The quality control in pancreatic surgery.

AIM: Over the past decade, several centralization programs for major pancreatic surgery have been implemented in hospitals with high procedural volumes. Although the impact of this process was altogether positive, also possible negative effects have been evidenced, above all the lack of comprehensive coverage and access to specialized centers. In order to solve these problems, it was proposed the utilization of an outcome-based and not volume-based center selection. For this purpose the choice of an appropriate outcome assessment system is crucial. MATERIAL OF STUDY: We retrospectively reviewed 74 patients undergoing pancreatoduodenectomy. The outcomes were evaluated utilizing the Accordion Severity Classification of Postoperative Complications. RESULTS: The morbidity of 58 % and the mortality of 4 % were comparable with the ones reported in large series utilizing the same classification system. CONCLUSIONS: The Accordion system is an effective method of quality control for pancreatic surgery both in high- and low-volume hospitals.

Surgery and adjuvant therapies in the treatment of stage IV melanoma: our experience in 84 patients.

BACKGROUND AND AIMS: Survival rates of patients with stage IV melanoma are poor: Median survival is 7-8 months and 5-year survival rates about 5%. There is no agreement on the role of surgery at this stage. Most patients with metastatic melanoma are not able to undergo resection and usually are sent to systemic chemo- and immunotherapy. PATIENTS AND METHODS: Eighty-four patients operated on for stage IV melanoma were evaluated. Of them, 61.9% were submitted to reiterative surgery with 168 operations and 182 surgical procedures overall. A total of 90.5% was submitted to adjuvant therapies according to aggressive and reiterated schedules: chemotherapy, immunotherapy, dendritic cells vaccine, infusion of tumor infiltrating lymphocytes, local therapies as electrochemotherapy. RESULTS: The mean overall survival (Kaplan-Meier) was 56.7 months (1 year: 72.1%, 3 years: 46.5%, 5 years: 23.16%). The survival of reiterative surgery was significatively longer than single surgery (62.7 vs 42.4 months, median 50.9 vs 16.0), p = 0.03. Multivariated Cox analysis was performed for disease-free interval, repeated surgery, adjuvant therapies, and site of metastasis according to the American Joint Committee on Cancer: Reiterative surgery was shown as an independent prognostic factor (p < 0.05). CONCLUSION: Metastatic resection associated with adjuvant therapy may improve overall survival and, in some instances, can provide long-term survival, whatever site and numbers of metastasis. In our series, reiterative surgery was more significatively efficient in improving survival than single-time surgery.

Expression profiling of angiogenic genes for the characterisation of colorectal carcinoma.

The development of new blood and lymphatic vessels is a crucial event for cancer growth, metastatic spread and relapse after therapy. In this work, the expression levels of chemokines, angiogenic and angiostatic factors and their receptors were determined in paired mucosal and tumour samples of patients with colorectal carcinoma and correlated with clinical and histological parameters by advanced multivariate analyses. The most important predictors to discriminate between tumour and paired normal mucosa turned out to be the levels of expression of plexin-A1 and stromal cell-derived factor 1 (SDF-1), the former overexpressed and the latter downregulated in tumours. The levels of osteopontin and Tie-2 transcripts discriminated between the presence and absence of lymph node infiltration, the former overexpressed in the presence of infiltration whilst the latter providing a protective role. These results add support to the notion that the expression levels of selected genes involved in new blood and lymphatic vessel formation represent trustable biomarkers of tumour development and invasion and contribute to the identification of novel molecular classifiers for colorectal carcinoma.

Pancreatic Injury Following Blunt Abdominal Trauma during a Soccer Game.

UNLABELLED: This article reports a case of unusual pancreatic trauma, underestimated initially and treated surgically at a later stage. A 26-year-old man presented with an abdominal trauma sustained during a soccer game. The patient arrived 24 hours after the trauma with abdominal pain associated to vomiting and intestinal occlusion. Laboratory tests revealed elevated serum amylase levels. An abdominal computed tomography (CT) scan showed a pancreatic parenchymal dishomogeneity at the passage between body and tail, highly suspicious for pancreatic full thickness laceration. Magnetic resonance pancreatography (MRP) demonstrated possible duct involvement. The patient was urgently submitted to distal pancreatectomy with splenectomy. This case demonstrates a rare mechanism of injury and the potential importance of serial CT scans in the diagnosis, grading, and management of isolated pancreatic injury. KEYWORDS: pancreatic injury; blunt abdominal trauma; pancreas; duct disruption.

[Adhesive small bowel occlusion: a clinical and therapeutic study of 163 consecutive patients]. / L'occlusione intestinale da aderenze. Valutazioni cliniche e terapeutiche su 163 casi consecutivi.

The aim of this retrospective study is to evaluate the immediate and late outcomes of the surgical and conservative treatment of adhesive small bowel obstruction. A series of 163 consecutive patients affected by adhesive occlusion were analysed. 63 patients were submitted to emergency surgery and 100 to conservative treatment; 15 of these ones were operated on because they did not improve or deteriorated. The in-hospital mortality and morbidity, the length of the ileus, the time required for the operation, the length of the recovery, and the late results after a median follow-up of 3.6 years (range: 1-6 years) are reported. The overall mortality was 3.26% and there was no significant difference (p = 0.764) between the treatment modalities. The patients submitted to conservative therapy had a lower morbidity, shorter length of the ileus and shorter hospital stay and a better outcome at follow-up. In the surgical group, the patients submitted to emergency surgery had a lower mortality, a shorter ileus and shorter hospital stay than the patients submitted to delayed surgery. Conservative treatment of adhesive occlusions should be opted for when the indications are correct (no intestinal ischaemia, no occlusion by a bridle). In doubtful cases, the patient should be submitted to emergency surgery to avoid the risks of surgical delay.

[Early identification of patients with acute pancreatitis at risk of critical deterioration: a multiparameter case-control study]. / L'identificazione precoce dei pazienti con pancreatite acuta a rischio di peggioramento critico: uno studio multiparametrico caso-controllato.

The aim of the study was the early identification of patients with acute pancreatitis who subsequently developed critical complications. All patients admitted to a surgical ward for acute pancreatitis were recruited into the study. The severity of acute pancreatitis was assessed using Ranson and Balthazar scores. Patients transferred to the intensive care unit (Group A) were matched with patients with the same scores who did not require intensive care treatment (Group B). Several clinical and biochemical variables were compared between the two groups. A total of 221 patients were recruited (110 m, 121 f; mean age: 60.6 years; range: 17-94 years). Group A included 13 patients (7 m, 6 f; mean age: 59.6 +/- 13.5 years; range: 35-76), whereas Group B included 27 patients (11 m, 16 f; mean age 60.8 +/- 5.5 years; range: 44-93). Only glycaemia, pH, white cell count and body mass index differed between the two groups. The mortality rates were 31% in Group A and 7.4% in Group B, respectively (P<0.005) In the logistic regression analysis, only body mass index continued to show a significant difference. In this population of patients with acute pancreatitis, only body mass index proved capable of identifying patients at risk of critical complications.

Sentinel lymph node mapping in the management of colorectal cancer: preliminary report.

AIM AND BACKGROUND: The problem of understaging the lymph node status in colorectal cancer because of missed micrometastases led authors to investigate the role of sentinel node (SN) mapping also in colorectal malignancies. The aim of this study was to evaluate the feasibility of the technique and to correlate the results with some characteristics of the primary tumor. METHODS: Sentinel lymph node mapping was performed in 23 patients who underwent a standard lymphadenectomy for colorectal cancer. The vital dye Patent Blue had been injected into the peritumoral subserosa in vivo in 17 cases and ex vivo in seven, including one case where the in vivo method did not allow to identify the sentinel node. The nodes that took up the dye were removed and analyzed with standard hematoxylineosin staining in serial sections. Immunohistochemistry (AE1-AE3 cytokeratin markers) was performed in hematoxylineosin-negative nodes. SN status was related to the status of the other lymph nodes in the surgical specimen analyzed with the standard technique and to the following characteristics of the primary tumor: stage, grade and diameter. RESULTS: The in vivo technique allowed to identify the SN in 16/17 cases (94.1%), the ex vivo technique in 7/7. A total of 336 lymph nodes dissected from the surgical specimens was analyzed, with an average of 14.6 nodes per patient (range, 7-35). Of these nodes 58 were SNs, with an average of 2.5 nodes per patient (range, 1-8). In the 19 cases where the SN was tumor negative, the non-SNs were also negative (specificity: 100%), whereas in the four cases where the non-SNs were positive, in two cases the SN was positive and in two cases of pT3 rectal carcinoma the SN was negative (sensitivity: 50%). Immunohistochemistry did not modify the negative results of the standard hematoxylin-eosin evaluation. CONCLUSIONS: The method used to identify the SN using vital dye proved to be easy to use both in vivo and ex vivo and allowed to identify the SN in all cases. The preliminary results indicate that there is a risk of false negative findings and therefore further studies are required to improve the sensitivity and the specificity of the technique and to evaluate the role of SN mapping in colorectal cancer management.

Blood transfusions and results after curative resection for gastric cancer.

On the basis of an analysis of our experience and a review of the literature, this report discusses the effects of perioperative blood transfusions on postoperative morbidity, mortality and 5-year survival in a series of patients who underwent curative surgical treatment of gastric cancer. The authors analyze a consecutive series of 137 patients who underwent curative total or subtotal gastrectomy D2 or D3. Ninety-nine patients (72.2%) received perioperative transfusions. The data examined included the number and timing of transfusions (pre-, intra-, or postoperative), the type of operation (total or subtotal gastrectomy with or without splenectomy), tumor stage (pTNM), and the correlation between transfusions, mortality, morbidity and survival. Advanced T-stage (P = 0.01) and total gastrectomy (P = 0.009) were associated with a higher transfusion rate. No cases of operative mortality were recorded after 1988. Specific morbidity was 10.5% in non-transfused patients and 20.1% in transfused. Five-year survival rate in the transfused patients (28.3%) was significantly lower than in the non-transfused group (53.5%) (P = 0.03). Univariate analysis showed that T-stage (P = 0.001) and N-stage (P = 0.04) were associated with a lower survival. By multivariate analysis (Cox regression model) only T-stage (P = 0.001) and N-stage (P = 0.04) were independent prognostic factors, whereas transfusions were not an independent variable (P = 0.27). To conclude, the issue of the real impact of transfusions on the prognosis of gastric cancer is far from being settled, although the T and N parameters are known to be strictly correlated to prognosis. This study further confirms the importance of limiting homologous transfusions as well as of transfusing, whenever possible, autologous or leukodepleted blood; this, however, without losing sight of the primary goal of minimizing operative blood loss.

[Evaluation of surgical risk in elderly patients: a review of 207 cases]. / La valutazione del rischio operatorio nel paziente anziano: revisione di 207 casi.

Thorough evaluation of surgical risk represents the sine qua non for a correct therapeutic choice particularly in the elderly who are frequently affected by multiple pathologies. The aim of this study was to evaluate the prognostic value of two of the most common classification systems for predicting surgical risk (ASA and Reiss scores) and of other laboratory parameters. A consecutive series of 207 patients aged 70 or above were analysed retrospectively, considering age, ASA and Reiss scores, elective or emergency surgery, operative time, leucocytes, haemoglobin, creatinine, and albumin levels. Morbidity and mortality rates were compared in relation to these parameters. Emergency surgery was associated with significantly higher morbidity (P = 0.006 chi-square) and mortality (P = 0.001 chi-square) than elective surgery. No differences in morbidity were noted in association with the ASA classification (P = 0.07 chi-square), though there was a significant difference (P = 0.001 chi-square) in mortality. Significant differences in both morbidity (P = 0.04 chi-square) and mortality (P = 0.001 chi-square) were found to be associated with the Reiss classification. Multivariate analysis showed that ASA score (P = 0.006), Reiss score (P = 0.004), operative time (P = 0.005), and haemoglobin level (P = 0.01) were independent prognostic factors. The results of the study confirm the prognostic value of multiparametric classifications such as the ASA and Reiss score in elderly patients, even if the addition of other prognostic factors may be expected to improve the sensitivity.

[Crohn disease: prognostic factors and therapeutic choices]. / Morbo di Crohn: fattori prognostici e scelte terapeutiche.

The treatment of Crohn's disease is still a debatable issue especially as regards the integrated implementation of medical and surgical therapy, the timing of surgery and the choice of surgical technique. Prognostic factors seem to be important in the choice and planning of therapeutic procedures. The authors retrospectively review 81 patients, 31 of whom submitted to surgery. The parameters observed were the presenting symptoms, the time from onset of symptoms to surgery, previous medical treatment, disease location, and complications. Bowel resection and the treatment of fistulas and abscesses were carried out. Emergency resections were performed in 14 patients (45%): 11 for bowel obstruction, 2 for perforation and 1 for bleeding. The mean follow-up (which included laboratory tests and endoscopy) was 132 months (range: 6 months to 32 years). In-hospital mortality was 2.3% and morbidity 12.9%. Long-term mortality amounted to 3 patients, only 1 of whom died of complications related to recurrence of the disease. Statistical analysis showed that the recurrence rate was 51.3% at 5 years after the first surgical treatment, 65.4% at 10 years and 88.1% at 20 years. Recurrences requiring surgery amounted to 15.3%, 20.5% and 42.5%, respectively. No statistically significant correlations were observed between recurrence rate and time of onset of the disease (p = 0.5601), time of the first surgical treatment, disease location, or specific medical therapy, (p = n.s.). Recurrence requiring surgical treatment was observed in 33.3% of patients when the disease was located only in the ileum, in 33.3% when it was located in both the ileum and colon, and in 28.6% when only the colon was involved (p = 0.9767). The quality of life was good in 66.6% of patients, fair in 26.6%, and poor in 6.6%. The authors conclude that the treatment of Crohn's disease must be multidisciplinary and surgery must be limited to complications. When surgery is indicated, it must be performed promptly, because, in these cases, persisting with medical treatment increases the postoperative morbidity. Short resections must be performed in order to preserve the bowel as much as possible. As far as risk factors are concerned, the most important are the location and the aggressiveness of the disease, whilst biological and laboratory parameters do not seem to influence the results.