Pancreaticoduodenectomy and Outcomes for Groove Pancreatitis.

BACKGROUND/AIMS: The operative management of groove pancreatitis (GP) is still a matter of controversy and pancreaticoduodenectomy (PD) can be a high-risk procedure for patients. The aim of this study was to report our 9-year experience of surgical resection for GP and to review relevant literature. METHODS: A retrospective review of patients undergoing pancreatectomy for GP from August 1, 2008, through May 31, 2017 was performed. Patients with clinical, radiologic, and final pathologic confirmation of GP were included. Literature on the current understanding of GP was reviewed. RESULTS: Eight patients from total 449 pancreatectomies met inclusion criteria. Four male and 4 female patients (mean age, 51.9 years; mean body mass index, 25.3) underwent pylorus-preserving pancreatoduodenectomy (3 by laparoscopy and 5 by open approach). Mean (range) operative time and blood loss was 343 (167-525) min and 218 (40-500) mL respectively. Pancreatic fistula and delayed gastric emptying were noted in one patient each. No major complications occurred, but minor complications occurred in 5 (62%) patients. Mean hospital stay was 6.1 (range 3-14) days. At median follow-up of 18.15 (interquartile range 7.25-33.8) months, all patients experienced a resolution of pancreatitis and improvement in symptoms. CONCLUSIONS: PD is a safe procedure for GP. Short-term surgical outcomes are acceptable and long-term outcomes are associated with improved symptom control.

Fluorescence in robotic surgery.

Currently, there are several clinical applications for intraoperative ICG, such as identification of vascular and biliary anatomy, assessment of organ and tissue perfusion, lymph node mapping, and real-time identification of lesions. In this paper we present a review of the available literature related to the use of ICG fluorescence in robotic surgery in order to provide a better understanding of the current applications, show the rapid growth of this technique, and demonstrate the potential future applications.

The Gliding Brow Lift.

Subcutaneous undermining for brow lifting is not a new technique, but the gliding brow lift is evolutionary in the sense that it can be done through 1 or 2 tiny incisions and the brow shape maintained with transcutaneous running sutures (the hemostatic net). Undermining over the frontalis muscle and galea is performed using blunt dissectors and the lifting is done with superior traction, holding the brow in the desired shape with the hemostatic net.

Hyperglycemia cooperates with Tet2 heterozygosity to induce leukemia driven by proinflammatory cytokine-induced lncRNA Morrbid.

Diabetes mellitus (DM) is a risk factor for cancer. The role of DM-induced hyperglycemic (HG) stress in blood cancer is poorly understood. Epidemiologic studies show that individuals with DM are more likely to have a higher rate of mutations in genes found in pre-leukemic hematopoietic stem and progenitor cells (pre-LHSPCs) including TET2. TET2-mutant pre-LHSPCs require additional hits to evolve into full-blown leukemia and/or an aggressive myeloproliferative neoplasm (MPN). Intrinsic mutations have been shown to cooperate with Tet2 to promote leukemic transformation. However, the extrinsic factors are poorly understood. Using a mouse model carrying Tet2 haploinsufficiency to mimic the human pre-LHSPC condition and HG stress, in the form of an Ins2Akita/+ mutation, which induces hyperglycemia and type 1 DM, we show that the compound mutant mice developed a lethal form of MPN and/or acute myeloid leukemia (AML). RNA-Seq revealed that this was due in part to upregulation of proinflammatory pathways, thereby generating a feed-forward loop, including expression of the antiapoptotic, long noncoding RNA (lncRNA) Morrbid. Loss of Morrbid in the compound mutants rescued the lethality and mitigated MPN/AML. We describe a mouse model for age-dependent MPN/AML and suggest that hyperglycemia acts as an environmental driver for myeloid neoplasms, which could be prevented by reducing expression levels of the inflammation-related lncRNA Morrbid.

Targeting Bim via a lncRNA Morrbid Regulates the Survival of Preleukemic and Leukemic Cells.

Inhibition of anti-apoptotic proteins BCL-2 and MCL-1 to release pro-apoptotic protein BIM and reactivate cell death could potentially be an efficient strategy for the treatment of leukemia. Here, we show that a lncRNA, MORRBID, a selective transcriptional repressor of BIM, is overexpressed in human acute myeloid leukemia (AML), which is associated with poor overall survival. In both human and animal models, MORRBID hyperactivation correlates with two recurrent AML drivers, TET2 and FLT3ITD. Mice with individual mutations of Tet2 or Flt3ITD develop features of chronic myelomonocytic leukemia (CMML) and myeloproliferative neoplasm (MPN), respectively, and combined presence results in AML. We observe increased levels of Morrbid in murine models of CMML, MPN, and AML. Functionally, loss of Morrbid in these models induces increased expression of Bim and cell death in immature and mature myeloid cells, which results in reduced infiltration of leukemic cells in tissues and prolongs the survival of AML mice.

Pneumoperitoneum caused by tubo-ovarian abscess in an elderly patient.

Perforation of the gastrointestinal tract may present with abdominal pain and imaging demonstrating pneumoperitoneum. These findings usually require exploratory laparotomy for diagnosis and treatment. Tubo-ovarian abscess (TOA) is a complication of pelvic inflammatory disease presenting as an encapsulated inflammatory mass, but it can occasionally involve other pelvic organs. TOA is most commonly seen in females of reproductive age. Here we report a case of a 63-year-old female presenting with abdominal pain, fever and vomiting. Chest x rays and computed tomography scan revealed pneumoperitoneum. Emergent exploratory laparotomy was performed, and the findings were consistent with TOA and intact bowel. The patient recovered well after surgery with antibiotic therapy. In conclusion, while pneumoperitoneum is mostly caused by perforation of the gastrointestinal tract, other possibilities such as gynecological complications should be considered.

Accuracy of MRI in Diagnosing Appendicitis during Pregnancy.

Appendectomy for presumed appendicitis is the most common surgical emergency during pregnancy. Delayed diagnosis and treatment of appendicitis carries risk for the fetus and mother. We sought to evaluate the accuracy of MRI in pregnant patients with suspected appendicitis. All pregnant patients with suspected appendicitis between January 2014 and April 2016 were included. MRI reports were categorized into positive, negative, and inconclusive groups. Diagnosis of appendicitis was based on pathology report. Fifty-two patients were included in the study. The MRI was positive in two, negative in 29, and inconclusive in 21 patients. Twelve patients had surgery, 11 of which had positive appendicitis on pathology. Both positive MRI patients had appendicitis. In the negative MRI group, 3 of 29 (10%) had appendicitis. In the inconclusive MRI group, 6 of 21 (29%) had appendicitis. A positive MRI result was very specific with a 100 per cent positive predictive value; however, the sensitivity was as low as 18 per cent (diagnosed only 2 of 11 cases). Although a positive MRI finding was reliable in making a decision to operate, a negative or inconclusive MRI was not. In patients with a high clinical suspicion of appendicitis, surgery should still be considered even without definitive positive MRI findings.