Long-term pancreatic exocrine and endometabolic functionality after pancreaticoduodenectomy. Comparison between pancreaticojejunostomy and pancreatic duct occlusion with fibrin glue.

OBJECTIVE: Even if pancreatic pathologies, residual fibrosis, residual amount of parenchyma, and anastomotic patency are recognized as main causes of exocrine and glycemic impairment after pancreaticoduodenectomy (PD), few data are reported concerning the role of the different pancreatic remnant treatment techniques. The objective of the study is to assess and compare exocrine functionality, glycemic pattern, nutritional status, and quality of life (QoL) after PD between pancreaticojejunostomy (PJ) and pancreatic duct occlusion (PDO), both in an objective and a subjective manner. PATIENTS AND METHODS: Thirty-two patients (16 PJ and 16 PDO) were evaluated after a mean follow-up of 21 months after surgery. Exocrine insufficiency was objectively evaluated through the 13C-labelled mixed triglyceride breath test. Fasting glucose, fasting insulin, HbA1c and HOMA-IR values were used to assess glucose metabolism. For these two outcomes, anamnestic data were also collected. QoL was assessed with GIQLI, SF-36, EORTC-QLQ-C30, and EORTC-PAN-26 questionnaires. RESULTS: The 13C-labelled mixed triglyceride breath test detected a lipid digestive insufficiency in 56% of patients after PJ and 100% after PDO respectively (p = 0.007). However, no difference was observed between the two groups regarding postoperative necessity of substitutive pancreatic enzymes. Nutritional status, fasting plasma glucose, fasting insulin, HbA1c levels, HOMA-IR values and postoperative necessity of insulin or oral antidiabetic agents were comparable between the two groups. QoL measurements showed similar results. However, in the subdomains analysis, better outcomes were reported regarding digestive symptoms and physical functioning for PJ and PDO respectively. CONCLUSIONS: Even if an objective exocrine major impairment was evidenced after PDO, this result did not impact the need for a higher rate of postoperative substitutive enzymes. In terms of glycemic pattern, nutritional status, and QoL, the two techniques turn out to be comparable.

The hyperthermic intraoperative intraperitoneal chemotherapy in the treatment of advanced abdominopelvic cancer. Personal experience on 103 procedures during a seventeen year period in a single Italian center.

OBJECTIVE: Integration of different therapeutic strategies in cancer surgery in the last years has led from treating primary lesions to the surgical treatment of metastases. The purpose of this paper is to report a single Italian center experience of treatment of peritoneal carcinosis of the abdominopelvic malignancies. PATIENTS AND METHODS: 103 HIPEC procedures were performed in 17 years on 94 selected patients affected by abdominopelvic cancer. The PCI score was calculated at laparotomy. The CC score was calculated before doing HIPEC. HIPEC was carried out according to the Coliseum technique. RESULTS: The surgical cytoreduction allowed 89 patients to be subjected to HIPEC treatment with a CC score 0; 9 patients with a CC 1; 3 patients with a CC 2 and 2 patients with a CC 3. In 22 patients postoperative complications were recorded. No operative mortality occurred. The median follow-up of 53 months shows a rate of survival equivalent to 49 %, with a relapse in 46 patients, 29 of them reached exitus. CONCLUSIONS: The surgical resection alone for patients affected by advanced cancer with peritoneal carcinomatosis cannot be considered a sufficient treatment any longer and HIPEC would help to prolong survival in these patients.

Complications related to hyperthermia during hypertermic intraoperative intraperitoneal chemiotherapy (HIPEC) treatment. Do they exist?

BACKGROUND AND OBJECTIVES: Hyperthermia, either alone or in combination with anticancer drugs, is becoming more and more a clinical reality for the treatment of far advanced gastrointestinal cancers, acting as a cytotoxic agent at a temperature between 40-42.5 degrees C. Although hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) is demonstrated to have some benefit in selected patients with peritoneal seeding, there are not enough data on the risk of damage of normal tissue that increases as the temperature rises, with possible serious and, sometimes, lethal complications. MATERIALS AND METHODS: We searched on medline words like "intraoperative intraperitoneal chemohyperthermia and morbidity", focusing our attention on studies (published since 1990) which reported morbidity as bowel obstruction, bowel perforation or anastomic leak, during intraoperative intraoperitoneal chemotherapy in hyperthermia (HIPEC). RESULTS: Heat acts increasing cancer cell killing after exposure to ionizing radiation, inhibiting repairing processes of radiation-induced DNA lesions (radiosensitization), and also sensitizing cancer cells to chemotherapeutic drugs, particularly to alkylating agents (chemosensitization). The peritoneal carcinomatosis (a frequent evolution of advanced digestive cancer) represents one of the main indication to hypertermic treatment. In the last fifteen years, in fact, different methods were developed for the surgery treatment (peritonectomy) and for loco-regional chemotherapic treatment of the carcinomatosis (intraperitoneal intra/post-operative iper/normothermic chemotherapy) to act directly on neoplastic seeding. We found, as result of different studies, 9 articles, written about perforation after HIPEC. CONCLUSION: The aim of the present study is to present the review of the literature in terms of peri-operative complications related to the hyperthermia during intraoperative chemohyperthermia procedure.

Role of oxidized regenerated cellulose in preventing infections at the surgical site: prospective, randomized study in 98 patients affected by a dirty wound.

AIM: The aim of this study was to evaluate whether oxidized regenerated cellulose (ORC), applied to "dirty" surgical wounds, is able to reduce the microbial load and, consequently, the infection rate as compared to conventional local wound treatment. METHODS: The study included 98 patients who underwent intestinal recanalization procedures between December 2003 and December 2008, with the stoma as the surgical site. Authors considered several risk factors for SSI. The patients were divided into two groups. In group A (50 patients), the surgical wound, previous site of the stoma, was packed with ORC, whereas in group B (48 patients) gauze soaked in iodine was used. Microbial contamination was evaluated with three swabs (in subcutaneous tissue and the dermis), in the operating room before wound packing and on the 2nd and 3rd postoperative day (before suturing the skin). RESULTS: There were no cases of wound dehiscence and no clinically evident superficial or deep surgical site infections in either group. Analysis of all data revealed that there was no or reduced bacterial contamination in the second and third swab in 33 patients (66%) of Group A versus 12 patients (25%) of Group B. CONCLUSION: Although it is necessary to consider all factors which can have an influence on SSI and use all the means shown to be effective to reduce the risk of SSI, there is a rationale for using ORC to prevent this kind of infection, especially in patients who undergo "dirty" surgery.

International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery.

PURPOSE: To provide uniform terminology and definition of post-herniorrhaphy groin chronic pain. To give guidelines to the scientific community concerning the prevention and the treatment of chronic groin and testicular pain. METHODS: A group of nine experts in hernia surgery was created in 2007. The group set up six clinical questions and continued to work on the answers, according to evidence-based literature. In 2008, an International Consensus Conference was held in Rome with the working group, with an audience of 200 participants, with a view to reaching a consensus for each question. RESULTS: A consensus was reached regarding a definition of chronic groin pain. The recommendation was to identify and preserve all three inguinal nerves during open inguinal hernia repair to reduce the risk of chronic groin pain. Likewise, elective resection of a suspected injured nerve was recommended. There was no recommendation for a procedure on the resected nerve ending and no recommendation for using glue during hernia repair. Surgical treatment (including all three nerves) should be suggested for patients who do not respond to no-surgery pain-management treatment; it is advisable to wait at least 1 year from the previous herniorraphy. CONCLUSION: The consensus reached on some open questions in the field of post-herniorrhaphy chronic pain may help to better analyze and compare studies, avoid sending erroneous messages to the scientific community, and provide some guidelines for the prevention and treatment of post-herniorraphy chronic pain.

[Pancreatic fistula after left pancreatectomy. Risk factors analysis on 68 patients]. / La fistola pancreatica dopo pancreasectomia sinistra. Analisi dei fattori di rischio su 68 casi.

AIM: The aim of this study was to identify risk factors related to pancreatic fistula after left pancreatectomy, considering the difference between the use of mechanical suture and the manual suture to close the pancreatic stump. METHODS: Sixty-eight patients, undergoing left pancreatectomy, were included in this study during a 10-year period. Eight possible risk factors related to pancreatic fistula were examined, such as demographic data (age and sex), pathology (pancreatic and extrapancreatic), technical characteristics (stump closure, concomitant splenectomy, additional procedures), texture of pancreatic parenchyma, octreotide therapy. RESULTS: Fourty-one patients (60%) underwent left pancreatectomy for primary pancreatic disease and 27 (40%) for extrapancreatic malignancy. Postoperative mortality and morbidity rates were 1.5% and 35%, respectively. Fourteen patients (20%) developed pancreatic fistula: 4 of them were classified as Grade A, 9 as Grade B and only one as Grade C. Three factors have been significantly associated to the incidence of pancreatic fistula: none prophylactic octreotide therapy, spleen preserving and soft pancreatic texture. It's still unclear the influence of pancreatic stump closure (stapler vs hand closure) in the onset of pancreatic fistula. CONCLUSION: In this study the incidence of pancreatic fistula after left pancreatectomy has been 20%. This rate is lower for patients with fibrotic pancreatic tissue, concomitant splenectomy and postoperative prophylactic octreotide therapy.

[Indications and outcomes of surgical management of chronic pancreatitis: literature review]. / Indicazioni e risultati del trattamento chirurgico nella pancreatite cronica: revisione della letteratura.

Surgical management of chronic pancreatitis remains a challenge for surgeons. Last decades, the improvement of knowledge regarding to pathophysiology of chronic pancreatitis, improved results of major pancreatic resections, and new diagnostic techniques in clinical practice resulted in significant changes in the surgical approach of this condition. Intractable pain, suspicion of malignancy, and involvement of adjacent organs are the main indications for surgery, while the improvement of patient's quality of life is the main purpose of surgical treatment. The surgical approach to chronic pancreatitis should be individualized based on pancreatic anatomy, pain characteristics, exocrine and endocrine function, and medical co-morbidity. The surgical treatment approach usually involves pancreatic duct drainage procedures and resectional procedures including longitudinal pancreatojejunostomy, pancreatoduodenectomy, pylorus-preserving pancreatoduodenectomy, distal pancreatectomy, total pancreatectomy, duodenum-preserving pancreatic head resection (Beger's procedure), and local resection of the pancreatic head with longitudinal pancreatojejunostomy (Frey's procedure). Recently, non-pancreatic and endoscopic management of pain have also been described (splancnicectomy). Surgical procedures provide long-term pain relief, improve the patients? quality of life with preservation of endocrine and exocrine pancreatic function, and are associated with low mortality and morbidity rates. However, new studies are needed to determine which procedure is safe and effective for the surgical management of patients with chronic pancreatitis.

[Late complication after colon self-expandable metal stent placement: a case report]. / Complicanza tardiva dopo posizionamento colico di stent metallico autoespandibile: caso clinico.

Treatment of acute colorectal malignant obstruction, by using self-expandable metallic stents is useful for both palliative and decompressive therapy before the final surgical treatment. In this case, the patient may be benefit from a period of medical optimization prior to undergoing planned surgical resection by a colorectal surgeon. This is a minimally invasive procedure, relatively safe, which obviates the need for colostomy for evacuation relieving physical and psychological burden and contributing the improvement of quality of life. Furthermore, this method also has the advantage of being cost-effective. The previous experience in the benign biliary stenosis allowed the extension of using the metallic stents also for the treatment of benign colorectal diseases (diverticular occlusion, anastomotic strictures, colonic endometriosis). Complications of colon self-expandable metallic stents placement may occur during the procedure and soon after placement (early complications) or, rarely, late after insertion (late complications). These include bleeding, re-obstruction, pain, tenesmus, stent migration, and perforation. The authors report a case of an 81 year-old woman with inoperable rectal carcinoma with liver metastasis who underwent palliative treatment of self-expanding metallic stent endoscopic placement. One month later, the patient presented with acute abdomen at Accidents and Emergencies Department. The diagnosis was a late rectosigmoid junction perforation by stent placement.