Preoperative pancreatic radiologic characteristics predict pancreatic-specific complications before pancreaticoduodenectomy: the pancreatic acinar radiologic score.

BACKGROUND: High acinar pancreatic contents are associated with a higher rate of postpancreatectomy acute pancreatitis and pancreatic fistula formation (POPF). Predicting acinar contents preoperatively might identify those at high risk of developing postoperative complications. METHODS: A multivariable analysis was performed to identify radiological factors associated with high pancreatic acinar content at histology in patients undergoing pancreaticoduodenectomy. Clinical and radiological variables identified were used to build a composite score predicting low, moderate, and high acinar pancreatic contents. RESULTS: Pancreatic density, wirsung caliber, and pancreatic thickness on preoperative CT-scan predicted acinar contents. These three variables predicted low, moderate, and high acinar content in 94 (26%), 122 (33.6%), and 147 (40.5%) patients, respectively. Patients with high radiological acinar scores compared with patients with intermediate-low risk scores were more frequently male (73.4% vs. 54.1%; p = 0.0003), obese (14% vs. 6%; p = 0.01), and had a statistically significant higher rate of pancreatic-specific complications (23.8% vs. 8.33%; p = 0.01), POPF (12.9% vs. 4.63%; p = 0.005) and pancreaticogastrostomy bleeding (10.8% vs. 4.17%; p = 0.01). CONCLUSION: A simple radiological score combining pancreatic thickness, density, and wirsung caliber at CT scan preoperatively predicts patients with pancreatic parenchyma that are at higher risk of postoperative pancreatic-specific complications.

Successful Conservative Management of Hepatic Portal Venous Gas Following Percutaneous Endoscopic Gastrostomy: A Case Report.

BACKGROUND Hepatic portal venous gas (HPVG) is a rare radiologic finding mostly associated with life-threatening diseases like bowel necrosis, but can also be benign; its overall mortality rate is 39-75%. In rare cases HPVG is associated with endoscopic procedures such as percutaneous endoscopic gastrostomy (PEG) placement. However, due to the rarity of this condition, there is no recommendation about its management. The aim of this case report was to describe a successful conservative management of HPVG without antibiotic administration based on the clinical presentation. CASE REPORT A 78-year-old male patient known for a history of esophageal cancer treated with radio- and chemotherapy, complicated by a post-radiation esophageal stenosis requiring a PEG tube placement 1 month prior was admitted to our Emergency Department for vomiting and abdominal pain. A contrast-enhanced abdominal CT scan showed small-bowel dilatation without obstruction, as well as gastric wall pneumatosis and HPVG. We opted for a conservative approach. The PEG was put to suction for 2 days. The clinical evolution was favorable, with resolution of abdominal pain and a restored transit on day 2. A follow-up CT scan at day 5 showed resolution of HPVG. Nutrition through the PEG was restored at day 6 without complication. CONCLUSIONS HPVG can be a benign finding after a PEG tube placement. Conservative management without antibiotics can be used in oligosymptomatic and hemodynamically stable patients after life-threatening associated diseases like bowel necrosis have been ruled out.

Severe mediastinitis caused by an infected bronchogenic cyst.

Bronchogenic cysts (BCs) are congenital foregut malformations and usually asymptomatic, thin-walled, incidentally diagnosed cysts which can be easily resected by a minimal invasive approach at this time point. However, they may develop symptoms such as infection, bleeding or compression of adjacent structures. There is no consensus about the risk of developing complications during a lifetime; however, recent reports suggest a higher incidence than initially believed. Here, we report a case of severe life-threatening mediastinitis emerging from an infected BC requiring complex surgery, which could have been avoided if surgery had been performed at an early, asymptomatic stage.

Metronidazole and Peripheral Neuropathy: A Report of Two Cases of (Unusual) Side Effects.

Metronidazole is an antibiotic commonly prescribed for anaerobic and protozoan infections. Despite its good safety profile, this drug frequently causes a series of well-known side effects (nausea and intestinal transit disorders, dysgeusia, headaches, and alcohol intolerance). However, there are few data in the literature, mainly case reports and case series, about the onset of peripheral neuropathy with a generally self-limiting course after drug withdrawal. Thus, we herein describe two cases of peripheral neuropathy due to treatment with metronidazole. A 69-year-old woman treated with a total of 55 g of metronidazole for diverticular disease and a 52-year-old male patient on a long course of antibiotic therapy for hepatic abscesses (a cumulative dose of 168 g) developed peripheral neuropathy. The suspicion of metronidazole side effects was raised after the exclusion of other causes. After the suspension of the drug, different degrees of improvement were observed. Metronidazole is an effective antibiotic for treating infections caused by anaerobic or protozoan pathogens, and it has a good pharmacological and economic safety profile. However, in the existing literature, prolonged therapy regimens (>4 weeks of treatment and/or 42 g cumulative dose) may increase the risk of developing neurological complications, in particular peripheral polyneuropathy.

Management of spontaneous portosystemic shunts at the time of liver transplantation: treatment or observation? Results of a systematic review.

BACKGROUND: Optimal treatment of spontaneous portosystemic shunts (SPSS) during liver transplantation (LT) remains debated. We systematically reviewed the literature on definitions, treatment and outcomes of patients presenting SPSS undergoing LT. METHODS: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we used PubMed to retrieve all studies dealing with SPSS and LT between January 1987 and January 2020. The primary endpoints were definitions and outcomes according to the management of SPSS (treatment vs observation). RESULTS: Thirteen studies detailing the management of 962 SPSS were retrieved. Hemodynamically significant SPSS were defined as those having diameter ≥ 10 mm in 41% (n = 395) of patients. SPSS were splenorenal (42%), cavo-gastric (15.2%), umbilical (7.4%), mesenterico-caval (n = 31; 3.2%), mesenterico-renal (0.1%) and unreported (31.9%), respectively. At the time of LT 372 shunts (38.7%) were treated while 590 were observed (61.3%). During a follow-up time ranging from 4 months to 5 years, the reported overall survival (OS) at 1 year was not significantly different except for one study. Portal vein anastomosis complications (i.e. reduced flow, stenosis or thrombosis) were similarly reported in observed [n = 26 (4%)] and ligated SPSS [n = 10 (2%)] (p = 0.22) but the rate of relaparotomy was significantly higher in observed SPPS (16 vs 2; p = 0.01) to rescue post LT portal vein thrombosis (n = 6) and reduced portal flow and graft dysfunction (n = 10). CONCLUSIONS: There was a heterogeneous management of SPSS during LT in the literature. Ligation of SPPS did not reduce vascular complications neither improved survival. A randomized prospective study might contribute to identify best management of SPSS at time of LT.

Perforated Duodenal Diverticulitis: A Case Report of a Rare Surgical Entity Treated by Roux-en-Y Deriving Intestinal Patch.

Perforated diverticulitis is a rare but serious complication associated with a significant mortality rate. Although many cases of conservative treatment have been reported, surgery remains the mainstay for perforated duodenal diverticulitis. We report a rare case of a 55-year-old female who presented with epigastric pain without fever. Computed tomography revealed a 3 cm perforated duodenal diverticulum of the D2 part of the duodenum with a localized abscess. After the failure of conservative treatment, we performed a deriving intestinal patch completed by cholecystectomy and biliary decompression via a transcystic drain, as well as feeding jejunostomy. The patient was discharged on day 32. Removal of the transcystic drainage at eight weeks postoperatively was complicated by the appearance of an iatrogenic bilioperitoneum, which was effectively treated with percutaneous drainage. Surgery remains challenging; our experience suggests that perforation covering with a deriving jejunal patch offers an alternative to direct beach suturing when the latter is deemed precarious. Part of the treatment success lies in local drainage and duodenal exclusion that can be achieved by various surgical approaches.

Simultaneous Propionibacterium avidum and Propionibacterium acnes Chronic Periprosthetic Hip Joint Infection: A Case Report.

Prosthetic hip joint replacement is considered the operation of the 20th century because of its wide diffusion and good outcome. More than 1 million prostheses are implanted worldwide annually. Although hip arthroplasty is considered a safe procedure, different complications can occur in relation with surgery. Periprosthesic joint infection is the most feared for its morbidity for the patients, and for the economic costs it generates. Most surgical site infections after hip arthroplasty are related to frequent germs as Staphylococci or Enterobacteriaceae, while Propionibacterium infections are more rare and often challenging in diagnosis and therapy. We report a case of a 77-year-old diabetic overweight male patient who developed a periprosthetic hip infection due to P. avidum and P. acnes after a mini-invasive direct anterior approach. To our knowledge, this represents the first case of chronic periprosthetic hip joint co-infection.