Updated European guidelines for clinical management of familial adenomatous polyposis (FAP), MUTYH-associated polyposis (MAP), gastric adenocarcinoma, proximal polyposis of the stomach (GAPPS) and other rare adenomatous polyposis syndromes: a joint EHTG-ESCP revision.

BACKGROUND: Hereditary adenomatous polyposis syndromes, including familial adenomatous polyposis and other rare adenomatous polyposis syndromes, increase the lifetime risk of colorectal and other cancers. METHODS: A team of 38 experts convened to update the 2008 European recommendations for the clinical management of patients with adenomatous polyposis syndromes. Additionally, other rare monogenic adenomatous polyposis syndromes were reviewed and added. Eighty-nine clinically relevant questions were answered after a systematic review of the existing literature with grading of the evidence according to Grading of Recommendations, Assessment, Development, and Evaluation methodology. Two levels of consensus were identified: consensus threshold (≥67% of voting guideline committee members voting either 'Strongly agree' or 'Agree' during the Delphi rounds) and high threshold (consensus ≥ 80%). RESULTS: One hundred and forty statements reached a high level of consensus concerning the management of hereditary adenomatous polyposis syndromes. CONCLUSION: These updated guidelines provide current, comprehensive, and evidence-based practical recommendations for the management of surveillance and treatment of familial adenomatous polyposis patients, encompassing additionally MUTYH-associated polyposis, gastric adenocarcinoma and proximal polyposis of the stomach and other recently identified polyposis syndromes based on pathogenic variants in other genes than APC or MUTYH. Due to the rarity of these diseases, patients should be managed at specialized centres.

Quality of Life in Patients Undergoing Emergency Surgery for Complex Colorectal Cancer: Protocol and Piloting of the Surgical Utilization and Recovery Patterns for Advanced Stage Colorectal Cancer Study.

Introduction: Globally, cancer is the leading cause of mortality, with colorectal neoplasia ranking third in terms of incidence and mortality worldwide. Patients face disease- and treatment-specific impacts, which can significantly influence their quality of life (QoL). Aim: This study aimed to propose a protocol to measure in-hospital and long-term QoL in patients with complicated colorectal cancer (CRC). Material and Methods: multicenter prospective observational cohort study. Results: QoL is a multidimensional concept that includes criteria for physical, mental, emotional, and social functionality as perceived by the patient. Periodically evaluating QoL offers measurable and objective tools to intervene at the appropriate time to decrease the Years of Life Lost and Years Lived with Disabilities for CRC patients. However, a structured and functional system requires dedicated and common institutional effort. A pilot study using this protocol included 69 patients, 65.12+-10.92 years, M:F ratio = 56.5:43.5%. Surgical procedure was right hemicolectomy, left colectomy, transverse colectomy, sigmoidectomy, total colectomy, rectal resection, and colorectal resection with stoma (ileostomy or colostomy) in 21.7%, 11.6%, 2.9%, 11.6%, 1.4%, 23.2%, and 27.5% of the cases, respectively. The mean Global Health Status Score, Symptom Score, and Functional Score was 82.36+-18.60, 11.89+-10.27, and 86.27, 74.50-94.11, respectively. Conclusions: CRC diagnosis has major effects on patients physical and psychological status, and concentrated efforts should be made by the involved medical team and healthcare systems to improve QoL throughout the treatment pathway.

Design and validation of a patient-reported outcome measure scale in acute pancreatitis: the PAN-PROMISE study.

OBJECTIVE: This study aimed to develop and validate a patient-reported outcome measure (PROM) in acute pancreatitis (AP) as an endpoint centred on the patient. DESIGN: A PROM instrument (PAtieNt-rePoRted OutcoMe scale in acute pancreatItis, an international proSpEctive cohort study, PAN-PROMISE scale) was designed based on the opinion of patients, professionals and an expert panel. The scale was validated in an international multicentre prospective cohort study, describing the severity of AP and quality of life at 15 days after discharge as the main variables for validation. The COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) methodology was applied. Both the design and validation stages considered the content and face validity of this new instrument; the metric properties of the different items, reliability (reproducibility and internal consistence), the construct, structural and criterion validity, responsiveness and interpretability of this scale. RESULTS: PAN-PROMISE consists of a seven-item scale based on the symptoms that cause the most discomfort and concern to patients with AP. The validation cohort involved 15 countries, 524 patients. The intensity of symptoms changed from higher values during the first 24 hours to lower values at discharge and 15 days thereafter. Items converged into a unidimensional ordinal scale with good fit indices. Internal consistency and split-half reliability at discharge were adequate. Reproducibility was confirmed using test-retest reliability and comparing the PAN-PROMISE score at discharge and 15 days after discharge. Evidence is also provided for the convergent-discriminant and empirical validity of the scale. CONCLUSION: The PAN-PROMISE scale is a useful tool to be used as an endpoint in clinical trials, and to quantify patient well-being during the hospital admission and follow-up. TRIAL REGISTRATION NUMBER: NCT03650062.

European Society of Coloproctology guidance on the use of mesh in the pelvis in colorectal surgery.

This is a comprehensive and rigorous review of currently available data on the use of mesh in the pelvis in colorectal surgery. This guideline outlines the limitations of available data and the challenges of interpretation, followed by best possible recommendations.

Patient-Reported Outcome Measures in Colorectal Surgery: Construction of Core Measures Using Open-Source Research Method.

Purpose. The primary aim of the study was to review the existing literature about patient-reported outcome measures (PROMs) in colorectal cancer and IBD. The secondary aim was to present a road map to develop a core outcome set via opinion gathering using social media. Method. This study is the first step of a three-step project aimed at constructing simple, applicable PROMs in colorectal surgery. This article was written in a collaborative manner with authors invited both through Twitter via the #OpenSourceResearch hashtag. The 5 most used PROMs were presented and discussed as slides/images on Twitter. Inputs from a wide spectrum of participants including researchers, surgeons, physicians, nurses, patients, and patients' organizations were collected and analyzed. The final draft was emailed to all contributors and 6 patients' representatives for proofreading and approval. Results. Five PROM sets were identified and discussed: EORTC QLQ-CR29, IBDQ short health questionnaire, EORTC QLQ-C30, ED-Q5-5L, and Short Form-36. There were 315 tweets posted by 50 tweeters with 1458 retweets. Awareness about PROMs was generally limited. The general psycho-physical well-being score (GPP) was suggested and discussed, and then a survey was conducted in which more than 2/3 of voters agreed that GPP covers the most important aspects in PROMs. Conclusion. Despite the limitations of this exploratory study, it offered a new method to conduct clinical research with opportunity to engage patients. The general psycho-physical well-being score suggested as simple, applicable PROMs to be eventually combined procedure-specific, disease-specific, or symptom-specific PROMs if needed.

Preoperative factors associated with prolonged postoperative in-hospital length of stay in patients with Crohn's disease undergoing intestinal resection or strictureplasty.

PURPOSE: To investigate factors that influence postoperative in-hospital length of stay (LOS) in patients with Crohn's disease (CD) undergoing bowel surgery. Furthermore, the study aimed to evaluate LOS as a surrogate for postoperative outcome. METHODS: This is a multicentre retrospective cohort study. Inclusion criteria were adult patients with CD who underwent bowel surgery with either anastomosis or stricturoplasty. All timings of surgeries were included regardless of the method of access to the abdominal cavities. Patients with stoma were excluded. Demographic data, preoperative medications, previous operations for CD, preoperative sepsis, and operation were recorded. Primary outcome was LOS while secondary outcome variable was postoperative complications. RESULTS: A total of 449 patients who underwent abdominal surgery for CD were included. Of the 449 patients, 265 were female (59%). Median age was 37 years (IQR = 20), median LOS was 7 days (IQR = 6). Patients with longer LOS had higher rates of re-laparotomy/re-laparoscopy (45/228 (19.7%) versus 9/219 (4.1%) p = 0.01). In multivariate analysis, age (OR = 1.024 [CI 95% 1.007-1.041], p = 0.005), preoperative intra-abdominal abscess (OR = 0.39 [CI 95% 0.185-0.821], p = 0.013), and previous laparotomy/laparoscopy (OR = 0.57 [CI 95% 0.334-0.918], p = 0.021) were associated with prolonged LOS. LOS correlated with postoperative complications after adjustment for age, gender, previous laparotomy/laparoscopy, and preoperative intra-abdominal abscesses (OR = 1.28 [CI 95% 1.199-1.366], p < 0.0001). CONCLUSION: Age, preoperative intra-abdominal abscess, and previous laparotomy/laparoscopy significantly prolonged LOS. LOS correlated with postoperative complications and can therefore be used in epidemiological or register-based studies as a surrogate for postoperative outcome.

Retrocaval ureter: a meta-analysis of prevalence.

INTRODUCTION: Retrocaval ureter is a congenital abnormality of the right ureter, which has been shown, in rare cases to cause clinical symptoms, mainly due to the development of ureterohydronephrosis. PURPOSE: The purpose of this article is to identify the prevalence of the retrocaval ureter, and to emphasize its clinical and surgical importance. DESIGN: A meta-analysis of prevalence, on cases obtained from PubMed, Web of Science, and Scopus databases. RESULTS: A total number of 13 studies contained data that allowed us to estimate the prevalence of the retrocaval ureter, which was identified overall in 9 cases, out of 18,493 subjects. The overall prevalence of retrocaval ureter was 0.13%, with a 95% confidence interval between 0.06 and 0.27%. There was no publication bias, all studies being under the funnel. CONCLUSIONS: The overall prevalence of retrocaval ureter is 0.13%. Even if this is obviously a rare condition, its presence must be suspected by practitioners, especially in the presence of urological symptoms without a clear cause.

Application of the AAST EGS Grade for Adhesive Small Bowel Obstruction to a Multi-national Patient Population.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) anatomic severity grading system for adhesive small bowel obstruction (ASBO) has demonstrated to be a valid tool in North American patient populations. Using a multi-national patient cohort, we retrospectively assessed the validity the AAST ASBO grading system and estimated disease severity in a global population in order to correlate with several key clinical outcomes. METHODS: Multicenter retrospective review during 2012-2016 from four centers, Minnesota USA, Bologna Italy, Pietermaritzburg South Africa, and Bucharest Romania, was performed. Adult patients (age ≥ 18) with ASBO were identified. Baseline demographics, physiologic parameters, laboratory results, operative and imaging details, outcomes were collected. AAST ASBO grades were assigned by independent reviewers. Univariate and multivariable analyses with odds ratio (OR) and 95% confidence intervals (CIs) were performed. RESULTS: There were 789 patients with a median [IQR] age of 58 [40-75] years; 47% were female. The AAST ASBO grades were I (n = 180, 23%), II (n = 443, 56%), III (n = 87, 11%), and IV (n = 79, 10%). Successful non-operative management was 58%. Conversion rate from laparoscopy to laparotomy was 33%. Overall mortality and complication and temporary abdominal closure rates were 2, 46, and 4.7%, respectively. On regression, independent predictors for mortality included grade III (OR 4.4 95%CI 1.1-7.3), grade IV (OR 7.4 95%CI 1.7-9.4), pneumonia (OR 5.6 95%CI 1.4-11.3), and failing non-operative management (OR 2.4 95%CI 1.3-6.7). CONCLUSION: The AAST EGS grade can be assigned with ease at any surgical facility using operative or imaging findings. The AAST ASBO severity grading system has predictive validity for important clinical outcomes and allows for standardization across institutions, providers, and future research. Disease severity and outcomes varied between countries. LEVEL OF EVIDENCE III: Study type Retrospective multi-institutional cohort study.

Testing decision-making competency of schizophrenia participants in clinical trials. A meta-analysis and meta-regression.

BACKGROUND: The process of assessing the decision-making capacity of potential subjects before their inclusion in clinical trials is a legal requirement and a moral obligation, as it is essential for respecting their autonomy. This issue is especially important in psychiatry patients (such as those diagnosed with schizophrenia). The primary purpose of this article was to evaluate the degree of impairment in each dimension of decision-making capacity in schizophrenia patients compared to non-mentally-ill controls, as quantified by the (MacCAT-CR) instrument. Secondary objectives were (1) to see whether enhanced consent forms are associated with a significant increase in decision-making capacity in schizophrenia patients, and (2) if decision-making capacity in schizophrenia subjects is dependent on the age, gender, or the inpatient status of the subjects. METHODS: We systematically reviewed the results obtained from three databases: ISI Web of Science, Pubmed, Scopus. Each database was scrutinised using the following keywords: "MacCAT-CR + schizophrenia", "decision-making capacity + schizophrenia", and "informed consent + schizophrenia." RESULTS: We included 13 studies in the analysis. The effect size between the schizophrenia and the control group was significant, with a difference in means of -4.43 (-5.76; -3.1, p < 0.001) for understanding, -1.17 (-1.49, -0.84, p < 0.001) for appreciation, -1.29 (-1.79, -0.79, p < 0.001) for reasoning, and -0.05 (-0.9, -0.01, p = 0.022) for expressing a choice. CONCLUSIONS: Even if schizophrenia patients have a significantly decreased decision-making capacity compared to non-mentally-ill controls, they should be considered as competent unless very severe changes are identifiable during clinical examination. Enhanced informed consent forms decrease the differences between schizophrenia patients and non-mentally-ill controls (except for the reasoning dimension) and should be used whenever the investigators want to include more ill patients in their clinical trials. Increased age, men gender and an increased percentage of inpatients might increase the differential of decision-making incompetence compared to non-mentally-ill subjects in various dimensions of the decision-making competence as analysed by the MacCAT-CR scale, but the small number of subjects did not allow us (except for one instance) to reach statistical significance.

Nonelective Left-Sided Colon Cancer Resections are Associated with Worse Postoperative and Oncological Outcomes: A Propensity-Matched Study.

Background: Emergency general surgery patients are at significant risk of postoperative complications and mortality compared with their elective counterparts. Although challenged by some studies, increasing evidence shows that emergency colectomy for cancer is associated with worse early postoperative and long-term outcomes. Methods: We have included all patients with colon cancer admitted to the Emergency Hospital of Bucharest between January 2011 and January 2016. SELECTION CRITERIA: (1) colon tumor; (2) left-sided localization of the tumor; (3) pathology exam revealing adenocarcinoma. EXCLUSION CRITERIA: (1) rectal cancers; (2) benign pathology (e.g. diverticulitis). Results: We included 615 patients with left-sided colon cancer. 275 (44.7%) patients presented complicated disease. The complication was represented by obstruction in 205 (33.3%) patients (OG), hemorrhage in 55 (8.9%) patients (HG), and perforation in 15 (2.4%) patients (PG). The anastomotic leakage rate was similar between obstructive and elective cases (6.2% versus 6.5%, P 0.05), but was significantly higher for hemorrhagic patients (16%) (P=0.046). The 30-day complication rate and mortality were significantly higher in emergency patients (P 0.05). Conclusions: We found significant worse short- and long-term outcomes for patients with nonelective left-sided colon cancer resections. Correlating the ominous prognosis with the high incidence of the complicated disease, we may emphasize the impact on de complicated colon cancer on the general population.

EUS-Guided Transgastric Drainage of Intraabdominal Fluid Collections.

Intraabdominal fluid collections can be a significant cause of morbi-mortality among patients with acute pancreatitis and those who underwent surgery, especially oncological ones. Nowadays, the treatment tends to be minimally invasive, so that the patient's recovery would be shorter and the quality of life higher. EUS (endoscopic ultrasound) has emerged in the last decade to fulfill that demand, alongside percutaneous and surgical drainage in the management of perigastric collections. Objectives: The main objective of this paper is to evaluate the efficacy of EUS guided drainage in terms of techincal and clinical success. Secondary objectives refer to the assessment of complete resolution of intraabdominal collection, presence of infection after drainage, overall survival. Methods: We conducted a prospective study by enrolling 31 patients who were diagnosed using EUS with perigastric intraabdominal fluid collections, from an overall of 788 EUS performed over a period of 2 years. We analyzed their evolution during 6 months after treatment, by regular examinations (ultrasound/endoscopic/computed tomography). All of them were in-patients of Bucharest Clinical Emergency Hospital, either in Endoscopy or in Surgery Departments. Data collected was processed in IBM SPSS Statistics 20. Results: Overall mean age was 51 year and intraabdominal collections average was 109 mm (range 34 250 mm) and was correlated with the method of treatment (p 0.005). Patients underwent different methods for their intraabdominal collections: EUS drainage, CT (computed-tomography)- guided percutaneous drainage, surgical intervention, alone or combined when needed. Overall mortality was 9,3% and was mainly related to the severity of the case and sepsis. Conclusions: We conclude that endoscopic ultrasound can be the first choice for drainage of intraabdominal perigastric fluid collections because it is a safe and effective technique with 100 % technical success, and with over 80 % clinical success assures a better quality of life. For collections with a diameter larger than 127 mm, we can expect however the need of combined treatment, EUS and surgery.

Sarcopenia is a Predictive Factor for Postoperative Morbidity and Mortality in Patients Having Radical Gastrectomy for Cancer.

Introduction: Patients with gastric cancer are frequently malnourished with 30% to 38% of them losing more than 10% of their weight in preceding six months. Sarcopenia represents a decrease in the skeletal muscle mass and function and is usually associated with the aging process. The prevalence of sarcopenia in patients with gastric cancer is reported to be as high as 57.7%. Although many studies support the negative impact of sarcopenia in patients with gastric cancer, contradictory results are also present in the literature. The objective of this study is to investigate if sarcopenia is correlated with increased morbidity and mortality, in patients with gastric adenocarcinoma. Methods: We studied retrospectively all patients having radical resection for gastric adenocarcinoma managed in the Emergency Hospital of Bucharest between December 2014 and May 2016. ImageJ software was used to measure the patients' body composition. We identified the L3 landmark and extracted that corresponding single cross-sectional image contained within a CT study. Results: We reviewed 89 patients who had gastrectomy for cancer, but 11 Computed Tomography images were not available for analysis. Therefore, the study group consisted of 78 patients of which 50 were (64.1%) males and 28 (35.9%) females. The average age of patients diagnosed with gastric cancer was 67.7 years (range 22 to 92 years). The primary tumor location was the middle third of the stomach in 45 patients (57.7%), and the second in the lower third of the stomach in 29 patients (37.2%). There were 72 (92.3%) patients who were living on discharge, with mortality in 6 (7.7%) patients. 72.22% of patients are sarcopenic, and 27.78% were non-sarcopenic. The average sarcopenia value for both males and females is 43.77. The greatest number of patients had a skeletal muscle index between 40.00 and 45.00. The second greatest is between 35.00 and 40.00. The muscular skeletal index correlated with the age of the patients. The overall complications rate and the surgical site infection rate correlated with the sarcopenia. Conclusions: Sarcopenia is highly prevalent in patients having surgery for gastric cancer in Romania and correlates with increased postoperative morbidity. Especially with the increased trend for neoadjuvant therapy, the multidisciplinary team should evaluate and address sarcopenia through the perioperative period.

Superior mesenteric artery first approach versus standard pancreaticoduodenectomy: a systematic review and meta-analysis.

BACKGROUND: The superior mesenteric artery (SMA) first approach was proposed recently as a new modification of the standard pancreaticoduodenectomy. Increasing evidence showed that a periadventiceal dissection of the SMA with early transection of the inflow during pancreaticoduodenectomy associates better early perioperative results, and setup the scene for long-term oncological benefits. The objectives of the current study are to compare the operative results and long-term oncological outcomes of SMA first approach pancreaticoduodenectomy (SMA-PD) with standard pancreaticoduodenectomy (S-PD). DATA SOURCES: Electronic search of the PubMed/MEDLINE, EMBASE, Web of Science and Cochrane Library was performed until July 2015. We considered randomized controlled trials (RCTs) and non-randomized comparative studies (NRCSs) comparing SMA-PD with S-PD to be eligible if they included patients with periampullary cancers. RESULTS: A total of one RCT and thirteen NRCSs met the inclusion criteria, involving 640 patients with SMA-PD and 514 patients with S-PD. The SMA-PD was associated with less intraoperative bleeding, less blood transfusions and higher rate of associated venous resections. The pancreatic fistula and delayed gastric emptying had a significantly lower rate in the SMA-PD group. There were no differences between the two approaches regarding overall complications, major complication rates and in-hospital mortality. There was no difference regarding R0 resection rate, and one-, two- or three-year overall survival. The SMA-PD was associated with a lower local, hepatic and extrahepatic metastatic rate. CONCLUSIONS: The SMA-PD is associated with better perioperative outcomes, such as blood loss, transfusion requirements, pancreatic fistula, and delayed gastric emptying. Although the one-, two- or three-year overall survival rate is not superior, the SMA-PD has a lower local and metastatic recurrence rate.

Right Hemihepatectomy for Colon Cancer Metachronous Liver Metastasis in a Patient with Crohn\'s Disease: Case Report and Review of the Literature.

Introduction: Twenty percent of patients with colorectal cancer present stage IV disease at the time of diagnosis. The Crohn's disease increases 20 times the risk of colorectal cancer and worsens the patients' prognosis. The objective of this case report is to illustrate the surgical resection of a liver metachronous metastasis of colon cancer origin in a patient with Crohn's disease. CASE REPORT: A 53-year old female patient was admitted to our hospital for a colon cancer metachronous liver metastasis. The patient was diagnosed for more than ten years with colonic Crohn's disease and ankylosing spondylitis. She had a Hartmann's type resection for sigmoid colon adenocarcinoma four years ago, and a secondary resection of the transverse colon with a right transverse colostomy for colonic stenosis one month before current admission. Abdominal Computed Tomography revealed a liver metastasis of 10/11 cm located in segments 6, 7, 8, in close contact with the right and middle hepatic veins and right Glissonian pedicle. A right hemihepatectomy was performed, using Pringle maneuver for 30 minutes. The patient was discharged after 12 days, without additional morbidities. Conclusions: Patients with liver metastases of colorectal origin in the presence of Crohn's disease come with significant clinical challenges. Inside the multimodality approach, liver resection represents the therapeutic approach associated with the best long-term oncological results.

Probability of Survival Scores in Different Trauma Registries: A Systematic Review.

INTRODUCTION: A mixed score to predict the probability of survival has a key role in the modern trauma systems. The aim of the current studies is to summarize the current knowledge about estimation of survival in major trauma patients, in different trauma registries. METHOD: Systematic review of the literature using electronic search in the PubMed/Medline, Web of Science Core Collection and EBSCO databases. We have used as a MeSH or truncated words a combination of trauma "probability of survival" and "mixed scores". The search strategy in PubMed was: "((((trauma(MeSH Major Topic)) OR injury(Title/Abstract)) AND score (Title/Abstract)) AND survival) AND registry (Title/Abstract))))". We used as a language selection only English language literature. RESULTS: There is no consensus between the major trauma registries, regarding probability of survival estimation in major trauma patients. The German (RISC II), United Kingdom (PS Model 14) trauma registries scores are based of the largest population, with demographics updated to the nowadays European injury pattern. The revised TRISS, resulting from the USA National Trauma Database, seems to be inaccurate for trauma systems managing predominantly blunt injuries. CONCLUSIONS: The probability of survival should be evaluated in all major trauma patients, with a score derived from a population which reproduce the current demographics.Only a careful audit of the unpredicted deaths may continuously improve our care for severely injured patients.

Laparoscopic Approach has Benefits in Gynecological Emergencies - Even for Massive Hemoperitoneum.

OBJECTIVE: The purpose of this study is to compare the laparoscopic with the open approach in hemoperitoneum of gynecological origin. MATERIALS AND METHODS: Retrospective study of patients admitted to a tertiary emergency hospital between January 2013 - January 2015. RESULTS: There were 56 patients, 27 in the laparoscopic group (LG) and 28 in the open group (OG). The gynecological emergency was a ruptured ovarian cyst in 20 (74%) versus 17 (59%) cases, and an ectopic pregnancy with tubal rupture in 7 (26%) versus 12 (41%) patients in both the laparoscopic and open approaches, respectively. The main outcome - mean intraoperative hemoglobin decrease - was 1.5 +- 1.2 g/dl in the laparoscopic and 1.9 ‚+-1.4 in the open approach (p=0.344). There were no differences regarding red blood transfusion rate, needs for analgesics, postoperative complications and in-hospital stay. CONCLUSION: The laparoscopic approach in acute abdomen of gynecologic origin is non-inferior to open surgery.

The epithelial to mesenchymal transition in pancreatic cancer: A systematic review.

BACKGROUND/OBJECTIVES: The present article summarizes and analyzes the current knowledge about the role of the epithelial to mesenchymal transition (EMT) in the systemic invasiveness of pancreatic cancer. METHOD: An electronic search of PubMed/MEDLINE, EMBASE, and the Web of Science was used to identify relevant original articles and reviews. RESULTS: The EMT represents a key step during normal embryogenesis. However, increasing evidence reveals its essential role in the local progression and metastasis of pancreatic cancer. Areas of interest are the cross-linking between cells undergoing the EMT and pancreatic cancer stem cells, and the correlation between the EMT and chemoresistance to standard therapies. During carcinogenesis, malignant pancreatic cells at the primary site acquire the ability to undergo the EMT, a transformation associated with increased mobility. The reverse process at secondary sites, the mesenchymal to epithelial transition (MET), has devastating consequences, allowing neoplastic epithelial cells to invade surrounding tissues and spread to distant sites. Consequences of the EMT are the loss of E-cadherin expression and the acquisition of mesenchymal markers including fibronectin or vimentin. Detailed knowledge of the molecular processes underlying the EMT has opened possibilities for new therapeutic agents. These include an EMT approach for patients with early cancers, to prevent invasion and dissemination, and anti-MET therapy for patients with established metastasis. CONCLUSIONS: The current literature shows a strong correlation between the EMT and the systemic aggressiveness of pancreatic tumors. Individualized therapy, targeting the process of EMT and its cross-linking with cancer stem cells, may increase survival of patients with pancreatic cancer.

Complex Ebstein's malformation: defining preoperative cardiac anatomy and function.

INTRODUCTION: Ebstein's malformation is a congenital malformation of the tricuspid valve and right ventricle, with a highly variable morphology, and clinical presentation, accounting for less than 1% of all congenital heart diseases, and about 40% of congenital malformations of the tricuspid valve. METHOD: Systematic review of English language literature regarding the morphogenesis and progress of imaging techniques, especially echocardiography and cardiac magnetic resonance imaging, in the preoperative planning of Ebstein's malformation, using the MEDLINE database with the PubMed Entre interface. RESULTS: Technological developments of the recent years, with 3D echocardiographic and cardiac magnetic resonance imaging evolution, have resulted in better understanding of the malformed tricuspid valve and right ventricle in vivo anatomy. Through a better understanding of Ebstein's malformation, there is a continuous trend of surgical techniques favoring tricuspid valve sparing procedures, with a constant decrease in early and late postoperative mortality. CONCLUSIONS: Although imaging methods to investigate Ebstein's malformation have continuously evolved, standardization of assessment protocols by 3D echocardiographic imaging, speckle tracking imaging, and cardiac magnetic resonance imaging is required.

Ethical Challenges Regarding Cosmetic Surgery in Patients with Body Dysmorphic Disorder.

Body dysmorphic disorder (BDD) is an obsessive-compulsive disease, associated with increased addressability to plastic surgeons; however, as patients perceive body defects due to decreased insight, they are often unsatisfied with their appearance after cosmetic surgery. The purpose of this study is to evaluate the ethical reasoning that should be performed before accepting these patients as cosmetic surgery candidates. We will focus our analysis on three main areas of interest: autonomy, which in these patients is significantly decreased, beneficence as satisfaction, which in these particular patients does not justify performing the intervention, and loyalty, which should render cosmetic procedures immoral in patients with body dysmorphic disorder.