Role of TachoSil® in distal pancreatectomy: a single center experience.

AIM: Distal pancreatectomies (DP) are associated with high risk of postoperative complications, and in many series higher morbidity rate than duodenopancreatectomies has been reported. To evaluate the role of a collagen sponge with human fibrinogen and thrombin film (TachoSil®) in limiting the incidence of complications after DP. METHODS: From 1996 to 2013, 221 patients have been submitted to distal pancreatectomy (± splenectomy) in our Division. A retrospective analysis has been conducted in a group of 36 consecutive and prospectively collected DP treated with intraoperative placement of TachoSil® on pancreatic stump from 2010 to 2013 (group 1). A control series of 36 consecutive patients (group 2) was matched 1:1 from hystorical database. The variables considered in the analysis were: age, gender, ASA score, pancreatic texture (hard vs. soft), histology, operative time, postoperative mortality, morbility (postoperative pancreatic fistula - POPF, postoperative hemorrage - PPH, delayed gastric emptying - DGE) and hospital stay. Differences between POPF, PPH, DGE and hospital stays between grops were investigated with χ² and t-Student test. Univariate analysis was conducted to determine factors related to POPF development. Statistical analysis was performed using freeware Microsoft Excel based program. RESULTS: Post operative mortality was 0% in both groups. POPF were registered in 36.1% (13/36) and 41.6 % (15/36) in groups 1 and 2, respectively (P=n.s.); in group 1 we didn't observe grade C POPF, while 4 patients in control group developed grade C POPF (P<0,05). No differences were found between two groups in terms of incidence of PPH and DGE. The median duration of postoperative hospital stay in group 1 was 21.8 (7-189) days compared with 31.13 (9-249) days in group 2 (P<0.001). CONCLUSION: The use of TachoSil® seems to be associated with lower incidence of grade C POPF but larger controlled trials are needed to surely assess the usefulness of TachoSil® in pancreatic surgery in order to reduce pancreatic specific complications and their severity.

Solitary pancreatic head metastasis from tibial adamantinoma: a rare indication to pancreaticoduodenectomy.

Pancreatic metastases are rare, <2% of all pancreatic neoplasia. This is the first case of pancreatic metastasis from adamantinoma, a rare, low grade and slow growing tumor which is frequently localized in long bones. We describe a case of a 45-year-old woman presenting with increased bilirubin level. Computed tomography and ecoendoscopic ultra sonography revealed a pancreatic head mass. Fine-needle aspiration biopsy was consistent with metastatic adamantinoma. The patient was submitted to a standard pancreaticoduodenectomy. As in the case presented, standard pancreatic resections are safe and feasible options to treat non-pancreatic primary tumor improving patient's survival and quality of life.

[Role of EUS in a diagnostic and staging algorithm of pancreatic carcinoma: the surgeon point of view]. / Il ruolo dell'EUS in un algoritmo diagnostico-stadiativo del carcinoma pancreatico: il punto di vista del chirurgo.

Survival of pancreatic cancer is improved by surgery and is related to R0 resection. An accurate diagnosis and a careful staging are mandatory. Differential diagnosis must be estabilished between the different pancreatic lesions as carcinoma, chronic pancreatitis, cystic or endocrine neoplasms. Endoscopic ultrasound (EUS) is the best technique for diagnosis and allows cytological examination by fine needle aspiration (FNA). Preoperative resectability is defined by EUS in borderline tumors. EUS is a useful procedure for the surgical strategy of pancreatic cancer.

Laparoscopic repair of Morgagni hernia and cholecystectomy in a 40-year-old male with Down's sindrome. Report of a case.

Morgagni-Larrey hernia (MH) is an unusual diaphragmatic hernia of the retrosternal region. Few cases of MH, treated laparoscopically, associated with Down's syndrome (DS) have been reported in literature. On October 2004, a DS 40-year-old male was admitted to our Department with mild abdominal pain and nausea. Hematochemical tests were within the normal range. Ultrasonography showed biliary sludge and multiple gallstones. Chest X-ray revealed a right-sided paracardiac mass that appeared as MH after a thoraco-abdominal computed tomography (CT). Four trocars were placed as a routinary cholecystectomy. Abdominal exploration confirmed the presence of a voluminous hernia through a wide diaphragmatic defect (12 cm) on the left side of the falciform ligament, containing the last 20 cm ileal loops and right colon with the third lateral of transverse. After retrograde cholecystectomy and reduction of the herniated ileo-colonic tract from multiple adherences, the defect was repaired with an interrupted 2/0 silk suture and then a running 2/0 polypropylene suture. Postoperative course was complicated by pulmonary edema but subsequently the patient was discharged without further complications and has no recurrence after 2 years. In conclusion, surgery is necessary for symptomatic MH and to prevent possible severe complications. We preferred laparoscopy for the reduced morbidity compared to laparotomy, even if in our case the postoperative course was not uneventful. There are still few comparative data about the modality of closure of the defect between primary repair with nonabsorbable suture material, in case of small defects, or continuous monofilament suture or prosthesis in case of large defects.

Preoperative oral immunonutrition versus standard preoperative oral diet in well nourished patients undergoing pancreaticoduodenectomy.

BACKGROUND: Pancreaticoduodenectomy is still associated to high morbility, especially due to pancreatic surgery related and infectious complications: many risk factors have already been advocated. Aim of this study is to evaluate the role of preoperative oral immunonutrition in well nourished patients scheduled for pancreaticoduodenectomy. METHODS: From February 2014 to June 2015, 54 well nourished patients undergoing pancreaticoduodenectomy were enrolled for 5 days preoperative oral immunonutrition. A series of consecutive patients submitted to the same intervention in the same department, with preoperative standard oral diet, was matched 1:1. For analysis demographic, pathological and surgical variables were considered. Mortality rate, overall postoperative morbility, pancreatic fistula, post pancreatectomy haemorrhage, delayed gastric emptying, infectious complications and length of hospital stay were described for each groups. Chi squared test, Fisher's Exact test and Student's T test were used for comparison. Differences were considered statistically significant at p < 0.05. Statistics was performed using a freeware Microsoft Excel (®) based program and SPSS v 10.00. RESULTS: No statistical differences in term of mortality (2.1% in each groups) and overall morbility rate (41.6% vs 47.9%) occurred between the groups as well as for pancreatic surgery related complications. Conversely, statistical differences were found for infectious complications (22.9% vs 43.7%, p = 0.034) and length of hospital stay (18.3 ± 6.8 days vs 21.7 ± 8.3, p = 0.035) in immunonutrition group. CONCLUSION: Preoperative oral immunonutrition is effective for well nourished patients scheduled for pancreaticoduodenectomy; it helps to reduce the risk of postoperative infectious complications and length of hospital stays.

Hepatocellular carcinoma in a non-cirrhotic liver. Two case reports and literature review.

Hepatocellular carcinoma (HCC) is closely associated with cirrhosis, but it also develops, although much less frequently, in a non-cirrhotic liver. It is suspected that hepatocellular carcinoma has a different etiology when associated and not associated with chronic liver disease. We report two cases of patients with hepatocellular carcinoma that developed in a non-cirrhotic liver. In the first case we describe an incidental liver nodular lesion containing multiple foci of HCC including pseudogland or trabecular formation and areas of sclerosis. The non-cancerous parenchyma of the liver was histologically unremarkable except for mild fatty changes of hepatocytes and minimal dysplasia. The second case describes a combined hepatocellular carcinoma and cholangiocellular carcinoma (CCC) (mixed carcinoma) in a patient who was serologically negative for both hepatitis B and C viruses. The adjacent liver parenchyma showed mild piecemeal necrosis and mild lobular activity compatible with chronic viral hepatitis, but cirrhosis was not established. This case appears to indicate that mixed type carcinoma can develop in a non-cirrhotic liver, with CCC being far more dominant than HCC; such a finding is extremely unusual, based on previously published reports.

Management strategies in resection for carcinoma of the hepatic duct confluence: how to increase the resectability rate. Our experience and literature review.

The resectability rate of hilar bile duct carcinoma is reported to be variable and to inversely correlate with the size of the associated liver resection. In an attempt to reduce the risk of postoperative liver failure, the induction of a hypertrophy of remnant liver by preoperative portal vein embolization (PVE) has been proposed. We hereby analyse the results and the technical aspects of this procedure along with our personal experience.

Surgery for carcinoma of the gallbladder. Our experience.

BACKGROUND: Carcinoma of the gallbladder is a gastrointestinal malignancy with a very poor prognosis. The 5-year survival rate amounts to less than 5% in most series. In this study we reviewed the results of surgical treatment for gallbladder carcinoma with special reference to extended radical procedures. METHODS: Between 1995 and 2000 we enrolled 36 patients (17 males and 19 females), 24 of whom were treated with simple cholecystectomy and 12 with radical resection (partial hepatectomy, regional lymphadenectomy, and common bile duct resection). The tumours were classified by stage using the criteria of the American Joint Committee on Cancer (AJCC). Stages, operative procedures, results of pathologic examinations and the outcome of the resected cases were reviewed. RESULTS: There were 2 postoperative deaths (0.55%). The mean follow-up period was 19.1 months (range 1-60). For stage I and II disease extended cholecystectomy had a better result than simple cholecystectomy: the 5-year survival rates were 38.4 versus 19%, respectively. For the patients with advanced stage III or IV gallbladder carcinoma, a significant advantage of survival resulted in case of liver resection as compared to surgical treatment without liver resection: the 5-year survival rates were 20 and 0%, respectively. CONCLUSIONS: The survival of stage I-II patients was good. For the patients in higher stages the prognosis was significantly worse. In these cases more aggressive surgery may be needed.

[Role of surgery in the multidisciplinary treatment of lithiasis of the common bile duct]. / Il ruolo della chirurgia nel trattamento multidisciplinare della litiasi della via biliare principale (VBP).

The efficacy of surgery was evaluated in 32 patients with common bile duct stones. Twenty-two patients have not undergone a previous cholecystectomy. In 13 cases an endoscopic approach was attempted before surgery. In 13 patients biliary-intestinal anastomoses were performed for large stones or bile duct strictures. In 19 cases common bile exploration with biliary drainage insertion was performed for uncomplicated biliary stones. We had no mortality and morbidity was 9%. We conclude that surgery is the treatment of choice in patients with gallbladder in situ or in cases of endoscopic failure. Endoscopic sphincterectomy may be preferred in poor-risk patients.

[Gastric cancer. New frontiers in surgical therapy]. / Il carcinoma gastrico. Le nuove frontiere della terapia chirurgica.

The authors compare their experience in the surgical treatment of gastric carcinoma with the literature and point out that therapeutic value of a wide gastric resection and adequate lymphadenectomy can improve a 5-year survival without increasing mortality and morbidity. In an 8-year experience in 258 patients with gastric carcinoma, 249 underwent operation, 139 with curative intention. Wide gastric resection proved to be effective and safer than elective total gastrectomy, and D2-lymphadenectomy showed the same morbidity of D1 and seems to offer a better 5-year survival. Extended resections for gastric cancer, that result in simultaneous pancreatectomy, splenectomy, hesophagectomy, resection of the colon and hepatectomy, do not show significant improvement of the survival.

[Refractory ascites: a fifteen-year experience with the peritoneovenous shunt]. / L'ascite irriducibile: 15 anni di esperienza con la derivazione peritoneo-venosa (DPV).

The authors consider the various causes of ascites and they also develop the concept of refractory ascites. They consider the various possibilities of medical and dietary therapy whose failure constitutes the basis for a surgical approach. In the latter case it is being considered the Peritoneo Venous Shunt (PVS) that employs different types of valves. In the light of their personal experience, matured over a period of 15 years, in which 75 valves were positioned in 64 patients and precisely: 55 valves of Le Veen, 15 Hakim and 5 Denver, it is emphasized that the best results, as for as mortality and morbidity goes, were obtained through careful attention in the preoperative stage and during surgery itself with the privileged use of a Le Veen's valve. For such motives, since in a high percentage of these patients there persists a poor prognosis a year away from the onset of refractory ascites, a PVS seems proposable anyway and even though this will not alter the pathological outcome, there's a clear improvement in the quality of life without precluding any other surgical approach. Finally, the authors outline the possibilities offered by the Transjugular Intrahepatic Portosystemic Shunt (TIPS), as a new original approach for the resolution of refractory ascites.

[Groove pancreatitis. A case report of chronic focal pancreatitis]. / La "groove pancreatitis". Descrizione di un caso di pancreatite cronica focale.

The "groove pancreatitis" is a special form of segmental chronic pancreatitis affecting the "groove" between pancreatic head, duodenum and common bile duct. This type of chronic pancreatitis was first described in 1973 and only few cases have been reported in literature. Unlike other forms of chronic pancreatitis, this is often preceded by peptic ulcers, gastric resections or biliary tract diseases; it could be associated with cysts of the duodenal wall and pancreatic cysts. Abdominal pain, vomiting due to duodenal stenosis, obstructive jaundice and weight loss are the most common presenting symptoms. The radiological features show a pancreatic mass similar to a pancreatic head carcinoma and the discrimination of groove pancreatitis from pancreatic carcinoma is often difficult or even impossible in some patients. We describe a case of groove pancreatitis treated with pancreatoduodenectomy, reviewing the clinical and radiological features. We remark that the groove pancreatitis is a disease that must be known and should be considered in the differential diagnosis of pancreatic carcinoma.

[Management of sepsis of the biliary tract: indications to surgical treatment]. / Trattamento delle sepsi delle vie biliari. Indicazioni alla terapia chirurgica.

Sepsis of the biliary tract is a severe disease, due to its course and its significant association with relevant diseases, either benign or malignant, of the biliary tract, pancreas, hepatic hilus. In many cases it remains difficult to set the limit between medical therapy, percutaneous or endoscopic therapy and surgical treatment. Through a thorough review of the last 20 years' literature, we have studied this topic and classified cholangitis according to its etiology: Iithiasis, benign stenosis or Klatskin tumor as malignant diseases. The sequential approach, endoscopy-surgery, seems to provide the best results in lithiasic cholangitis. In patients with benign stenosis of the biliary tract, a percutaneous drainage is indicated as a first choice, meanwhile surgery is limited to unsuccessful bilioplasty and to segmental extrahepatic localization of sclerosing cholangitis. On the contrary, in Klatskin tumours preoperative percutaneous drainages are useful to obtain an accurate map, which is indispensable to perform an aggressive radical hepatic resection.

[Instrumental follow-up of patients treated by internal biliary drainage]. / Il follow-up strumentale dei pazienti trattati con drenaggio biliare interno.

The various radiological techniques available for the long-term follow-up of patients given definitive percutaneous trans-hepatic biliary implants (DTBI) are evaluated on the basis of personal experience. After a rapid examination of the available technics it is concluded that direct X-ray, echotomography and sequential hepatobiliary scintigraphy are more than sufficient for an accurate follow-up of the disease in such patients.

[Surgical treatment of endocrine tumors of the pancreas]. / Il trattamento chirurgico dei tumori endocrini del pancreas.

Following a brief review of the literature dealing with the rarity of this disease, and the diagnostic progress made to date, the surgical techniques applicable to the various locations of the neoplasia are described. Personal experience with 8 insuloma patients is reported.

[Septic complications in subclavian vein catheterization]. / Complicanze settiche dell'incannulamento della vena succlavia.

Authors have studied the incidence of septic complications due to subclavian vein catheterization, According to literature, have considered that this is generally connected to the operating ability. Septic contamination, though of high incidence, only exceptionally is reason of a septic clinical condition.

[Lipohyperplasia or intestinal lipomatosis]. / Lipoiperplasia o lipomatosi intestinale.

Lipohyperplasia or intestinal lipomatosis is an infrequent disease characterised by anomalous infiltration of adipose tissue in the intestinal submucosa. Localised forms are generally asymptomatic, whereas diffuse forms may lead to intestinal subocclusion, digestive hemorrhage or diarrhoea. Although benign, the differential diagnosis of intestinal lipomatosis with malignant pathologies of the colon or appendix often prompts the need for surgical exploration and the histological analysis of biopsy material. Surgical exeresis of the lesion is generally associated with the normalisation of clinical symptoms. The authors report the onset and clinical evolution of two cases of intestinal lipomatosis referred to their attention.

Pirenzepine does not impair liver blood flow in the rat.

The present study was performed with the aim of establishing whether the muscarinic-receptor antagonist pirenzepine impairs liver blood flow, as previously observed for H2-blockers. For this purpose, two different doses of pirenzepine (0.3 and 0.6 mg/100 g b.w. respectively) were administered to two groups of rats. Liver plasma flow was measured 30 min after treatment by the new sorbitol clearance test which is simple and does not require hepatic vein catheterization. The results were compared with those obtained in a control group and in a group treated with cimetidine. It was shown that, compared to the control group in which the observed functional liver plasma flow was 5.0 +/- 1.3 ml/min/100 g b.w. (MV +/- SD), rats treated with either dose of pirenzepine showed no significant impairment of liver perfusion. On the other hand, cimetidine treatment produced a significant reduction (p less than 0.001) of functional liver plasma flow. Our results show that pirenzepine treatment does not significantly impair liver functional activity through reduced liver perfusion. They also suggest that muscarinic receptors are probably not involved in the control of splanchnic blood flow.

[Diagnosis of primary and secondary tumors of the liver]. / La diagnosi dei tumori primitivi e secondari del fegato

A brief epidemiological and clinical introduction is followed by an examination of the most useful methods for the diagnosis of primary and secondary tumours of the liver: alpha protein values, scintiscanning, arteriography of the coeliac artery, splenoportography, and laparotomy with directed biopsy. The diagnostic specificity and percent positivity of each method are illustrated.

[Internal pancreatic fistulae. The authors' experience]. / Fistole pancreatiche interne. Nostra esperienza.

The paper describes the authors' personal experience of internal pancreatic fistulas. This is an uncommon pathology which should however be taken into account in the presence of ascites or pleural effusion without a clear cause. Essential diagnostic tests are chemical and physical examination and the assay of amylase in ascitic or pleural fluids. Medical treatment is sometimes efficient leading to the disappearance of the fistula. If medical therapy fails, surgery is necessary, based on pancreatic resection or the drainage of the cyst or interrupted pancreatic duct.