which at present no known effective therapy is available, tumor aggressiveness is related to elevated levels of circulating tumor cells (CTCs) and to patient outcome. DISCUSSION: Tumor aggressiveness is one of the major determinants of patient outcome in advanced disease. Despite its importance, supported by findings reported in the literature of extreme outcomes for patients with mCRC treated with chemotherapy, no objective tool allows clinicians to base treatment decisions on this factor. The CORIOLAN study will characterize TMPI using FDG-PET-based metabolic imaging of patients with chemorefractory mCRC during a period of time without treatment. Results will be correlated to other assessment tools like DW-MRI, CTCs and circulating DNA, with the aim to provide usable tools in daily practice and in clinical studies in the future. ClinicalTrials.gov Number: NCT01591590.

A Rare Case of Wirsung Duct Duplication with Chronic Pancreatitis.

Teaching point: Wirsung duct duplication is a very rare condition that can lead to chronic pancreatitis.

Isotoxic High-Dose Stereotactic Body Radiotherapy (iHD-SBRT) Versus Conventional Chemoradiotherapy for Localized Pancreatic Cancer: A Single Cancer Center Evaluation.

Given the lack of direct comparative evidence, we aimed to compare the oncological outcomes of localized pancreatic ductal adenocarcinoma (PDAC) treated in the same tertiary cancer center with isotoxic high-dose stereotactic body radiotherapy (iHD-SBRT) or conventional chemoradiotherapy (CRT). Biopsy-proven borderline/locally advanced patients treated with iHD-SBRT (35 Gy in 5 fractions with a simultaneous integrated boost up to 53 Gy) or CRT (45−60 Gy in 25−30 fractions) were retrospectively included from January 2006 to January 2021. The median overall survival (mOS) was evaluated trough uni- and multivariate analyses. The progression free survival (PFS) and the 1-year local control (1-yLC) were also reported. Eighty-two patients were included. The median follow-up was 19.7 months. The mOS was in favour of the iHD-SBRT group (22.5 vs. 15.9 months, p < 0.001), including after multivariate analysis (HR 0.39 [CI95% 0.18−0.83], p = 0.014). The median PFS and the 1-yLC were also significantly better for iHD-SBRT (median PFS: 16.7 vs. 11.5 months, p = 0.011; 1-yLC: 75.8 vs. 39.3%, p = 0.004). In conclusion, iHD-SBRT is a promising RT option and may offer an improvement in OS in comparison to CRT for localized PDAC. Further validation is required to confirm the exact role of iHD-SBRT and the optimal therapeutic sequence for the treatment of localized PDAC.

Decrease in Pancreatic Perfusion of Patients with Type 2 Diabetes Mellitus Detected by Perfusion Computed Tomography.

OBJECTIVES: The objectives of the study was to compare pancreatic perfusion by computed tomography in type 2 diabetes and non-diabetic subjects. MATERIAL AND METHODS: In this case-control study, 17 patients with type 2 diabetes and 22 non-diabetic controls were examined with a dynamic 192-slices perfusion computed tomography for estimating pancreatic perfusion parameters. RESULTS: Thirty-nine patients were included (22 with Type 2 diabetes mellitus [T2DM]), with a mean age of 64 years. There were significant differences in some pancreatic perfusion parameters in patients with and without type 2 diabetes. Blood volume (BV) was lower in pancreatic head (with T2DM: 14.0 ± 3.4 vs. without T2DM: 16.1 ± 2.4 mL/100 mL; P = 0.033), pancreatic tail (with: 14.4 ± 3.6 vs. without: 16.8 ± 2.5 mL/100 mL; P = 0.023), and in whole pancreas (with: 14.2 ± 3.2 vs. without: 16.2 ± 2.5 mL/100 mL; P = 0.042). Similar behavior was observed with mean transit time (MTT) in pancreatic head (with: 7.0 ± 1.0 vs. without: 7.9 ± 1.2 s; P = 0.018), pancreatic tail (with: 6.6 ± 1.3 vs. without: 7.7 ± 0.9 s; P = 0.005), and in whole pancreas (with: 6.8 ± 1.0 vs. without: 7.7 ± 0.9 s; P = 0.016). BV in head, tail, and whole pancreas had negative correlations with age (head r: -0.352, P = 0.032; tail r: -0.421, P = 0.031; whole pancreas r: -0.439, P = 0.007), and fasting plasma glucose (head r: -0.360, P = 0.031; tail r: -0.483, P = 0.003; whole pancreas r: -0.447, P = 0.006). In a multivariate linear regression model, HbA1c was independently associated with decrease in BV in whole pancreas (ß: -0.884; CI95%: -1.750 to -0.017; P = 0.046). CONCLUSION: Pancreatic BV and MTT were significantly lower in patients with type 2 diabetes. BV was decreased with older age and poorer glycemic control.

EUS-guided placement of fiducial markers for stereotactic body radiation therapy in pancreatic cancer: feasibility, security and a new quality score.

Background and study aims In borderline resectable/locally advanced pancreatic ductal adenocarcinoma (PDAC), stereotactic body radiation therapy (SBRT) is an emerging neoadjuvant treatment option. Endoscopic ultrasound (EUS)-guided insertion of fiducial markers being a prerequisite, our aim was to assess its feasibility and safety and also to evaluate its success, from both the endoscopist's and radiotherapist's perspectives. Patients and methods We prospectively collected data concerning PDAC patients submitted to EUS-guided fiducial placement, from February 2018 to November 2019. Technical success was defined as at least one marker presumed inside the tumor. Quality success was assessed at pre-SBRT computed tomography, accordingly to the number of markers inside or < 1 cm from the tumor, number of markers at the tumor extremity, their location in different planes, the distance between them, and their distance from the biliary stent (if present). A new quality score was then proposed and high-quality success defined as at least six of 12 points. Results Thirty-seven patients were enrolled. A total of 97 fiducials were implanted, with a median of three fiducials per patient (0-4). The technical success rate was 92 %, with failure of fiducial placement in three patients. Three patients (8 %) had adverse events (fever, mild acute pancreatitis, and biliary stent migration). At pre-SBRT evaluation, two patients' markers had migrated. The high-quality success rate was 62.5 %. Conclusions Our results contribute to demonstrating the feasibility and safety of EUS-guided fiducial placement for SBRT treatment in PDAC. It is hoped that the newly proposed quality score will pave the way for improving fiducial positioning and SBRT delivery.

Isotoxic high-dose stereotactic body radiotherapy integrated in a total multimodal neoadjuvant strategy for the treatment of localized pancreatic ductal adenocarcinoma.

BACKGROUND: Our aim was to evaluate the feasibility and safety of isotoxic high-dose (iHD) stereotactic body radiation therapy (SBRT) in a total neoadjuvant sequence for the treatment of localized pancreatic adenocarcinoma. MATERIALS AND METHODS: Biopsy-proven borderline resectable/locally advanced pancreatic cancer (BR/LAPC) patients were included in this observational prospective analysis from August 2017 to April 2020 without excluding tumours showing a radiological direct gastrointestinal (GI) invasion. An induction chemotherapy by modified fluorouracil, irinotecan and oxaliplatin was performed for a median of six cycles. In case of non-progression, an isotoxic high-dose stereotactic body radiotherapy (iHD-SBRT) was delivered in 5 fractions followed by a surgical exploration. The primary endpoint was acute/late gastrointestinal grade ⩾3 toxicity. Secondary endpoints were overall survival (OS), progression-free survival (PFS) and local control (LC). RESULTS: A total of 39 consecutive patients (21 BR and 18 LAPC) were included: 34 patients (87.2%, 18 BR and 16 LAPC) completed the planned neoadjuvant sequence. After iHD-SBRT, 19 patients [55.9% overall, 13/18 BR (72.2%) and 6/16 LAPC (37.5%)] underwent an oncological resection among the 25 patients surgically explored (73.5%). The median follow up was 18.2 months. The rates of acute and late GI grade 3 toxicity were, respectively, 2.9% and 4.2%. The median OS and PFS from diagnosis were, respectively, 24.5 and 15.6 months. The resected patients had improved median OS and PFS in comparison with the non-resected patients (OS: 32.3 versus 18.2 months, p = 0.02; PFS: 24.1 versus 7.1 months, p < 0.001). There was no survival difference between the BR and LAPC patients. The 1-year LC from SBRT was 74.1% and the median locoregional PFS was not reached for both BR and LAPC patients. CONCLUSIONS: iHD-SBRT displays an excellent toxicity profile, also for potentially high-risk patients with radiological direct GI invasion at diagnosis and can be easily integrated in a total neoadjuvant strategy. The oncological outcomes are promising and emphasise the need for further exploration of iHD-SBRT in phase II/III trials.

Intra- and interobserver reproducibility of pancreatic perfusion by computed tomography.

The aim of this study was to measure intra- and interobserver agreement among radiologists in the assessment of pancreatic perfusion by computed tomography (CT). Thirty-nine perfusion CT scans were analyzed. The following parameters were measured by three readers: blood flow (BF), blood volume (BV), mean transit time (MTT) and time to peak (TTP). Statistical analysis was performed using the Bland-Altman method, linear mixed model analysis, and intraclass correlation coefficient (ICC). There was no significant intraobserver variability for the readers regarding BF, BV or TTP. There were session effects for BF in the pancreatic body and MTT in the pancreatic tail and whole pancreas. There were reader effects for BV in the pancreatic head, pancreatic body and whole pancreas. There were no effects for the interaction between session and reader for any perfusion parameter. ICCs showed substantial agreement for the interobserver measurements and moderate to substantial agreement for the intraobserver measurements, with the exception of MTT. In conclusion, satisfactory reproducibility of measurements was observed for TTP in all pancreatic regions, for BF in the head and BV in the tail, and these parameters seem to ensure a reasonable estimation of pancreatic perfusion.