Current aspects in the management of esophageal trauma: a systematic review and proportional meta-analysis.

Trauma-related esophageal injuries (TEIs) are a rare but highly lethal condition. The presentation of TEIs is very diverse depending on the location and mechanism of injury (blunt vs. penetrating), as well as the presence or absence of concurrent injuries. The aim of the present systematic review and meta-analysis is to delineate the clinical features impacting TEI management. A systematic review of the Medline, Embase, and web of science databases was undertaken for studies reporting on patients with TEIs. A random effects model was employed in the meta-analysis of aggregated data. Eleven studies, incorporating 4605 patients, were included, with a pooled mortality rate of 19% (95% confidence interval (CI) 13-25%). Penetrating injuries were 34% more likely to occur (RR 0.66, 95% CI 0.49-0.89, P = 0.01), predominantly in the neck compartment. Surgery was employed in 53% of cases (95% CI 32-73%), with 68% of patients having associated injuries (95% CI 43-94%). In terms of choice of surgical repair technique, primary suture repair was most frequently reported, irrespective of injury location. Postoperative drainage was employed in 27% of the cases and was more common following repair of thoracic esophageal injuries. The estimated dependence on mechanical ventilation was 5.91 days (95% CI 5.1-6.72 days), while the length of stay in the intensive care unit averaged 7.89 days (95% CI 7.14-8.65 days). TEIs are uncommon injuries in trauma patients, associated with considerable mortality and morbidity. Open suture repair of ensuing esophageal defects is by large the most employed approach, while stenting may be indicated in carefully selected cases.

The Efficacy of Probiotics, Prebiotics, and Synbiotics in Patients Who Have Undergone Abdominal Operation, in Terms of Bowel Function Post-Operatively: A Network Meta-Analysis.

BACKGROUND: Abdominal operations may lead to post-operative bowel dysfunction, while administration of probiotics, prebiotics and synbiotics may limit its manifestation. Τhe study aimed to assess the efficacy of probiotics, prebiotics and synbiotics in patients who undergone abdominal operation, in terms of bowel function post-operatively. METHODS: PubMed, Scopus, Cochrane Central Register of Controlled Trials (Central), Embase, US Registry of clinical trials, and sources of grey literature were searched. The relative effect sizes were estimated, and we obtained the relative ranking of the interventions using cumulative ranking curves. RESULTS: In total, 30 studies were included in the analysis. For the outcome of post-operative ileus, probiotics was superior to placebo/no intervention (relative risk, RR: 0.38; 95%CI: 0.14-0.98) with the highest SUCRA (surface under the cumulative ranking) value (92.1%). For time to first flatus, probiotics (MD: -0.47; 95%CI: -0.78 to -0.17) and synbiotics (MD: -0.53; 95%CI: -0.96 to -0.09) were superior to placebo/no intervention. For time to first defecation and for post-operative abdominal distension probiotics were superior to placebo/no intervention. For post-operative hospitalization days, synbiotics were superior to placebo/no intervention (MD: -3.07; 95%CI: -4.80 to -1.34). CONCLUSIONS: Administration of probiotics in patients who had undergone abdominal surgery reduced the prevalence of post-operative ileus, time to first flatus, time to first defecation, and prevalence of post-operative abdominal distension. Synbiotics reduce time to first flatus and post-operative hospitalization days.

Laparoscopic para-aortic lymphadenectomy for metastatic colon cancer in a patient with left-sided inferior vena cava: a case report.

Transposition of inferior vena cava, or, left-sided inferior vena cava (LS-IVC) is a rare clinical entity, in which the inferior vena cava ascends along the left side of the abdominal aorta. Literature contains mainly clinical case reports. Although it is usually not associated with clinical symptomatology, this anomaly should be detected during preoperative planning to avoid iatrogenic injuries intraoperatively. We present a case of left-sided inferior vena cava encountered during laparoscopic lymphadenectomy in a 45-year-old man with previous laparoscopic hemicolectomy due to colon adenocarcinoma. Preoperative CT abdomen revealed the left-sided location of infrarenal IVC and laparoscopic trans-peritoneal aortic lymphadenectomy was decided. Intraoperatively, transposition of inferior vena cava was confirmed in accordance with the CT findings. Resection of lymph node block was conducted with no complications and with minimal blood loss. The postoperative course was uneventful, and the patient was discharged from the hospital the day following surgery. In conclusion, transposition of the inferior vena cava, although rare, constitutes an anatomical variant that should be identified preoperatively to decrease intraoperative risks. Several anatomical variants have been associated with left-sided inferior vena cava.

Hemobilia Caused by Arterioportal Fistula Following Percutaneous Liver Biopsy Complicated by Acute Cholecystitis and Review of the Literature.

We present a case of a 44-year-old male with chronic hepatitis B that visited the Emergency Department due to epigastric pain after a liver biopsy. The ultrasonography revealed signs of bleeding in the bile ducts. and angiography visualized an arterioportal fistula. Selective right hepatic artery branch embolization was performed, and the bleeding was controlled. Although, the clinical picture was initially improved, the patient presented later with acute abdomen, obstructive jaundice and fever. The patient underwent cholecystectomy with bile duct exploration and placement of a Kehr's T tube in the common bile duct. The postoperative course was uneventful. We also review the relevant literature concerning arterioportal fistula manifested as hemobilia as well as acute cholecystitis occurring after hemobilia.

Oral administration of n-3 fatty acids positively affect the mucosal lesions after experimental ischemic enteritis in the rat.

AIM: The purpose of the study was to evaluate the effect of oral administration of n-3 polyunsaturated fatty acids in experimental ischemic enteritis in rats. METHODS: Forty Wistar rats were submitted to control narrowing of the superior mesenteric artery and were divided in two groups: N3 polyunsaturated fatty acids, which received a high-molecular polymer solution of artificial total enteral nutrition enriched with n-3 fatty acids and CONTROL which received a high-molecular polymer solution of artificial total enteral nutrition. RESULTS: Reduction of the animals' body weight was observed in both groups, but there was no difference between the two groups. Regarding the level of cytokines interleukin (IL)-1b, IL-6, and tumor necrosis factor a (TNF-a) there was no statistically significant difference between the two groups. Ischemic lesions to the small bowel mucosa were observed in both groups. A statistically significant difference in the extent of intestinal lesions was observed between the two groups with the animals that received enteral nutrition enriched with n-3 fatty acid developing fewer lesions. CONCLUSION: Enteral nutrition enriched with n-3 polyunsaturated fatty acids reduces the mucosal lesions caused by mesenteric ischemia compared to standard enteral nutrition, by modifying the local, but not the systemic, immune, and inflammatory response.

OBJETIVO: El propósito del estudio fue evaluar el efecto de la administración oral de ácidos grasos poliinsaturados n-3 en enteritis isquémica experimental en ratas. MÉTODOS: 40 ratas Wistar fueron sometidas a un estrechamiento controlado de la arteria mesentérica superior y se dividieron en dos grupos: N3PUFA, que recibieron una solución de polímero de alto peso molecular de nutrición enteral total artificial enriquecida con ácidos grasos n-3 y CONTROL que recibió un alto -Solución de polímero molecular de nutrición enteral total artificial. RESULTADOS: Se observó una reducción del peso corporal de los animales en ambos grupos, pero no hubo diferencias entre los dos grupos. Con respecto al nivel de citocinas IL-1b, IL-6 y TNF-a, no hubo diferencia estadísticamente significativa entre los dos grupos. Se observaron lesiones isquémicas de la mucosa del intestino delgado en ambos grupos. Se observó una diferencia estadísticamente significativa en la extensión de las lesiones intestinales entre los dos grupos y los animales que recibieron nutrición enteral enriquecida con ácido graso n-3 desarrollaron menos lesiones. CONCLUSIÓN: La nutrición enteral enriquecida con ácidos grasos poliinsaturados n-3 reduce las lesiones mucosas causadas por isquemia mesentérica en comparación con la nutrición enteral estándar, al modificar la respuesta local, pero no sistémica, inmunitaria e inflamatoria.

The Combined Use of Platelet-Rich Plasma and Adipose-Derived Mesenchymal Stem Cells Promotes Healing. A Review of Experimental Models and Future Perspectives.

Wound healing and tissue regeneration are a field of clinical medicine presenting high research interest, since various local and systematic factors can inhibit these processes and lead to an inferior result. New methods of healing enhancement constantly arise, which, however, require experimental validation before their establishment in everyday practice. Platelet-rich plasma (PRP) is a well-known autologous factor that promotes tissue healing in various surgical defects. PRP derives from the centrifugation of peripheral blood and has a high concentration of growth factors that promote healing. Recently, the use of adipose-derived mesenchymal stem cells (ADMSCs) has been thoroughly investigated as a form of wound healing enhancement. ADMSCs are autologous stem cells deriving from fat tissue, with a capability of differentiation in specific cells, depending on the micro-environment that they are exposed to. The aim of the present comprehensive review is to record the experimental studies that have been published and investigate the synergistic use of PRP and ADMSC in animal models. The technical aspects of experimentations, as well as the major results of each study, are discussed. In addition, the limited clinical studies including humans are also reported. Future perspectives are discussed, along with the limitations of current studies on the long-term follow up needed on efficacy and safety.

Variations of plasma levels of insulin, glucagon, amylase and glucose and histopathological lesions of pancreatic tissue after complete elimination of exocrine pancreatic function with surgical ligation versus prolamine occlusion.

OBJECTIVE: Pancreaticoduodenectomy has been established as the treatment of choice for the management of benign and malignant lesions of the pancreatic head, and pancreaticojejunal or pancreaticogastric anastomosis seems to be the safer choice for the management of the pancreatic duct. However, in certain seldom, but still existing circumstances, pancreatic duct ligation or occlusion with a chemical substance is a valuable and viable alternative. The aim of the current study is to compare these two methods of occlusion of the pancreatic duct regarding the endocrine and exocrine function of the pancreas and its histopathology. MATERIALS AND METHODS: 18 health mixed breed dog of both sexes were randomized in two groups: group A, in which the pancreatic duct was ligated and group B, in which the pancreatic duct was occluded with prolamine. RESULTS: None of the animals presented postoperatively steatorrhea and significant body weight changes. Peripancreatic inflammation at sacrifice, inflammatory cell infiltration and edema of the pancreas on the 15th postoperative day and 30th postoperative day were milder after occlusion with prolamine than after ligation. Ligation of pancreatic duct lead to significantly greater hyperamylasemia than prolamine occlusion every day until the 15th. Mild hyperglycemia presented from the first to the fourth day in both groups, which was associated with a significant drop in insulin. Glucagon remained within the normal values at all times during the experiment. None of glucose, insulin and glucagon differed between groups. CONCLUSION: Prolamine occlusion of the pancreatic duct causes milder hyperamylasemia and less extensive inflammation both macroscopically and microscopically than ligation. KEY WORDS: Pancreas, Pancreaticoduodenectomy, Hyperamylasemia.

Transdiaphragmatic Intercostal Hernia-An Unusual Hepatic Injury After a Car Accident: A Case Report and Review of the Literature.

Transdiaphragmatic intercostal hernia, in which the abdominal contents of the hernia protrude through the diaphragm and the thoracic wall defect. is a very rare type of hernia with only a few cases having been reported in the literature. That type of hernia is usually manifested in male patients after trauma, penetrating or blunt. It is frequently presented with a palpable thoracic mass and pain. The indicated treatment is surgery. We present the case of a 60-year-old female admitted to the hospital after a car accident and suffered multiple rib fractures (6th, 7th, 8th right ribs / 7th, 8th, 9th left ribs), as well as flail thorax, hemothorax bilaterally, left subcutaneous emphysema and swelling of soft tissues of the right lateral thoracoabdominal wall. CT scan revealed herniation of hepatic parenchyma and intestinal loops into the thorax. The patient was treated surgically, and his postoperative course was uneventful. We also review the relevant literature concerning this transdiaphragmatic, intercostal hernia and identify 42 cases. Transdiaphragmatic intercostal hernia is a rare condition, usually manifested in male patients after trauma, penetrating or blunt. It is frequently presented with a palpable thoracic mass and pain. The indicated treatment is surgery.

Case Report: A Virilizing Adrenal Oncocytoma.

A 64-year-old female was admitted to our clinic with a 9-cm-sized adrenal mass. The patient's main symptom was hirsutism, which included thinning scalp hair and excessive hair growth over her torso and arms. Upon investigation, elevated values of testosterone, androsterone D4, and DHEA-S were found. Contrast-enhanced abdominal CT and MRI scans revealed a heterogenous large mass (diameter 9 × 8.5 cm) with focal calcifications, necrotic areas, and a clear distinction from the adjacent structures. The patient underwent a right adrenalectomy. The histological examination of the tumor revealed a borderline adrenocortical oncocytoma. The patient had an uncomplicated postoperative course and was discharged on postoperative day 8. Similar cases reported in the literature are also being reviewed in this case report.

Technical aspects, short- and long-term outcomes of laparoscopic and robotic D2-lymphadectomy in gastric cancer.

PURPOSE: Gastric cancer is a common malignancy and its radical excision with an adequate lymph node resection provides an improved oncologic outcome. D2 lymphadenectomy in distal or total gastrectomy is considered a highly desirable technique for curable early or locally advanced gastric cancer. Many studies with high-level of evidence confirm the importance of the application of minimally invasive techniques in improving the short and long term outcomes of patients who undergo gastrectomy. METHODS: A MEDLINE search was performed with the following keywords; "d2 gastrectomy open laparoscopic", "d2 gastrectomy open robotic" and "d2 gastrectomy laparoscopic robotic". The search was narrowed on randomized control trials (RCT). RESULTS: 6 studies in total are included in the study; 5 RCTs on open vs laparoscopic group and 1 RCT on open vs robotic group. There is currently no RCT comparing the laparoscopic vs robotic techniques. CONCLUSIONS: The superiority of laparoscopic gastrectomy towards the open technique is widely accepted, yet the proven acceptance of minimally invasive robotic techniques is still debated and not scientifically established. Technical challenges are the main point of discussion among the experts on the field, as well as the advantages of laparoscopic and robotic assisted gastrectomy over the conventional open. This review provides a comparison on technical aspects, the short and long term outcomes of open and minimally invasive gastrectomy with D2 lymphadenectomy in early and advanced gastric cancer.

Klatskin tumors and "Klatskin-mimicking lesions": our 22-year experience.

Background and study purpose: Hilar cholangiocarcinoma, also known as Altemeier-Klatskin tumor, is a rare malignancy that arises in the confluence of the hepatic ducts of the porta hepatis. The prognosis is rather poor. Several lesions mimic these tumors and lead to a misdiagnosis, resulting in radical hepatic resections. These lesions are known as Klatskin-mimicking lesions. We present our experience with the diagnosis and treatment of pathological lesions that can mimic a perihilar cholangiocarcinoma and establish an algorithm of treatment Methods: For the current retrospective study, a prospectively established bile-duct tumor database was analyzed by selecting patients with a preoperative diagnosis of perihilar cholangiocarcinoma. Results: In the last 22 years (from January 1, 1996, to December 31, 2017), 73 patients who were referred to our tertiary center with a primary diagnosis of a Klatskin tumor were treated. All patients underwent a thorough evaluation before deciding upon the treatment. However, only 58 cases had a confirmed preoperative diagnosis of hilar cholangiocarcinoma in the final histopathological examination. The final diagnosis in 15 patients differed from the primary cause for referral and the lesions were regarded as Klatskin-mimicking lesions. Conclusions: Clinicians should always highly suspect Klatskin-mimicking lesions when they evaluate a patient for a possible hilar cholangiocarcinoma in order to avoid a misdiagnosis and propose a proper treatment.

Laparoscopic resection of large pelvic lipoma causing obstructive uropathy in a 66 year old female - A case report from Greece.

Lipomas are benign, usually asymptomatic, tumours and pelvic lipomas are extremely rare. We describe the case of a giant pelvic lipoma causing obstructive uropathy to a 66-year-old morbidly obese female treated in the 4th Surgical Department of the Medical School of Aristotle University of Thessaloniki in General Hospital "G. Papanikolaou" in March 2016. The patient presented with a history of nocturia and frequent daytime urination for 1 year. Her medical history included diffuse lipomatosis. Computer tomography revealed a giant pelvic mass which lead to left side hydronephrosis, hydrouterer and a pear-shaped bladder, with the differential diagnosis including pelvic lipoma or liposarcoma. An ultrasound guided biopsy excluded the diagnosis of liposarcoma. The patient was submitted to laparoscopic resection of the pelvic lipoma, with complete remission of urinary symptoms. The key-point is to consider the possibility that the pelvic mass is a well-differentiated liposarcoma and to manage it adequately and thus, we recommend intact excision of the mass through a wound protector, and extreme caution to avoid any rupture of the capsule.

[Polymetastatic highly aggressive Small Cell Undifferentiated Neuroendocrine Carcinoma of Ascending Colon]. / Carcinoma neuroendocrino indiferenciado polimetástatico altamente agresivo de células pequeñas de colon ascendente.

Neuroendocrine carcinoma (NEC) of the colon is a rare and very aggressive tumor with poor prognosis. The current case report presents a 53-year-old male with a 6 cm × 10 cm ascending colon carcinoma, causing large intestine obstruction, with simultaneous multiple hepatic metastases and peritoneal carcinomatosis. Surgical resection of the primary tumor was performed, because of the bowel obstruction, to ameliorate the symptoms before the onset of chemotherapy. Histopathology revealed that the tumor was a small-cell undifferentiated NEC. During the post0operative period, the patient presented pulmonary metastases, and on the 36th post-operative day, death occurred due to respiratory failure.

El carcinoma neuroendocrino del colon es un tumor raro y muy agresivo, con mal pronóstico. Se presenta el caso de un hombre de 53 años con un carcinoma de colon ascendente de 6 × 10 cm que causa obstrucción del intestino grueso, con metástasis hepáticas múltiples simultáneas y carcinomatosis peritoneal. Se realizó la resección quirúrgica del tumor primario, debido a la obstrucción intestinal, para mejorar los síntomas antes del inicio de la quimioterapia. La histopatología reveló que el tumor era un carcinoma neuroendocrino indiferenciado de células pequeñas. Durante el posoperatorio, el paciente presentó metástasis pulmonares y el día 36 posoperatorio se produjo la muerte por insuficiencia respiratoria.

Laparoscopic Resection of Desmoid Type Fibromatosis of the Splenic Hilum Mimicking a Greater Curvature Gastric GIST.

Desmoid tumor, recently renamed as desmoid type fibromatosis, is an uncommon neoplasm. The mesentery is the usual origin of intra-abdominal desmoid-type fibromatosis and despite the fact there is no metastatic potential, it can infiltrate adjacent organs. There etiology remains unknown, preoperative diagnosis is difficult and differential diagnosis includes among other gastrointestinal stromal tumor (GIST). In resectable tumors, the mainstay of treatment is surgical resection with at least clean microscopic margins. We present a case of a 51-year lady who presented with a 6.2 x 4.5 x 3.3 cm neoplasm in the anatomic area of the greater gastric curvature, the splenic hilum and the tail of the pancreas that was diagnosed as GIST on the CT scan. The patient was submitted to laparoscopic excision of the tumor and histopathological examination revealed desmoid type fibromatosis of the splenic hilum infiltrating the spleen, pancreatic tale and greater gastric curvature. According to the authors' knowledge, this is the first reported case of a sporadic splenic desmoid tumor, which has been treated successfully by laparoscopic en block resection.

Atypical anastomotic malignancies of small bowel after subtotal gastrectomy with Billorth II gastroenterostomy for peptic ulcer: Report of three cases and review of the literature.

AIM: To present patients who developed small-bowel malignancy at the level of the gastrointestinal anastomosis decades after a subtotal gastrectomy for ulcer, to review relevant literature, and to attempt to interpret the reasons those cancers developed to these postsurgical non-gastric sights. METHODS: For the current retrospective study and review of literature, the surgical and histopathological records dated from January 1, 1993 to December 31, 2017 of our department were examined, searching for patients who have undergone surgical treatment of small-bowel malignancy to identify those who have undergone subtotal gastrectomy for benign peptic ulcer. A systematic literature search was also conducted using PubMed, EMBASE, and Cochrane Library to identify similar cases. RESULTS: We identified three patients who had developed small-intestine malignancy at the level of the gastrointestinal anastomosis decades after a subtotal gastrectomy with Billroth II gastroenterostomy for benign peptic ulcer-two patients with adenocarcinoma originated in the Braun anastomosis and one patient with lymphoma of the efferent loop. All three patients were submitted to surgical resection of the tumor with Roux-en-Y reconstruction of the digestive tract. In the literature review, we only found one case of primary small-intestinal cancer that originated in the efferent loop after Billroth II gastrectomy because of duodenal ulcer but none reporting Braun anastomosis adenocarcinoma following partial gastrectomy for benign disease. We also did not find any case of efferent loop lymphoma following gastrectomy. CONCLUSION: Anastomotic gastric cancer following distal gastrectomy for peptic ulcer is a well-established clinical entity. However, malignancies of the afferent or efferent loop of the gastrointestinal anastomosis are extremely uncommon. The substantial diversion of the potent carcinogenic pancreaticobiliary secretions through the Braun anastomosis and the stomach hypochlorhydria, allowing the formation of carcinogenic factors from food, are the two most prominent pathogenetic mechanisms for those tumors.

A 20-year single center experience in the surgical treatment of colorectal liver metastasis.

PURPOSE: To present our experience in the treatment of patients with liver metastases from colorectal cancer. METHODS: The surgical and histopathological records of our department dating from 1st January 1997 to 31 December 2016 were examined, searching for patients who have undergone surgical treatment of colorectal liver metastasis. RESULTS: A total of 90 patients with colorectal liver metastases were treated in the last 20 years in our department. Their mean age was 65.28 years and 54 (60%) were male. The primary tumor was in the colon in 71 patients (78.9%) and in 19 (21.1%) patients in the rectum. Thirty-six (40%) patients presented with synchronous metastatic liver disease, from which 27 were subjected to simultaneous resection, 2 underwent a liver-first approach and 7 were subjected to resection of primary tumor first. Regarding the number of metastases 67 (74.4%) patients had single metastasis, 12 (13.3%) had 2 lesions, 4 (4.4%) had 3 lesions and 7 (7.8%) had 4-8 lesions. In-hospital and 30-day mortality was 3.85%. Median survival was 41 months. CONCLUSION: Surgical resection is the treatment of choice for the management of liver metastasis from colorectal cancer and can be safely performed. Follow up of patients with colorectal cancer is imperative as metachronous metastasis presents in a significant percentage of patients with negative locoregional lymph nodes of the primary tumor. The order of resection doesn't seem to alter outcome in synchronous metastasis. Recurrence is common and re-resection if feasible is the only chance of cure.

Fournier's Gangrene: Lessons Learned from Multimodal and Multidisciplinary Management of Perineal Necrotizing Fasciitis.

BACKGROUND: Fournier's gangrene (FG) is a rapidly evolving necrotizing fasciitis of the perineum and the genital area, the scrotum as it most commonly affects man in the vast majority of cases. It is polymicrobial in origin, due to the synergistic action of anaerobes and aerobes and has a very high mortality. There are many predisposing factors including diabetes mellitus, alcoholism, immunosuppression, renal, and hepatic disease. The prognosis of the disease depends on a lot of factors including but not limited to patient age, disease extent, and comorbidities. The purpose of the study is to describe the experience of a general surgery department in the management of FG, to present the multimodal and multidisciplinary treatment of the disease, to identify predictors of mortality, and to make general surgeons familiar with the disease. METHODS: The current retrospective study is presenting the experience of our general surgery department in the management of FG during the last 20 years. The clinical presentation and demographics of the patients were recorded. Also we recorded the laboratory data, the comorbidities, the etiology, and microbiology and the therapeutic interventions performed, and we calculated the various severity indexes. Patients were divided to survivors and non-survivors, and all the collected data were statistically analyzed to assess mortality factors using univariate and then multivariate analysis. RESULTS: In our series, we treated a total of 24 patients with a mean age 58.9 years including 20 males (83.4%) and 4 females (16.6%). In most patients, a delay between disease onset and seeking of medical help was noted. Comorbidities were present in almost all patients (87.5%). All patients were submitted to extensive surgical debridements and received broad-spectrum antibiotics until microbiological culture results were received. Regarding all the collected data, there was no statistically significant difference between survivors and non-survivors except the presence of malignancy in non-survivors (p = 0.036) and the lower hemoglobin (p < 0.001) and hematocrit (p = 0.002) in non-survivors. However, multivariate analysis did not reveal any predictor of mortality. CONCLUSION: Early diagnosis, aggressive thorough surgical treatment, and administration of the proper antibiotic treatment comprise the cornerstone for the outcome of this disease. In small populations like in the present study, it is difficult to recognize any predictors of mortality and even the severity indexes, which take into account a lot of data cannot predict mortality.

Pancreatic cancer from bench to bedside: molecular pathways and treatment options.

In the last forty years the pancreatic cancer treatment has made advances, however; still novel drugs are needed. It is known that the five year survival rate remains around 5%. The best treatment option still remains surgery, if patients are diagnosed early. In the last decade the biology of pancreatic cancer has been vastly explored and novel agents such as; tyrosine kinase agents, or vaccines have been added as a treatment perspective. The big challenge is now to translate this knowledge in better outcomes for patients. In this current review we will present information from pancreatic cancer diagnosis to molecular pathways and treatment options; current and future.

Heterotopic mesenteric ossification of ileostomy - "intraabdominal myositis ossificans".

UNLABELLED: Heterotopic mesenteric ossification is a rare clinical entity with less than 40 reported cases. Moreover, heterotopic mesenteric ossification around a stoma is described in fewer cases. CASE PRESENTATION: An 81-year-old male patient, who underwent a sigmoidectomy two years ago for a sigmoid colon cancer, was admitted in our Department in order to be investigated for a local recurrence of his disease. Because of unresectable pelvic lesions, the patient was taken in the operating room for a palliative double barrel ileostomy. The patient presented two weeks after the ileostomy clinical signs suggesting its obstruction. A revision of the ileostomy is performed. Macroscopically, the end part of the ileostomy was inflamed and resected. Histological findings revealed heterotopic ossification of the mesentery. CONCLUSIONS: The surgeon should be alert to the possibility of heterotopic ossification, especially within a previously operated wound and be prepared for the difficulties it may cause during reopening of an incision, during the operation itself, at closure of the wound and, if not removed, also in the postoperative setting.

Massive Localized Lymphedema in the Morbidly Obese Patient: A Clinical Entity Mimicking Lymphosarcoma.

Massive localized lymphedema (MLL) is a rare benign soft tissue lesion that develops in morbidly obese patients, most commonly on the medial thigh (though other locations have also been described). The cause of MLL remains unknown, but the common denominator in all reported cases is obesity. The diagnosis of MLL is usually made based on clinical history and presentation but it is believed to be underdiagnosed due to a lack of awareness of this distinct entity. When left untreated, MLL can degenerate into angiosarcoma. This report describes a case of MLL of the right lower abdominal wall in an obese 61-year-old female (BMI = 42 kg/m(2)).