Multiple Pancreatic Metastasis of Clear Renal Cell Carcinoma Associated with Neuroendocrine Tumor.

Introduction: Metastatic tumors of the pancreas are uncommon, but renal cell carcinoma is one of the few known cancers that can metastasize to the pancreas. Few cases have been reported as being metachronous multicentric metastases to the pancreas, but none associated with a pancreatic neuroendocrine tumor and reported in literature, to our knowledge. Case presentation: We describe a case of 66-year-old woman who was diagnosed with multicentric pancreatic metastases from clear renal cell carcinoma associated with concomitant pancreatic neuroendocrine tumor, after 14 years from the initial diagnosis of kidney cancer. For this patient, the symptoms were unspecific for neoplastic disease, she had multiple pancreatic metastases which is an uncommon finding, but even rarer was the association of metastases with neuroendocrine tumor in the pancreas. Because of the good outcome and survival, surgical resection is recommended for solitary and multiple pancreatic metastases, as well as for pancreatic neuroendocrine tumors. Conclusion: Differential diagnosis for multiple pancreatic tumors is undisputedly important, even though it would not have changed anything in our patient's preoperatively course. Patients with renal cell carcinoma must follow long-term surveillance with regular examination and imaging investigation so that any possible metastases can be detected early and treated properly.

Postoperative Analgesia after Laparoscopic Cholecystectomy - Prospective, Randomized, Double Blind, Control Trial.

In this prospective, randomized, double blind control trial we aim to investigate which of the most used analgesic techniques after laparoscopic cholecystectomy is the most efficient. Methods: This study included 81 patients that were randomly distributed into 3 groups using a computer-generated random number which was enclosed in a sealed envelope: group A (control) received classic multimodal iv opioid analgesia, group B received Tap block in oblique subcostal approach (OSTAP) and group C received local anesthetic infiltration of the trocar insertion sites (LAI). The primary outcome of this trial was to evaluate the efficacy of each analgetic technique by measuring VAS pain scores. Secondary outcome included intraoperative opioid requirement and the opioid consumption in the first 24h postoperatively. Intraoperative parameters and outcome data were recorded by an anesthesiologist who was blinded to the study groups. Results: We analyzed a total of 75 patients. For the primary outcome variable, VAS pain scores at rest were significantly reduced in OSTAP group at each time point assessed in the first 24 hours after surgery compared with LAI group and IV opioid analgesia group (p 0.001). Intraoperative fentanyl consumption and 24h pethidine consumption were also significantly reduced in TAP block group compared with LAI group and IV opioid analgesia group (p 0.001). Conclusions: Our study showed that OSTAP block is a more efficient analgesia technique compared with IV opioid analgesia and with local anesthetic infiltration of trocar sites after laparoscopic cholecystectomy surgery. This trial was registered at www.clinicaltrials.gov (NCT02707250).

Spleen Preserving, Splenic Vessels Spearing, Pure Laparoscopic Total Duodenopancreatectomy for Intraductal Papillary Mucinous Pancreatic Neoplasia (IPMN): Case Report and Technique.

Total duodenopancreatectomy (TDP), performed exclusively by laparoscopic approach is considered one of the most complex abdominal surgical procedures. TDP with preservation of spleen vessels (operation Kimura) is a more technically-demanding procedure, but is beneficial in selected cases. While some high-volume centers have gained experience in minimally-invasive pancreatectomies, laparoscopic approach remains a recommendation for well selected patients with benign or low-grade malignant tumors and should be performed with caution, by experienced HPB surgeons. In this paper, we present a spleen preserving, splenic vessels spearing, pure laparoscopic TDP on a 40-year-old patient diagnosed with diffuse IPMN performed in our center, illustrating the operative steps.

The Role of Radio-Frequency and Stereotactic Ablation in the Treatment of Pancreatic Cancer.

Pancreatic adenocarcinoma is a very aggressive tumor with a low overall survival rate. The prognostic and the treatment of this disease are strongly interconnected and highly dependent on the resectability criteria of the tumor, surgical excision being the golden standard. For local advance disease or for unresectable tumors, with or without metastasis we can take into consideration as adjuvant therapy, together with chemotherapy, the radiofrequency ablation or stereotactic ablation radiotherapy of the solid tumor mass. This article is a narrative review that aims to describe these two interventional techniques: radiofrequency ablation and stereotactic ablation radiotherapy. We will discuss the techniques themselves, benefits that they bring and also, about the possible complications that can appear when using them in the management of pancreatic cancer.

Rare Causes of Gastrointestinal Bleeding: Focus on Pancreatic Pathology and Visceral Artery Aneurysms.

Beside the common situations of upper gastrointestinal bleeding (GIB) managed by endoscopy, there are clinical situations when the endoscopic approach is limited by the amount of blood, the hemodynamic instability, the intermittent nature of bleeding and a proper diagnosis and treatment requires radiological interventional methods and even surgery. The pancreatic pathology is rarely considered as a possible cause for patients that presents in emergencies with GIB. The rupture of visceral artery aneurysms (VAAs), without underlying pancreatic pathology, should also be regarded in the differential diagnosis of GIB. Even the natural history of VAAs is not well understood, there is a potential risk of bleeding in the gastrointestinal tract, peritoneal cavity and retroperitoneal space, that can result in death. In this paper, we aim to review the rare causes of GIB focusing on pancreatic pathology and VAAs, unrevealed by the underlying pathology and presenting in the emergency department with bleeding symptoms and signs.

Abdominal Sepsis - Current Definitions and Practice.

Abdominal sepsis remains the second most common source of sepsis, a life-threatening condition that became a global health priority in the medical field research. Open abdomen is part of the damage control surgery, a life-saving strategy in a well-selected group of surgical patients with severe abdominal sepsis and intra-abdominal hypertension. Definitions and recommendations in the management of abdominal sepsis and open abdomen have gradually evolved, as a reflection of the progress of both the comprehension of physiopathological mechanisms involved in sepsis and the technology of different temporary abdominal closure systems. The aim of this paper is to make an up-to-date literature narrative review of the definitions and current practice guidelines in abdominal sepsis, with illustration of clinical experience in the management of open abdomen wounds. In the past decades, progress has been made in the management of abdominal sepsis, with greatly ameliorated survival rates. Rapid diagnosis, extensive comprehension of the physiopathological mechanisms of sepsis, adapted fluid resuscitation, antimicrobial therapy and damage-control surgery, orchestrated by a multy-disciplinary team, play an equally important role in the prognosis of a patient.

Laparoscopic Central Pancreatectomy with Pancreato-Gastric Anastomosis for Pancreatic Cystadenoma.

We present the case of a 42-year-old woman diagnosed with a cystic pancreatic lesion, suggestive of a serous cystadenoma of 27/13 mm. The diagnosis was established by the examination of abdominal CT and eco-endoscopy. The patient was referred to the surgery department for treatment. The benign etiology suggested by imaging and the desire to preserve the spleen along with as much of the pancreatic parenchyma, indicated a laparoscopic central pancreatectomy with a anastomosis between the distal pancreatic stump and the stomach. The authors reviewed the national and international publications related to the indications of this minimally invasive surgery.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for the Treatment of Peritoneal Carcinomatosis: Our Initial Experience.

Introduction: Peritoneal carcinomatosis represents an advanced stage of tumor dissemination of abdominal cancers in general and colorectal cancer in particular. The only therapeutic methods currently available for the treatment of this pathology are systemic chemotherapy (palliative character) and cytoreductive surgery (CR) with intraperitoneal chemotherapy. After evaluation of evidence-based medical literature and current guide lines we can state that CR + HIPEC procedure is considered to be the treatment of choice in case of patients with peritoneal carcinomatosis of colorectal, ovarian and mucinous appendicular origin. Material and method: In the present study we prospectively analyzed the immediate postoperative results obtained in the first 50 patients that were treated by our team for peritoneal carcinomatosis of different origin. We described the protocol of selection, the patients characteristics that were included in our CR+HIPEC program and analyzed the complications and death rate. Results: From January 2015 till Dec 2018 we evaluated 98 patients with peritoneal carcinomatosis. From them, 51 received radical CR+HIPEC treatment, 33 were not suitable for surgery because of the exclusion criteria's and 15 had only exploratory laparotomies. In regard with the histopathological diagnosis, 30 patients had ovarian cancer and 19 had colorectal cancer or peritoneal pseudomixoma of appendicular origin. There was no 30 days postoperative mortality. The incidence of significant postoperative complications was 15%. Conclusions: Cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy is a complex technique accompanied by an acceptable rate of complications and postoperative deaths, the results being optimized by a standardized perioperative management and patient selection. The initial results obtained by our team emphasize the feasibility of this procedure, with immediate good results, as a result of a standardization protocol of patient selection and perioperative care.

Recent achievements in colorectal cancer diagnostic and therapy by the use of nanoparticles.

Colorectal cancer is a major public health issue, being the third most common cancer in men and the second in women. It is one of the leading causes of cancer deaths. Nanomedicine is an emerging field of interest, many of its aspects being linked to cancer research. Chemotherapy has a well-established role in colorectal cancer management, unfortunately being limited by inability to have a selective distribution, by multidrug resistance and adverse effects. Researches carried out in recent years about nanotechnologies aimed, among others, to resolve the issues mentioned above. Targeted and localized delivery of the chemotherapeutic drugs, using nanoparticles, with selective destruction of cancerous cells would minimize the toxicity on healthy tissues. Also, the use of nanomaterials as contrast agent could improve sensitivity and specificity of diagnosis. The purpose of this review is to highlight the recent achievements of cancer research by use of nanomaterials, in the idea of finding the ideal composite, capable to simultaneous diagnostic and treat cancer.

Intraoperative Ultrasound guided Palliative Radiofrequency Ablation of Unresectable Nonmetastatic Pancreatic Malignancies: A Pilot Observational Study.

BACKGROUND AND AIMS: Radiofrequency ablation of unresectable pancreatic tumors represents a palliative method in selected patients. The lack of standardization of the technique used as well as the non-homogeneous immediate and long-term results from the reports in the literature made us evaluate in a pilot study the application of a standardized technique through a surgical approach, with the evaluation of the immediate and long-term results. METHODS: Ten consecutive patients diagnosed with unresectable nonmetastatic pancreatic adenocarcinoma were referred for radio-frequency ablation by surgical approach. For that, a UniBlate (AngioDinamics®) internal cooled electrode was used, under intraoperative ultrasound guidance. We analysed the morbidity, mortality and survival associated with this procedure. The median follow-up period was 12 months. RESULTS: Intraoperative ultrasound was essential for guiding the procedure. No mortality and no major postoperative complications after intraoperative tumoral ablations were noted. The median survival after the procedure was 7.5 months. CONCLUSIONS: Radiofrequency intraoperative ablation of unresectable pancreatic tumors is a feasible procedure, with low morbidity and mortality if standardized, being noninferior to palliative chemotherapy alone in regards with survival. A larger study is necessary to demonstrate the potential benefits in survival, the role of multidisciplinary selection being also mandatory.

The Learning Curve for Pancreaticoduodenectomy: The Experience of a Single Surgeon.

BACKGROUND AND AIMS: Pancreaticoduodenectomy (PD) is a complex and high-skill demanding procedure often associated with significant morbidity and mortality. However, the results have improved over the past two decades. However, there is a paucity of research concerning the learning curve for PD. Our aim was to report the outcomes of 100 consecutive PDs representing a single surgeon's learning curve and to depict the factors that influenced the learning process. METHODS: We reviewed the first 121 PDs performed at our academic center (2013-2019) by a single surgeon; 110 were PDs (5 laparoscopic and 105 open) and 11 were total PDs (1 laparoscopic and 10 open). Subsequent statistics was performed on the first 100 PDs, with attention paid to the learning curve and survival rate at 5 years. The data were analyzed comparing the first 50 cases (Group 1) to the last 50 cases (Group 2). RESULTS: The most frequent histopathological tumor type was pancreatic ductal adenocarcinoma (50%). A total of 39% of patients had preoperative biliary drainage and 45% presented with positive biliary cultures. The preferred reconstruction technique included pancreaticogastrostomy (99%), in situ hepaticojejunostomy (70%), and precolic gastro-jejunal anastomosis (88%). Postoperative complications included biliary fistula (1%), pancreatic fistula (8%), pancreatic stump bleeding (4%), and delayed gastric emptying (13%). The mean operative time decreased after the first 50 cases (p < 0.001) and blood loss after 60 cases (p = 0.046). R1 resections lowered after 25 cases (p = 0.025). Vascular resections (17%) did not influence the rate of complications (p = 0.8). The survival rate at 5 years for pancreatic adenocarcinoma was 32.93%. CONCLUSIONS: Outcomes improve as surgeon experience increases, with proper training being the most important factor for minimizing the impact of the learning curve over the postoperative complications. Analyzing the learning curve from the perspective of a single surgeon is mandatory for accurate statistical results and interpretation.

Trends in Preoperative Airway Assessment.

Airway management is a vital part of anesthesia practices, intensive care units, and emergency departments, and a proper pre-operative assessment can guide clinicians' plans for securing an airway. Complex airway assessment has recently been at the forefront of anesthesia research, with a substantial increase in annual publications during the last 20 years. In this paper, we provide an extensive overview of the literature connected with pre-operative airway evaluation procedures, ranging from essential bedside physical examinations to advanced imaging techniques such as ultrasound (US), radiography, computed tomography (CT), and magnetic resonance imaging (MRI). We discuss transnasal endoscopy, virtual endoscopy, 3D reconstruction-based technologies, and artificial intelligence (AI) as emerging airway evaluation techniques. The management of distorted upper airways associated with head and neck pathology can be challenging due to the intricate anatomy. We present and discuss the role of recent technological advancements in recognizing difficult airways and assisting clinical decision making while highlighting current limitations and pinpointing future research directions.

The Influence of Intravenous Lidocaine Infusion on Postoperative Outcome and Neutrophil-to-Lymphocyte Ratio in Colorectal Cancer Patients. A Pilot Study.

BACKGROUND AND AIMS: In the last years increasing scientific evidence drew attention on the potential effects of anesthetic drugs on postoperative outcome in cancer patients. Local anesthetics, especially lidocaine, have been intensively studied in relation with postoperative outcome in colorectal cancer patients. Our study objectives were to investigate the effects of perioperative intravenous lidocaine infusion on neutrophil-to-lymphocyte ratio and short-term postoperative outcome. Additionally, we also looked at 1 year outcome after intended radical colorectal cancer surgery. METHODS: 150 patients scheduled for colorectal cancer surgery were randomized to receive sevoflurane anaesthesia with or without 48 hours lidocaine infusion. RESULTS: 73 patients were included in the group A (sevoflurane) and 77 in the group B (sevoflurane with lidocaine). Lidocaine infusion did not modify neutrophil-to-lymphocyte ratio at 24 hours after surgery (p=0.58). Patients receiving intravenous lidocaine had significantly lower morphine consumption (p=0.04), faster mobilization time (p=0.001) and fewer days spent in the hospital (p=0.04). Moreover, at 1 year follow- up, patients in group B had a significant decreased rate of recurrences (p=0.03). There was no significant difference in 1 year survival (p=0.22). CONCLUSIONS: In our study, intravenous lidocaine infusion hastened the postoperative recovery of patients in terms of mobilization, hospital discharge and opioid consumption and reduced 1 year recurrence rate. Further studies on larger groups of patients are needed.

Sedation for Endoscopic Retrograde Cholangiopancreatography in Elderly Patients - the Effect of Intravenous Lidocaine Infusion. A Randomised, Double-Blind, Placebo Controlled Trial.

BACKGROUND: Sedation of elderly patients with associated comorbidities, subjected to ERCP procedure, can produce serious complications including respiratory instability and hemodynamics caused by the administration of anesthetic substances. In this study we aimed to evaluate whether the administration of lidocaine in continuous infusion during ERCP procedure reduces the consumption of propofol and the rate of complications in these patients. METHODS: 83 patients over 65-year old, ASA II-IV score, undergoing an ERCP procedure were randomized in two groups: lidocaine group (group L) who received 1.5 mg/kg lidocaine 1% and propofol 1mg/kg at induction and then 2 mg/kg lidocaine 1% in continuous infusion during the procedure and control group (group C) who received saline in the same amount as group L and propofol 1mg/kg. The consumption of propofol, intraprocedural complications, the time of awakening and recovery, the quality of postprocedural analgesia, the satisfaction of the endoscopist were registered. RESULTS: Propofol consumption was statistically significantly lower in group L compared to group C [135.37 (±43.23) vs. 214.88 (±51.83), p=0.001]. The same result was obtained related to the awakening time [2.85 (±1.50) vs. 5.38 (±1.36), p=0.001] and recovery time [23.90 (±12.66) vs. 26.17 (±12.41), p<0.001], the episodes of intraprocedural desaturation (p=0.001), the involuntary intraprocedural movements (p=0.001), the endoscopist's satisfaction (p=0.006). No differences were found in terms of post-procedure pain scores (p=0.54). CONCLUSIONS: Lidocaine can be administered to reduce the need for propofol, faster awakening and lower intraprocedural complications in elderly patients undergoing the ERCP procedure.

Laparoscopic Pancreatoduodenectomy in Elderly Patients: A Systematic Review and Meta-Analysis.

Background and Aims: Recent single-center retrospective studies have focused on laparoscopic pancreatoduodenectomy (LPD) in elderly patients, and compared the outcomes between the laparoscopic and open approaches. Our study aimed to determine the outcomes of LPD in the elderly patients, by performing a systematic review and a meta-analysis of relevant studies. Methods: A comprehensive literature review was conducted utilizing the Embase, Medline, PubMed, Scopus and Cochrane databases to identify all studies that compared laparoscopic vs. open approach for pancreatoduodenectomy (PD). Results: Five retrospective studies were included in the final analysis. Overall, 90-day mortality rates were significantly decreased after LPD in elderly patients compared with open approaches (RR = 0.56; 95%CI: 0.32−0.96; p = 0.037, I2 = 0%). The laparoscopic approach had similar mortality rate at 30-day, readmission rate in hospital, Clavien−Dindo complications, pancreatic fistula grade B/C, complete resection rate, reoperation for complications and blood loss as the open approach. Additionally, comparing with younger patients (<70 years old), no significant differences were seen in elderly cohort patients regarding mortality rate at 90 days, readmission rate to hospital, and complication rate. Conclusions: Based on our meta-analysis, we identify that LPD in elderly is a safe procedure, with significantly lower 90-day mortality rates when compared with the open approach. Our results should be considered with caution, considering the retrospective analyses of the included studies; larger prospective studies are required.

Role of radio-ablative technique for optimizing the survival of patients with locally advanced pancreatic adenocarcinoma (Review).

Pancreatic ductal adenocarcinoma (PDAC) is one of the most common and frequently diagnosed malignant tumor of the pancreas with few treatment options and poor life expectancy. Despite the advances in the surgical field, 40% of the patients are diagnosed with locally advanced disease which is not suitable for surgery. Radio-frequency ablation (RFA) has been described as a new 'weapon' in the multimodal treatment of PDAC, representing a cytoreductive procedure which must be completed with radiotherapy or chemo-radiotherapy. A systematic research was carried out utilizing the PubMed database in regards to this subject, to evaluate the role of RFA in PDAC management. Abstracts, letters-to-the-editor and non-English language manuscripts were excluded. The literature showed that RFA can be used in open and laparoscopic surgery but it is also feasible for endoscopic ultrasound (EUS-guided RFA) or percutaneous approach. Even though we found optimistic and encouraging reports on overall survival (OS), randomized studies are still required to corroborate these findings. Our review research underline that surgical resection remains the only radical treatment option, RFA being a safe and feasible technique reserved for unresectable, non-metastatic pancreatic tumors. Its combination with oncological treatment can improve the OS of these patients.

Association of Moral Distress with Anxiety, Depression, and an Intention to Leave among Nurses Working in Intensive Care Units during the COVID-19 Pandemic.

BACKGROUND: Wide geographical variations in depression and anxiety rates related to the ethical climate have been reported during the COVID-19 pandemic in intensive care units (ICUs). The objective was to investigate whether moral distress is associated and has predictive values for depression, anxiety, and intention to resign. METHODS: 79 consenting ICU nurses completed MMD-HP and PHQ-4 scales in this cross-sectional study between October 2020-February 2021, after ethical approval. The association between MMD-HP and PHQ-4, and the predictive value of MMD-HP for anxiety, depression, and an intention to leave were analyzed (linear regression and receiver operating characteristics curve analysis). RESULTS: From MMD-HP items, system related factors had highest scores (Kruskal-Wallis test, p < 0.0001). MMD-HP and PHQ-4 were weakly correlated (r = 0.41 [0.21-0.58]). MMD-HP and its system-related factors discriminate between nurses with and without depression or anxiety, while system-related factors differentiate those intending to resign (p < 0.05). The MMD-HP score had 50 [37.54-62.46] sensitivity with 80.95 [60-92.33] specificity to predict the intention to leave, and 76.12 [64.67-84.73] sensitivity with 58.33 [31.95-80.67] specificity to detect anxiety or depression symptoms. CONCLUSIONS: During the COVID-19 pandemic, system-associated factors seem to be the most important root factors inducing moral distress. Moral distress is associated with negative psychological outcomes.

Nanomedicine and contrast enhanced imaging. Applications in cancer diagnosis and therapy.

OBJECTIVE: Nanotechnology and its applications in medicine made us live a new era of healthcare, particularly in oncology. The objective of this paper is to review the contribution of nanotechnology in clinical use of contrast agents for gastrointestinal cancer diagnosis and follow-up and to offer an overview of the impact of nanotechnology in the management of cancer. MATERIALS AND METHODS: In this regard, we reviewed the main areas of expertise where nanotechnology has contributed to the improvement of diagnostic methods (CE-US, CE-CT, MRI), along with the therapeutic applications that nanoparticles can have. Last but not least, the article highlights the potential that theragnostic molecules can have in the diagnosis and treatment of neoplasia, including those in an advanced stage. RESULTS AND CONCLUSIONS: Nanomedicine has the ability to improve the specificity and sensitivity of cancer diagnosis, together with the enhancing of the systemic cytostatic effect by developing nano bioconjugates that have a wider effect, higher tumor selectivity and thus, lower systemic toxicity. KEY WORDS: Ablative treatment, Cancer, Contrast enhanced imaging, Drug delivery, Nanomedicine.

Desmoid tumor of the mesentery. Case report of a rare non-metastatic neoplasm.

Desmoid tumors (DT) are rare non-metastatic neoplasms that occur through myofibroblast proliferation in musculoaponeurotic or fascial structures of the body, being commonly diagnosed in young women during pregnancy or in the post-partum period. We present the case of a 38-year-old woman, who recently gave birth, manifesting non-specific abdominal symptoms. Computed tomography indicated the presence of a solitary tumor arising from the intestinal wall or from the mesentery. Surgery confirmed the diagnosis, revealing a tumor that was localized at the level of the jejunal mesentery, having about 7 cm in diameter, in tight contact with the duodenum and the mesenteric vessels. "En bloc" resection of the tumor was performed, together with the involved enteral loops followed by end-to-end anastomosis of the jejunum. Histopathological examination of the surgical specimen sustained the diagnosis of desmoid tumor.