The diagnostic accuracy of endoscopic ultrasound vs. contrast-enhanced computed tomography in local staging of pancreatic adenocarcinoma: a bi-national multicenter study.

BACKGROUND: Identification of pancreatic cancer (PC) local invasion is crucial to optimize patients' selection for surgery. AIMS: To determine the diagnostic accuracy of contrast-enhanced computed tomography (CECT) and endoscopic ultrasound (EUS) in local staging of PC. METHODS: We performed a multicenter study including all patients with PC who underwent surgery. RESULTS: One hundred twelve patients were included. Surgical findings of peri-pancreatic lymph nodes (LN), vascular and adjacent organ involvement were seen in 67 (59.8%), 33 (29.5%) and 19 patients (17%), respectively. The diagnostic performance of EUS was better than CECT in peri-pancreatic LN. The sensitivity, specificity, positive predictive value (PPV) and negative predictive (NPV) of CECT vs. EUS were 28.4%, 80%, 67.9% and 42.9% vs. 70.2%, 75.6%, 81% and 63%, respectively. For vascular and adjacent organ involvement, the sensitivity, specificity, PPV and NPV were 45.5%, 93.7%, 75%, 80.4% and 31.6%, 89.2%, 37.5% and 86.5% for CECT, respectively, vs. 63.6%, 93.7%, 80.8%, 86.1% and 36.8%, 94.6%, 58.3% and 88% for EUS, respectively. Combining both CECT and EUS, the sensitivity for peri-pancreatic LN, vascular and adjacent organ involvement improved (76.1%, 78.8% and 42%), respectively. CONCLUSION: EUS was superior to CECT in local staging. Combined EUS and CECT had a higher sensitivity than either alone.

The effect of atrophied pancreas as shown in the preoperative imaging on the leakage rate after pancreaticoduodenectomy.

Backgrounds/Aims: The soft texture of the pancreas parenchyma may influence the incidence of pancreatic leakage after pancreaticoduodenectomy (PD). One possible method to assess pancreatic texture and atrophy, is via computed tomography (CT) scan of the abdomen. The purpose of our study was to evaluate the relation between the preoperative CT scan and the incidence of pancreatic fistula after PD. Methods: A retrospective single-center study including patients who underwent PD for a benign and malignant tumor of the periampullary region between the years 2000 and 2016. Demographic and imaging data were analysed and a correlation with the post-operative leak was evaluated. Results: Pancreatic leak was documented in 34 out of 154 (22.1%) patients. All the leakage cases occurred in the preserved pancreas group (33.1% of the total preserved pancreas group alone). No leak was documented in the atrophic pancreas group. This difference between the two groups was found to be statistically significant (p ≤ 0.00001). Conclusions: Atrophic pancreas in the preoperative CT scan may be protective against leakage after PD. These findings may help the surgeon to risk stratify patients accordingly. In addition, the findings suggest that patients with a preserved pancreas may require more protective methods to prevent leakage.

An analysis of 77 cases of pancreatic injuries at a level one trauma center: Outcomes of conservative and surgical treatments.

Backgrounds/Aims: Traumatic pancreatic injury (TPI) is rare as an isolated injury. There is a trend to perform conservative treatment even in patients with complete duct dissection and successful treatment. This study reviewed our 20 years of experience in the management of TPI and assessed patient outcomes according to age group and treatment strategy. Methods: A retrospective analysis of patients diagnosed and treated with TPI at a level-I trauma center from 2000-2019. Patients were divided into two groups: adults and pediatrics. Conservative treatment cases were subjected to subgroup analysis. Level of evidence: IV. Results: Of a total of 77 patients, the mean age was 24.89 ± 15.88 years. Fifty-six (72.7%) patients had blunt trauma with motor vehicle accident. Blunt trauma was the predominant mechanism in 42 (54.5%) patients. Overall, 38 (49.4%) cases had grade I or II injury, 24 (31.2%) had grade III injury, and 15 (19.5%) had grade IV injury. A total of 30 cases had non-operative management (NOM). Successful NOM was observed in 16 (20.8%) cases, including eight (32.0%) pediatric cases and eight (15.4%) adult cases. Higher American association for the surgery of trauma (AAST) grade of injury was associated with NOM failure (16.7% for grade I/II, 100% for grade III, and 66.7% for grade IV injury; p = 0.001). An independent factor for NOM failure was female sex (69.2% in females vs. 29.4% in males; p = 0.03). Conclusions: High AAST grade TPI is associated with a high rate of NOM failure in both pediatric and adults.

Impact of tozinameran (BNT162b2) mRNA vaccine on kidney transplant and chronic dialysis patients: 3-5 months follow-up.

BACKGROUND: Determining the humoral immunogenicity of tozinameran (BNT162b2) in patients requiring chronic renal replacement therapy, and its impact on COVID-19 morbidity several months after vaccination, may guide risk assessment and changes in vaccination policy. METHODS: In a prospective post-vaccination cohort study with up to 5 months follow-up we studied outpatient dialysis and kidney transplant patients and respective healthcare teams. Outcomes were anti S1/S2 antibody responses to vaccine or infection, and infection rate during follow-up. RESULTS: One hundred seventy-five dialysis patients (40% women, 65 ± 15 years), 252 kidney transplant patients (33% women, 54 ± 14 years) and 71 controls (65% women, 44 ± 14 years) were followed. Three months or longer after vaccination we detected anti S1/S2 IgG antibodies in 79% of dialysis patients, 42% of transplant recipients and 100% of controls, whereas respective rates after infection were 94%, 69% and 100%. Predictors of non-response were older age, diabetes, history of cancer, lower lymphocyte count and lower vitamin-D levels. Factors associated with lower antibody levels in dialysis patients were modality (hemodialysis vs peritoneal) and high serum ferritin levels. In transplant patients, hypertension and higher calcineurin or mTOR inhibitor drug levels were linked with lower antibody response. Vaccination was associated with fewer subsequent infections (HR 0.23, p < 0.05). Moreover, higher antibody levels (particularly above 59 AU/ml) were associated with fewer events, with a HR 0.41 for each unit increased in log10titer (p < 0.05). CONCLUSIONS: Dialysis patients, and more strikingly kidney transplant recipients, mounted reduced antibody response to COVID-19 mRNA vaccination. Lesser humoral response was associated with more infections. Measures to identify and protect non-responsive patients are required.

Weight Loss Outcomes and Lifestyle Patterns Following Sleeve Gastrectomy: an 8-Year Retrospective Study of 212 Patients.

PURPOSE: Sleeve gastrectomy (SG) is an effective treatment for extreme obesity; however, long-term weight loss outcomes remain largely understudied. We aimed to examine the long-term weight changes following SG and patient characteristics and lifestyle patterns related to weight loss outcomes. MATERIALS AND METHODS: Data from medical records of patients operated in a tertiary university medical center between 2008 and 2014 were reviewed, along with information derived from a telephone questionnaire. Information included the following: current medical status, medications, side effects, behavior, lifestyle habits, and weight changes. RESULTS: A total of 212 patients (69.3% females) were included, with a median follow-up duration of 8 years post-SG. Mean age and baseline body mass index (BMI) of participants were 39.7 ± 12.0 years and 42.2 ± 4.9 kg/m2, respectively. Mean BMI, percentage excess weight loss, and percentage total body weight loss were 33.1 ± 6.1, 55.5 ± 27.5%, and 21.7 ± 10.7%, respectively. Higher baseline BMI was found to be the strongest independent predictor for insufficient weight loss (OR = 0.90, P = 0.001, 95% CI 0.85, 0.96). Sweetened beverage intake, usage of psychiatric medications, higher initial BMI, and lower age were significant predictors for increased weight gain from nadir weight (P < 0.0001, P = 0.005, P = 0.035, and P < 0.0001, respectively). CONCLUSIONS: SG patients were found to maintain a notable long-term weight loss. Nevertheless, weight regain and insufficient weight loss were prevalent in the long-term post-operative period, and were related to certain lifestyle patterns. Clinical practice should emphasize the relationship between post-operative weight loss outcomes and specific behaviors. Efforts should be made to educate patients on the need for lifelong follow-up and support.

The impact of preoperative vitamin administration on skeletal status following sleeve gastrectomy in young and middle-aged women: a randomized controlled trial.

BACKGROUND: The appropriate strategies to minimize skeletal deterioration following bariatric surgeries are inconclusive. This randomized controlled trial evaluated the effect of preoperative vitamin supplementation on bone mineral density (BMD) and biochemical parameters in females post-sleeve gastrectomy (SG). METHODS: Participants were randomized to a 2-month preoperative treatment with a multivitamin and vitamin D 4000 IU/d (intervention arm) or 1200 IU/d (control arm). Preoperative and 12-month postoperative follow-up evaluations included anthropometrics, biochemical parameters, and dual energy X-ray absorptiometry (DEXA). RESULTS: Sixty-two females (median age 29.7 years and median BMI 43.4 kg/m2) were recruited, 87% completed the 12-month follow-up. For the intervention and control arms, significant and similar reductions at 12-months post-surgery were observed in BMD of the hip (-6.8 ± 3.7% vs. -6.0 ± 3.6%; P = 0.646) and of the femoral neck (-7.1 ± 5.8% vs. -7.2 ± 5.5%; P = 0.973). For the intervention compared to the control arm, the 25 hydroxyvitamin D (25(OH)D) increment was greater after 2 months treatment, and vitamin D deficiency rates were lower at 3 and 6-months follow-up (P < 0.016). However, at 12-months postoperative, 25(OH)D values and vitamin D deficiency were comparable between the arms (P > 0.339). Predictors for BMD decline in the total hip were the percentage of excess weight-loss, age>50 years, and lower initial BMI (P ≤ 0.003). CONCLUSIONS: SG was associated with a significant decline in BMD of the hip and femoral neck in young and middle-aged women, and was unaffected by preoperative vitamin D supplementation. Females who are peri-menopausal or with greater postoperative weight-loss should be particularly followed for BMD decline.

Splenic Vein as an Autologous Graft in Traumatic SMV Injuries: A Missed Valuable Alternative.

Traumatic superior mesenteric artery (SMA) and vein (SMV) injuries are rare but often lethal. The ideal management options of traumatic SMV injury are still controversial. Management options include venous repair and ligation. Splenic vein turndown procedure (SVTP) is a rare procedure that has been described in only 6 cases in the literature. Here, we reviewed the literature on the usage of the splenic vein turndown procedure (SVTP) as an alternative option in patients with traumatic SMV injury. METHODS: We performed a narrative review for the available literature on the usage of the splenic vein as an autologous graft in the management of the SMV injury. We included all studies of SVTP in traumatic SMV injuries only. RESULTS: We included only 5 studies. In total, 7 patients underwent SVTP. Five patients presented with a penetrating abdominal vascular trauma (AVT) and 2 patients with a blunt AVT. The advantages of the SVTP include no need for additional incisions to harvest potential autologous grafts, minimally increased operative time, and 1 less anastomotic site compared to other conduit options. CONCLUSIONS: In cases of traumatic SMV injuries with associated splenic or pancreatic injuries that need distal pancreatosplenectomy, surgeons may consider SVTP as an ideal management option rather than primary repair or ligation.

Food Addiction and Binge Eating During One Year Following Sleeve Gastrectomy: Prevalence and Implications for Postoperative Outcomes.

BACKGROUND: Food addiction and binge eating are common among individuals with obesity. However, a paucity of studies prospectively examined the prevalence and implications of food addiction before and post-bariatric surgery. We aimed to examine the prevalence of food addiction and binge eating before and after sleeve gastrectomy (SG) and to assess their associations with behavioral and weight loss outcomes. METHODS: We followed at 3 (M3), 6 (M6), and 12 (M12) months postoperative, 54 women who underwent SG. Data collected including anthropometrics, nutritional intake, food tolerance, and physical activity measures. The Yale Food Addiction Scale and the Binge Eating Scale were used to characterize food addiction and binge eating, respectively. RESULTS: The mean baseline age and BMI were 32.1 ± 11.1 years and 44.9 ± 4.9 kg/m2, respectively. Pre-surgery, food addiction, and binge eating were identified in 40.7% and 48.1% of patients, respectively. The prevalence of food addiction decreased significantly up to M6, but increased to 29.3% at M12. The prevalence of binge eating decreased significantly through the follow-up up to 17.4% at M12. Those who met criteria for food addiction at M12 achieved significantly lower excess weight loss at M12 compared with those not meeting this criterion (P = 0.005). Food addiction scores at M12 negatively correlated with weekly physical activity (r = - 0.559; P < 0.001) and food tolerance scores (r = - 0.428; P = 0.005). CONCLUSIONS: The reduction in food addiction observed at M6 was not maintained at M12. Food addiction at M12 was associated with poorer weight loss, eating, and lifestyle behaviors. Clinical practice should focus on the psychological aspects associated with obesity.

Gastric goblet cell carcinoma concurrent with a neuroendocrine tumor.

Goblet cell carcinoma, a tumor that is assumed to originate from crypt base stem cells, is a distinct type of tumor, that occurs typically in the appendix, however, extra-appendiceal locations were also described in few cases. We herein present a unique case of a 48-year-old male with a diagnosis of primary gastric Goblet cell carcinoma that was initially discovered at the time of an endoscopy performed to evaluate an unremitting abdominal pain that was accompanied by remarkable weight loss; four polypoid fragments of the gastric mucosa were sent for histopathologic examination which showed a moderately differentiated goblet cell carcinoma in addition to classical neuroendocrine tumor. Later, laparoscopic D2 total gastrectomy with appendectomy were performed and confirmed the previously mentioned findings along with a normal histopathology of the appendix.

Pleiotropic tumor suppressor functions of WWOX antagonize metastasis.

Tumor progression and metastasis are the major causes of death among cancer associated mortality. Metastatic cells acquire features of migration and invasion and usually undergo epithelia-mesenchymal transition (EMT). Acquirement of these various hallmarks rely on different cellular pathways, including TGF-ß and Wnt signaling. Recently, we reported that WW domain-containing oxidoreductase (WWOX) acts as a tumor suppressor and has anti-metastatic activities involving regulation of several key microRNAs (miRNAs) in triple-negative breast cancer (TNBC). Here, we report that WWOX restoration in highly metastatic MDA-MB435S cancer cells alters mRNA expression profiles; further, WWOX interacts with various proteins to exert its tumor suppressor function. Careful alignment and analysis of gene and miRNA expression in these cells revealed profound changes in cellular pathways mediating adhesion, invasion and motility. We further demonstrate that WWOX, through regulation of miR-146a levels, regulates SMAD3, which is a member of the TGF-ß signaling pathway. Moreover, proteomic analysis of WWOX partners revealed regulation of the Wnt-signaling activation through physical interaction with Disheveled. Altogether, these findings underscore a significant role for WWOX in antagonizing metastasis, further highlighting its role and therapeutic potential in suppressing tumor progression.

Nutritional Deficiencies in Patients with Severe Obesity before Bariatric Surgery: What Should Be the Focus During the Preoperative Assessment?

BACKGROUND: Nutritional deficiencies are a well-recognized long-term complication following bariatric surgery. The presence of preoperative deficiencies has been shown to be predictive of postoperative deficiencies. OBJECTIVE: The aim of the study was to investigate the prevalence of micronutrient deficiency in a large sample of patients with severe obesity preoperatively, and to determine whether such deficiencies may be related to patient's sex, body mass index, or ethnic subgroup. DESIGN: A cross-sectional study of data collected at the time of the preoperative evaluation. PARTICIPANTS/SETTING: Data were collected during the preoperative evaluation of 872 bariatric surgery candidates in a university hospital in Israel between 2011 and 2018. The patients were 72.9% women, with a mean age of 37.9±12.1 years and mean body mass index of 42.4±4.7 MAIN OUTCOME MEASURES: Nutritional deficiencies according to blood assays. Data on anthropometrics, comorbidities, and demographic characteristics was also collected. STATISTICAL ANALYSES: Baseline differences between patient subgroups were analyzed using independent-samples t test, analysis of variance, or χ2 test. RESULTS: Deficiencies of vitamin D, iron, folate, vitamin B-12, elevated parathyroid hormone and low transferrin saturation were present in 75.2%, 42.6%, 28.5%, 8.5%, 35.5%, and 70% of patients, respectively. Nutritional deficiencies were significantly more common among women compared with men for iron (45.9% vs 33.5%; P=0.002), low transferrin saturation (77.7% vs 44.6%; P<0.001), vitamin D (77.5% vs 69.2%; P=0.019) and elevated parathyroid hormone level (39.5% vs 22.9%; P=0.002). Iron, transferrin saturation, and vitamin D deficiencies were more prevalent in Arab patients compared with Jewish patients: 59.6% vs 36%; P<0.001, 80.2% vs 62.8%; P=0.003, and 85.1% vs 71.6%; P<0.001, respectively. Vitamin D and iron deficiency were more common among higher body mass index subgroups (P=0.004 and P=0.040, respectively). CONCLUSIONS: The results indicate a high prevalence of nutritional deficiencies, mainly of iron and vitamin D in bariatric surgery candidates. Patients at higher risk for nutritional deficiencies include those with higher body mass index, women, and Arabs.

VHL-Related Neuroendocrine Neoplasms And Beyond: An Israeli Specialized Center Real-Life Report.

OBJECTIVE: Von Hippel-Lindau (VHL) syndrome is a rare and complex disease. In 1996, we described a 3 generation VHL 2A kindred with 11 mutation carriers. We aim to share our experience regarding the long-term follow-up of this family and the management of all our other VHL patients focusing on frequently encountered neuroendocrine neoplasms: pheochromocytoma/paraganglioma and pancreatic neuroendocrine neoplasms (PNEN). METHODS: All VHL patients in follow-up at our tertiary center from 1980 to 2019 were identified. Clinical, laboratory, imaging, and therapeutic characteristics were retrospectively analyzed. RESULTS: We identified 32 VHL patients in 16 different families, 7/16 were classified as VHL 2 subtype. In the previously described family, the 4 initially asymptomatic carriers developed a neuroendocrine tumor; 7 new children were born, 3 of them being mutation carriers; 2 patients died, 1 due to metastatic PNEN-related liver failure. Pheochromocytoma was frequent (22/32), bilateral (13/22;59%), often diagnosed in early childhood when active screening was timely performed, associated with paraganglioma in 5/22, rarely malignant (1/22), and recurred after surgery in some cases after more than 20 years. PNEN occurred in 8/32 patients (25%), and was metastatic in 3 patients. Surgery and palliative therapy allowed relatively satisfactory outcomes. Severe disabling morbidities due to central-nervous system and ophthalmologic hemangiomas, and other rare tumors as chondrosarcoma in 2 patients and polycythemia in 1 patient were observed. CONCLUSION: A multidisciplinary approach and long-term follow-up is mandatory in VHL patients to manage the multiple debilitating morbidities and delay mortality in these complex patients.

Intussusception in a pregnant patient caused by an ectopic pancreatic mass.

Small bowel obstruction is an uncommon disease in pregnant women and rare when it is caused by intussusception. Intussusception is a rare cause of intestinal obstruction in adult. When it occurs, it is almost always secondary to an underlying pathology acting as a lead point for invagination, such as polyps, hemartomas, lipomas, leiomyomas, Meckel's diverticulum, adenomas, strictures, and malignancies. Ectopic pancreatic tissue is a very rare pathology acting as the lead point. In this case, we present a very rare case of intussusception in a young pregnant woman, caused by an intramural ectopic pancreatic tissue in the ileum.

Repeat Kidney Transplant in a Patient With a Double Inferior Vena Cava and Difficult Venous Access: A Case Report.

Many obstacles may complicate renal transplant, the preferred treatment for end-stage renal disease. Anatomic anomalies are of special importance during surgery. Double inferior vena cava is a rare anomaly reported in 0.2% to 3% of the population and may complicate renal transplant in certain cases. We present a case of a 29-year-old man with end-stage renal disease who was scheduled for repeat kidney renal transplant from a living related donor. His transplant posed many challenges to the transplant team. These included (1) difficult access for dialysis, which required transhepatic insertion of a dialysis catheter, (2) anomalous inferior vena cava anatomy with a double inferior vena cava, (3) a blocked right inferior vena cava, and (4) a small blocked bridging vein connecting the right inferior vena cava to an additional left inferior vena cava. A stent was inserted into the bridging vein to allow venous drainage from the graft. During the transplant procedure, the donated kidney was transplanted into the left iliac fossa and anastomosed to the left external iliac vein. The surgery was successful, without major operative or postoperative complications. The patient was discharged with normal renal function and enjoys normal renal function 6 months after surgery. This case emphasizes the importance of pretransplant evaluation and preparation and the need for high index of suspicion for anatomic variants in donors and recipients.

Multiplication product of Model for End-stage Liver Disease and Donor Risk Index as predictive models of survival after liver transplantation.

BACKGROUND: Liver transplantation (LT) is the treatment of choice for most end-stage liver diseases. This treatment increases survival rates and improves quality of life. Because of the shortage of organ donors, as opposed to waiting patients, the need to optimize the matching of donors to recipients for maximum utility is crucial. AIM: The aim of this study was to examine a predictive model based on the combination of donor and recipient risk factors using the liver Donor Risk Index (DRI) and recipient Model of End-stage Liver Disease (MELD) to predict patients' survival following LT. PATIENTS AND METHODS: The charts of 289 adult primary LT patients, who had undergone transplantation in Israel between 2010 and 2015, were studied retrospectively using prospectively gathered data. RESULTS: Two variables, DRI and MELD, were found to significantly affect post-transplant patient survival. DRI negatively affected survival in a continuous fashion, whereas MELD had a significantly negative effect only at MELD more than 30. Both female sex and the presence of hepatocellular carcinoma were associated with increased patient survival. CONCLUSION: According to our findings, the model described here is a novel prediction tool for the success of orthotopic LT and can thus be considered in liver allocation.

Laparoscopic cystectomy for pancreatic echinococcosis: A case report and literature review.

Cystic echinococcosis (CE) is a widely endemic helminthic disease caused by infection with the Echinococcus granulosus tapeworm. Following ingestion of eggs, hydatid cysts develop, most frequently in the liver and lungs, but occasionally in other organs. Infection of the pancreas by hydatid cysts is very rare, even in endemic areas. Most cases of pancreatic hydatid cysts reported in the literature were treated surgically using traditional open laparotomy. There are only few case reports describing laparoscopic treatment for this disease. Herein, we report on an eighteen-year-old female patient who was referred to our institution with a hydated pancreatic tail cyst. After a course of treatment with Albendazole, we successfully performed laparoscopic splenic-sparing distal pancreatectomy to remove the cyst with an uneventful intra- and post-operative course.

Successful Embolization of Hemorrhagic Hepatic Hydatid Cyst Followed by Surgical Resection: Report of Two Cases and Review of the Literature.

Hepatic hydatid cysts (HHCs) are common in endemic areas. Mostly they are asymptomatic, but some cause serious complications. We report 2 cases of HHC complicated arterial bleeding. Owing to signs of active bleeding, the patients were treated with selective embolization of the hepatic artery to stop the bleeding and stabilize the patients' condition. Subsequently, partial hepatectomy of the involved liver lobe was performed in an elective setting and without postoperative complications. We recommend bridging therapy by selective angiography and embolization for hemorrhagic hepatic hydatid cyst before definitive surgical treatment.

Operative treatment of hepatic hydatid cysts: A single center experience.

BACKGROUND: Hydatid cyst is a zoonotic disease caused by Echinococcus genera. Surgery is needed in most cases. We aimed to describe our center's experience in the surgical management of hepatic hydated cysts (HHC). METHODS: Data was retrospectively collected for patients who underwent operative management for HHC between the years 1994-2014. RESULTS: Sixty-nine underwent surgical treatment for HHC. Group A included 34 treated with an unroofing procedure, group B included 24 patients who underwent hepatectomy and group C included 11 patients who underwent peri-cystectomy. The median ± (range) age for groups A, B and C were 39.5 (6.5-69), 40 (17-74) and 32 (20-62), respectively (P > 0.1). Post-operative complications occurred in 16, 11 and 5 patients in group A, B and C, respectively, as assessed by clavien-dindo classification (CDC). The average CDC was significantly higher in the hepatectomy group as compared to the unroofing group (2.3 vs.1.5, P = 0.04). Recurrence was significantly higher after the unroofing procedure as compared to the hepatectomy group (P = 0.05). CONCLUSION: Surgery remains the mainstay of treatment for HHC, once surgery is pursued, the results are satisfactory.

Author Correction: WWOX controls hepatic HIF1α to suppress hepatocyte proliferation and neoplasia.

Since the publication of their article, the authors reported that duplication had mistakenly occurred in Fig 3A and D - H&E panels.