Acute pancreatitis after pancreatoduodenectomy: clinical outcomes and predictive factors analysis according to the International Study Group of Pancreatic Surgery definition.

BACKGROUND: Post-pancreatectomy acute pancreatitis (PPAP) is an increasingly described complication after pancreatic resection. No uniform definition criteria were present in the literature until the recent proposal of the International Study Group of Pancreatic Surgery (ISGPS). Aim of this study is to evaluate the clinical significance of the novel ISGPS definition of PPAP. METHODS: Patients who underwent pancreatoduodenectomy (PD) between 2006 and 2022 were enrolled. PPAP was defined and graded according to the ISGPS criteria. RESULTS: Among 520 PDs, 120 (23%)patients developed post-operative hyperamylasemia (POH), while PPAP occurred in 63(12.1%) cases. PPAP occurrence related to a higher rate of more severe complications (48-76.1%vs118-25.8%; p < 0.0001), delayed gastric emptying (DGE) (27-42.9%vd114-24.9%; p = 0.003) and post-operative pancreatic fistula (POPF) (57-90.5%vs186-40.8%; p < 0.0001). When stratified for PPAP severity, grade B and C patients more frequently developed major complications (p < 0.0001), POPF (p < 0.0001), DGE (p = 0.02) and post-operative hemorrhage (p < 0.0001) as compared to POH. At the multivariable analysis, soft pancreatic texture (p = 0.01)and a Wirsung diameter ≤3 mm (p = 0.01) were recognized as prognostic factors for PPAP onset, while a pancreatic duct ≤3 mm was the only feature significantly influencing a more severe course of PPAP (p = 0.01). CONCLUSION: The ISGPS classification is confirmed as a valuable method for a uniform definition and clinical course evaluation. Further studies in a prospective manner are still needed for a further confirmation.

Laparoscopic vs. open resection of gastrointestinal stromal tumors (GISTs) from gastric origin: different approaches for different diseases.

BACKGROUND: Although minimally-invasive techniques are currently recognized as effective and validated treatment for small gastric gastrointestinal stromal tumors (GISTs), the role of laparoscopy is not yet established. The aim of this study was to evaluate the outcomes of laparoscopic treatment of gastric GISTs compared to the results obtained in a group of patients treated with conventional surgery. METHODS: A retrospective analysis was performed, using a prospectively maintained comprehensive database of 100 patients treated for gastric GIST in the period from 2000 to 2015. Thirty-six patients were treated laparoscopically, and 64 patients underwent conventional surgery. The analyzed medical data included clinical and pathological features of removed tumors, perioperative parameters as well as short and long-term results of surgical treatment. RESULTS: Histopathological examination confirmed radical resections for all patients. No deaths were reported in the 90-day postoperative period. Patients in laparoscopic group had significantly shorter length of hospital stay (5.5 vs. 7 days, P<0.0001), fewer extended and combined surgical procedures (11.2% vs. 34.4% and 2.8% vs. 39%; P=0.02 and P<0.001, respectively), and a smaller tumor size compared to laparotomic group (3 vs. 6 cm, P<0.0001). The median postoperative follow-up for the entire study population was 42 months. During this period, 11 patients died and 4 of them developed a tumor recurrence. None of them was in the laparoscopic group. CONCLUSIONS: Laparoscopy in the treatment of gastric GISTs has unquestionable advantages, but its choice is strictly related to tumor features.

Incidence and Impact of Variant Celiacomesenteric Vascularization and Vascular Stenosis on Pancreatic Surgery Outcomes: Personal Experience.

Ischemic complications after pancreatic surgery can raise postoperative mortality from 4 to 83 per cent. Variants in vascular anatomy play a major role in determining such complications, but they have been only occasionally reported in the literature. We retrospectively analyzed 100 records of patients consecutively treated between January 2011 and December 2013 for resectable malignant diseases who underwent pancreaticoduodenectomy (PD) or total pancreatectomy to state the statistical impact of anatomical vascular variations in surgical outcomes (mean surgical timing, mean blood loss during surgery, and postoperative major complications onset) and to state whether preoperatively undetected vascular anomalies (VA) can raise the risk of postoperative ischemic complications. PD was performed in 89 patients, requiring multiorgan resections in three cases and total pancreatectomy was performed in 11 cases, which was associated to splenectomy in four patients. Incidence of VA was 25/100 (25%), whereas in 18/25 cases (72%) they were detected by preoperative radiologic setting. Their presence in patients undergoing PD significantly raised mean surgical timing (P = 0.003) and increased mean blood loss (P < 0.0001). Preoperatively undetected VA resulted in a major risk of postoperative acute liver ischemia (P = 0.008). Celiacomesenteric aberrant anatomy was proven to be related to an increased risk of intraoperative complications. If undetected preoperatively, they can be associated with anastomotic complications and liver failure. Maximal efforts must be done to detect and to preserve vascular anatomy of celiacomesenteric district.

Improved outcomes for rectal cancer in the era of preoperative chemoradiation and tailored mesorectal excision: a series of 338 consecutive cases.

Neoadjuvant chemoradiation (CRT), tailored mesorectal excision, and intraoperative radiotherapy (IORT) have become the leading measures for rectal cancer treatment. The objective of this study was to evaluate early and long-term results of a multimodal treatment model for rectal cancer followed by curative surgery. Prospectively collected hospital records of 338 patients surgically treated for rectal cancer between January 1998 and December 2008 were retrospectively reviewed. Patients with high rectum level cancers and those with middle and low rectum cancers with clinical stage T1 to T2 underwent surgery, whereas those with T3 to T4 and N+ disease at the middle and low rectum received neoadjuvant CRT in 96.2 per cent of cases. Short-course neoadjuvant radiotherapy was not considered for neoadjuvant treatment. Postoperative major complications and mortality rates were 12.7 and 2.3 per cent, respectively. Overall 5-year disease-specific and disease-free survival were 80 and 73.1 per cent, respectively, whereas local recurrence rate was 6.1 per cent. At multivariate analysis, nodal status and circumferential margin status were independently associated with poor survival; local recurrence rates were independently affected by nodal and marginal status and tumor stage. The extent of mesorectal excision should be tailored depending on tumor location and the use of neoadjuvant chemotherapy, combined with IORT in advanced middle and low rectal cancer, leading to remarkable tumor downstaging with excellent prognosis in responding patients.

Locally recurrent rectal cancer: prognostic factors and long-term outcomes of multimodal therapy.

BACKGROUND: Pelvic recurrent rectal cancer is still a challenging clinical problem, and patients generally have a dismal prognosis and a poor quality of life. Surgical resection represents the only potentially curative treatment; neoadjuvant treatments are presently being taken into consideration to increase the resectability rate and to improve long-term survival. METHODS: Among 157 patients observed with recurrent rectal cancer, a series of 58 patients who underwent surgical exploration with curative intent for isolated local recurrence at a single referral institution was retrospectively analyzed. Demographic, pathologic, and therapeutic factors were evaluated to assess long-term prognosis and local control. RESULTS: Forty-four (75.9%) of 58 patients underwent surgical resection. The overall 5-year survival rate for patients who underwent surgical resection was 54.2%, whereas none of the unresected patients lived 5 years (P < 0.001). Patients with R0 resection showed a statistically higher 5-year overall survival and local control rate (72.4 and 70.2%, respectively) compared to R1 patients (37.5 and 31.2%, respectively). At multivariate survival analysis, feasibility of a surgical resection and radicality of excision proved to be independent positive prognostic factors. In contrast, increased presalvage carcinoembryonic antigen serum levels, back pain at diagnosis, and an increasing degree of fixation of recurrent disease to the pelvic wall at preoperative computed tomographic scan were statistically significantly linked to decreased overall survival. Preoperative chemoradiation and radicality of the surgical excision independently influenced the local control among surgically resected patients. CONCLUSIONS: Surgical resection still remains the most important therapeutic and prognostic factor for patients with locally recurrent rectal cancer. Multimodal treatments can be safely performed by an experienced team in referral tertiary centers and can result in a safer outcome, better local disease control, and even long-term survival in carefully selected patients.

Giant retroperitoneal sarcomas: a single institution experience.

BACKGROUND: Retroperitoneal sarcomas (RS) are a rare group of malignant soft-tissue tumors; due to the flexibility of the retroperitoneum, they generally grow to a large size before becoming symptomatic, often involving surrounding structures. Therefore, the surgeon is frequently compelled to perform large excisions. The aim of this study is to assess clinical and pathological factors affecting prognosis in patients with RS who underwent surgical treatment, comparing giant forms (size > or = 25 cm) with smaller ones (size < 25 cm). METHODS: The hospital records of 73 consecutive patients who underwent surgical exploration for primary RS at our unit between 1984 and 2003 were reviewed. Statistical analysis of factors influencing overall and disease-free survival was performed including both the whole group of patients and only those who underwent complete surgical resection. RESULTS: Giant RS showed a lower resectability rate than smaller forms (54.2% vs. 84.2%, P = 0.005). In the group with complete surgical excision (51 out of 73), patients with giant RS had a higher rate of adjacent organ resection compared with the smaller ones (84.2% vs. 53.1%, P = 0.023). Tumor size did not influence prognosis: after complete resection, 5-year overall survival was 60.9% and 56.3% for giant RS and smaller forms respectively, while 5-year disease-free survival was 54.3% and 48.3% for the two groups respectively. Advanced stage, incomplete gross surgical resection, higher tumor grade, non-liposarcoma histology and microscopic infiltration of margins were found to be significantly negative prognostic factors. CONCLUSIONS: The present study confirms the importance of aggressive surgical management for RS, in order to offer these patients the best chance of long-term survival.