Comparison between two different reconstruction techniques after pancreatic head resection. Technical feasibility and clinical benefits.

BACKGROUND: The study aim was to evaluate if diverting drainage of bile and pancreatic secretions with an isolated Roux loop technique helps to decrease the rate of postoperative morbidity and mortality, in particular postoperative pancreatic fistula (POPF). METHODS: A prospectively maintained database between 2006 and 2018 was reviewed. Patients who underwent primary elective pancreaticoduodenectomy were included. Two types of reconstruction methods were compared: single loop (SJL) reconstruction (28 patients) and isolated Roux-en-Y (DJL) reconstruction (36 patients). Demographic characteristics and perioperative results were compared between the two groups. RESULTS: This study includes 64 patients. The average duration of surgery was 308 mins; it was longer for DJL (P<0.0001). Major postoperative complications were seen in 24 patients (9 in SJL; 15 in DJL) without statistically significant difference. The most frequent complication that occurred was PJ anastomosis failure (4 in SJL; 6 in DJL). The choice of postoperative complication management was not related to surgical reconstruction technique (P=0.389). Length of hospital stay in DJL was significantly longer than in SJL (P=0.04). CONCLUSIONS: No significant advantage of one technique over the other was found. In our opinion, surgeons should choose the approach with which they have the most experience and ease.

Soluble stroma-related biomarkers of pancreatic cancer.

The clinical management of pancreatic ductal adenocarcinoma (PDAC) is hampered by the lack of reliable biomarkers. This study investigated the value of soluble stroma-related molecules as PDAC biomarkers. In the first exploratory phase, 12 out of 38 molecules were associated with PDAC in a cohort of 25 PDAC patients and 16 healthy subjects. A second confirmatory phase on an independent cohort of 131 PDAC patients, 30 chronic pancreatitis patients, and 131 healthy subjects confirmed the PDAC association for MMP7, CCN2, IGFBP2, TSP2, sICAM1, TIMP1, and PLG Multivariable logistic regression model identified biomarker panels discriminating respectively PDAC versus healthy subjects (MMP7 + CA19.9, AUC = 0.99, 99% CI = 0.98-1.00) (CCN2 + CA19.9, AUC = 0.96, 99% CI = 0.92-0.99) and PDAC versus chronic pancreatitis (CCN2 + PLG+FN+Col4 + CA19.9, AUC = 0.94, 99% CI = 0.88-0.99). Five molecules were associated with PanIN development in two GEM models of PDAC (PdxCre/LSL-KrasG12D and PdxCre/LSL-KrasG12D/+/LSL-Trp53R172H/+), suggesting their potential for detecting early disease. These markers were also elevated in patient-derived orthotopic PDAC xenografts and associated with response to chemotherapy. The identified stroma-related soluble biomarkers represent potential tools for PDAC diagnosis and for monitoring treatment response of PDAC patients.

Reliability and validity assessment of administrative databases in measuring the quality of rectal cancer management.

PURPOSE: Measurement and monitoring of the quality of care using a core set of quality measures are increasing in health service research. Although administrative databases include limited clinical data, they offer an attractive source for quality measurement. The purpose of this study, therefore, was to evaluate the completeness of different administrative data sources compared to a clinical survey in evaluating rectal cancer cases. METHODS: Between May 2012 and November 2014, a clinical survey was done on 498 Lombardy patients who had rectal cancer and underwent surgical resection. These collected data were compared with the information extracted from administrative sources including Hospital Discharge Dataset, drug database, daycare activity data, fee-exemption database, and regional screening program database. The agreement evaluation was performed using a set of 12 quality indicators. RESULTS: Patient complexity was a difficult indicator to measure for lack of clinical data. Preoperative staging was another suboptimal indicator due to the frequent missing administrative registration of tests performed. The agreement between the 2 data sources regarding chemoradiotherapy treatments was high. Screening detection, minimally invasive techniques, length of stay, and unpreventable readmissions were detected as reliable quality indicators. Postoperative morbidity could be a useful indicator but its agreement was lower, as expected. CONCLUSIONS: Healthcare administrative databases are large and real-time collected repositories of data useful in measuring quality in a healthcare system. Our investigation reveals that the reliability of indicators varies between them. Ideally, a combination of data from both sources could be used in order to improve usefulness of less reliable indicators.

Transperitoneal laparoscopic treatment for recurrence of a giant multilocular prostatic cystadenoma: A case report and review of the literature.

Giant multilocular prostatic cystadenomas (GMPC) are very rare benign tumors that originate from the prostate with extensive spread into the pelvis. The lesion may present as large abdominal mass causing obstructive voiding dysfunction and usually not invading adjacent structures. All of the previously reported patients with GMPC underwent open surgery. Although the natural history of prostatic cystadenoma remains unknown, complete surgical excision may not always be necessary. We report the case of a 74-year-old male who presented a retrovesical recurrence of prostatic cystoadenoma after 16 years, treated with a laparoscopic approach. To our knowledge this is the first case of laparoscopic management of GMPC. In this article we review the current literature about this rare tumor and discuss the diagnostic and management dilemmas posed by this rare pathologic condition. We believe that physicians should at least be aware of the existence of this disease in the differential diagnosis of pelvic cavity tumours and, considering the benignity of GMPC, they should propose--as first--a minimally invasive approach.

Giant nodular pseudoangiomatous stromal hyperplasia (PASH) of the breast presenting as a rapidly growing tumour.

Pseudoangiomatous stromal hyperplasia (PASH) is often a microscopic incidental finding in breast biopsies performed for benign or malignant diseases. In rare cases, it presents as a localised breast mass. Since Vuitch et al first described this condition in 1986, only 109 cases of PASH presenting as a palpable or mammographically detectable mass have been documented. PASH is characterised by a dense, collagenous proliferation of mammary stroma, forming inter-anastomosing capillary-like spaces. It is important to distinguish this benign lesion from a low-grade angiosarcoma. Here we describe the clinical, radiological and histological features of a very unusual case of PASH that presented as a rapidly growing breast lesion in a 37-year old woman.

Unusual causes of acute intestinal obstruction in adults.

This paper refers to 50 unusual cases of 542 consecutive adult patients who underwent surgery because of acute intestinal obstruction. Of the 38 small bowel cases, 5 were caused by hernias in anomalous recesses (1 prevesical, 2 left paraduodenal, and 2 paracecal hernias), 6 by a gallstone ileus, 14 to the presence of a bezoar or foreign body, 8 to extended postradiation perivisceritis, 3 to Meckel diverticulum volvulus, 1 to transepiploic hernia, and 1 to ileus-Meckel hematoma during anticoagulation treatment. The 12 large bowel cases included 3 diaphragmatic hernias (1 late post-trauma), 3 cases of colo-colic intussusception, 1 case of obstructive cholecystitis, and 5 cases of Ogilvie's syndrome. Major technical problems have to be immediately solved in the case of left paraduodenal, prevesical, or diaphragmatic hernias; however, during laparotomy, there may also be some difficult and unpredictable problems caused by widespread postradiation perivisceritis.

[F.A.S.T. Ultrasound for emergency surgeon]. / Ecografia FAST per il chirurgo di pronto soccorso.

INTRODUCTION: FA.S. T (Focused Assessment with Sonography for Trauma) is an ultrasound investigation that can discover presence of peritoneal fluid. The availability of an investigation that can be used directly at the patient bed optimizes the Emergency Room Service. The learning curve is short and all doctors working in Emergency Room can use it. AIM OF THE STUDY: End point of the study was to evaluate the applicability of fast to our hospital, to study it's efficacy when compared to other investigations and to produce a flow chart for patients with abdominal trauma. MATERIAL AND METHODS: From July 2002 we evaluate 400 consecutive patients with medium - high grade abdominal trauma. After ATLS we investigate the patient with FAST Ultrasound. Patients with indication to immediate laparotomy (ATLS Flow Chart) where evaluated only with FAST and send to the operating theatre. All others patients follows the normal abdomial trauma flow chart as in use in our Emergency Room. RESULTS: We performed 2 immediate laparotomy (0.5%) and 8 (2%) after the results of investigations. In group of immediately laparotomy FAST ultrasound confirmed the presence of haemoperitoneum (Sensibility and Specificity of 100%). In the other group (not immediately laparotomy) in 6 over 8 cases FAST Ultrasiound was in accord with other conventional radiological investigations (Sensibility 75%, Specificity 100%). In 2 over 8 patients only TC permitted to evidence intrabdominal damage not seen by FAST (MesoColon Haemathom and Gastric Rupture). CONCLUSIONS: FAST ultrasound resulted an effective and reliable investigation to evidence abdominal fluid when compared with other radiological investigations. We hope this tipe of investigation will be adopted in all Emergency Room.

Gastric outlet obstruction due to inflammatory fibroid polyp.

INTRODUCTION: Inflammatory fibroid polyp (IFP) is a rare mesenchymal tumor of the gastrointestinal tract. The lesion is characterized by spindle-shaped stromal cells and an inflammatory infiltrate rich in eosinophils. CASE REPORT: The AA. present a case of the IFP of the stomach. A 85-year-old woman was admitted to the hospital for early vomiting and epigastric pain. The patient underwent a gastroduodenoscopy that revealed a polypoid lesion mimicking cancer of the antrum and subtotal obstruction of the gastric transit. CONCLUSIONS: The Endoscopic Ultrasound Sonography suggested the presence of a lesion of the submucosal layer such as lymphoma or other type of malignancy like gastrointestinal stromal tumor (G.I.S.T).

[Post-traumatic acute appendicitis. A case report]. / Appendicite acuta post traumatica. Descrizione di un caso.

Acute appendicitis is a frequent abdominal pathology, more frequent in the childhood. The pathophysiology of acute appendicitis is obstruction of the appendix lumen and distension due to continued mucosal secretion. The second step is a rapid multiplication of resident bacteria, excretion of toxine and wall inflammation. Causes of this processes are different: in most of cases there is an hyperplasia of intrinsic lymphoid tissue (60%) or hard stool. Another cause may be foreign body. But is there a relationship between abdominal trauma and appendicitis?

Verocytotoxin-producing Escherichia coli EH 0157:H7 colitis.

0157:H7 is a known etiologic agent of hemorrhagic colitis. The clinical and histologic picture of colitis is largely similar to that of ischemic colitis, with areas of submucosal hemorrhage and edema, erosions, and ulcerations. We present a case report and review of the literature. A 52-year-old HIV-positive man, in apparently good immunologic condition, developed severe hemorrhagic colitis characterized by the onset of multiple colonic perforations and an unfavorable outcome. The diagnosis of 0157:H7 colitis should therefore be considered in all patients with indeterminate hematic diarrhea. Further studies are warranted to verify whether HIV infection may play a determinant role in the clinical course of 0157:H7 infection.