Sarcopenia assessed by total psoas index - is it correlated with post-operative complications in all digestive cancers?

Background and aims: In cancer patients sarcopenia may be a predictor for postoperative complications of curative or palliative surgery. Several indices including the total psoas area index (TPAI) are proposed for the diagnosis of this condition, but there is no validated cut-off point.Our study aimed to assess the role of TPAI as a marker for sarcopenia and to compare the utility of previously proposed cut-off values for predicting post-operative complications in patients with digestive cancers undergoing surgery. Methods: We retrospectively included all adult patients with digestive cancers admitted to a tertiary center for elective surgery between January and December 2019. Sarcopenia was considered based on TPAI evaluated on abdominal computed tomography (CT) and for analysis we used different cut-off points published by various authors. The primary endpoint was the occurrence of any complications as defined by the Clavien-Dindo classification. The secondary endpoints were fistula development, low- versus high-grade Clavien-Dindo post-operative complications, moderate or severe anemia at discharge, major bleeding, hypoalbuminemia at discharge, and decrease in albumin levels by at least 1g/dL. Results: We included 155 patients with a mean age of 64.78 ± 11.40 years, of which 59.35% were males; 58.06% developed postoperative complications. TPAI evaluated as a continuous variable was not a predictor for the development of post-operative complications neither in the general study sample, nor in the gender subgroups of patients. Sarcopenia defined by previously proposed cut-off values was not a predictor of the secondary end-points either. Conclusion: TPAI as a sole parameter for defining sarcopenia was not a predictor for postoperative complications in patients undergoing surgery for digestive neoplasia.

Severe liver trauma with complex portal and common bile duct avulsion: A case report and review of the literature.

BACKGROUND: Given its size and location, the liver is the third most injured organ by abdominal trauma. Thanks to recent advances, it is unanimously accepted that the non-operative management is the current mainstay of treatment for hemodynamically stable patients. However, those patients with hemodynamic instability that generally present with severe liver trauma associated with major vascular lesions will require surgical management. Moreover, an associated injury of the main bile ducts makes surgery compulsory even in the case of hemodynamic stability, thereby imposing therapeutic challenges in the tertiary referral hepato-bilio-pancreatic centers' setting. CASE SUMMARY: We present the case of a 38-year-old male patient with The American Association for the Surgery of Trauma grade V liver injury and an associated right branch of portal vein and common bile duct avulsion, due to a crush polytrauma. The patient was referred to the nearest emergency hospital and because of the hemorrhagic shock, damage control surgery was performed by means of ligation of the right portal vein branch and right hepatic artery, and hemostatic packing. Afterwards, the patient was referred immediately to our tertiary hepato-bilio-pancreatic center. We performed depacking, a right hepatectomy and Roux-en-Y hepaticojejunostomy. On the 9th postoperative day, the patient developed a high output anastomotic bile leak that required a redo of the cholangiojejunostomy. The postoperative period was marked by a surgical incision site of incomplete evisceration that was managed non-operatively by negative wound pressure. The follow-up was optimal, with no complications at 55 mo. CONCLUSION: In conclusion, the current case clearly supports that a favorable outcome in severe liver trauma with associated vascular and biliary injuries is achieved thru proper therapeutic management, conducted in a tertiary referral hepato-bilio-pancreatic center, where a stepwise and complex surgical approach is mandatory.

The Optimal Management of Distal Pancreatic Stump After Pancreatico-Duodenectomy: Different Indications for Gastric and Jejunal Anastomoses.

BACKGROUND/AIM: The optimal management of distal pancreatic stump after pancreaticoduodenectomies (PD) remains unclear. The study aims to assess the early outcomes after anastomoses with jejunum vs. stomach of the distal pancreatic stump in a relatively large series of patients with PD. Patients and Methods: All patients with PD performed between Oct 1, 2016, and Oct 1, 2021, were retrospectively assessed: anastomoses with the jejunum (PJ group) vs. with the stomach (PG group). Results: A number of 360 PD: PJ group 293 patients (81.4%) and PG group 67 patients (18.6%). No statistically significant differences were observed between the groups regarding the early outcomes (p values 0.065), except for the clinically relevant delayed gastric emptying higher rates in the PG group (38.8% vs. 25.9%, p = 0.049). In the PG group there were statistically significant higher rates of pylorus-preservation (19.4% vs. 8.2%, p = 0.012), soft pancreas texture (76.1% vs. 34.4%, p 0.001), small Wirsung ducts (4 mm (0-25) vs. 3 mm (1-10), p 0.001) and intermediate and high-risk fistula scores (83.6% vs. 52.6%, p 0.001). Conclusions: No particular anastomotic technique can avoid postoperative complications. In patients with hard pancreas texture and dilated Wirsung duct, a duct-to-mucosa PJ anastomosis should be the first option, while for patients with small Wirsung duct and soft pancreas texture, an invagination PG anastomosis should be preferred.

The Impact of Postoperative Complications on Survival after Simultaneous Resection of Colorectal Cancer and Liver Metastases.

BACKGROUND: The aim of this study was to investigate the impact of postoperative complications on the long-term outcomes of patients who had undergone simultaneous resection (SR) of colorectal cancer and synchronous liver metastases (SCLMs). METHODS: We conducted a single-institution survival cohort study in patients with SR, collecting clinical, pathological, and postoperative complication data. The impact of these variables on overall survival (OS) and disease-free survival (DFS) was compared by log rank test. Multivariate Cox regression analysis identified independent prognostic factors. RESULTS: Out of 243 patients, 122 (50.2%) developed postoperative complications: 54 (22.2%) major complications (Clavien-Dindo grade III-V), 86 (35.3%) septic complications, 59 (24.2%) hepatic complications. Median comprehensive complication index (CCI) was 8.70. Twelve (4.9%) patients died postoperatively. The 3- and 5-year OS and DFS rates were 60.7%, 39.5% and 28%, 21.5%, respectively. Neither overall postoperative complications nor major and septic complications or CCI had a significant impact on OS or DFS. Multivariate analysis identified the N2 stage as an independent prognostic of poor OS, while N2 stage and four or more SCLMs were independent predictors for poor DFS. CONCLUSION: N2 stage and four or more SCLMs impacted OS and/or DFS, while CCI, presence, type, or grade of postoperative complications had no significant impact on long-term outcomes.

Synchronous arterial resection in pancreatic cancer: A case report.

Pancreatic cancer is one of the most lethal malignancies affecting people worldwide. As it is frequently diagnosed in advanced stages of the disease, the 5-year overall survival rate is <10%. Advanced stages are usually characterized by the local invasion of the superior mesenteric axis, celiac axis and portal vein and are considered a sign of unresectable cancer. The association between venous resections and survival outcomes has been widely reported. The effect of arterial invasion remains unclear as only isolated cases have been reported thus far. The present study investigated the preliminary experience in the field of arterial resection for locally advanced pancreatic cancer. Between January 2018 and January 2020 arterial resection was successfully associated with pancreatoduodenectomy in four cases. The mean age at the time of surgery was 48 years, and in all cases the indication of resection was represented by pancreatic head adenocarcinoma. Different types of venous resections were required in all cases. Postoperative reoperation was required in one case, while histopathological studies confirmed microscopic negative resection margins in all but one case. In selected cases, combined pancreatoduodenectomy with venous and arterial resection may be required to increase the chances of radical surgery.

Vascular Resections in Association With Pancreatic Resections for Locally Advanced Pancreatic Cancer.

BACKGROUND/AIM: Locally advanced pancreatic cancer has been considered for a long period of time as an unresectable lesion and therefore, all patients have been traditionally addressed to the oncological services for palliative purposes. However, due to the wide usage of newer oncological agents in association with improved surgical techniques, radical surgical procedures became feasible. The aim of this study was to present the different surgical procedures that were performed in locally advanced pancreatic cancer patients in order to achieve radical resections. PATIENTS AND METHODS: Between 2019 and 2020, six cases were submitted to pancreatic and vascular resections in Fundeni Clinical Hospital. RESULTS: In all cases, surgery with curative intent was attempted; portal vein resection was performed in five cases, whereas arterial resection was performed in three cases. Reconstruction was performed by direct re-anastomosis, by placing cadaveric or synthetic grafts. The postoperative outcomes were favourable in all cases. CONCLUSION: Vascular resections can be safely associated with pancreatic resections in cases presenting locally advanced pancreatic lesions, with acceptable morbidity rates.

Portal vein reconstruction with interposition of cryopreserved aortic graft: A case report and literature review.

Pancreatic cancer is one of the most aggressive malignancies with poor rates of survival especially in the event radical procedures are not feasible. However, improvements in surgical techniques have led to the successful association of vascular resection followed by reconstruction without a significant increase in the rates of postoperative complications. In the present article, we present the case of a 49-year-old patient diagnosed with pancreatic head cancer invading the portal vein. After discussing with the patient the risks and the benefits of the surgical procedure, the patient was submitted to pancreatoduodenectomy en bloc with portal vein resection while the continuity of the portal vein was reestablished by using a cadaveric graft originating from the abdominal aorta. The postoperative outcome was uneventful. In conclusion, in selected cases, arterial cadaveric grafts may be used in order to establish the continuity of the portal vein with good results. However, it should be emphasized that these are demanding procedures which should be carefully analyzed before deciding upon the opportunity for performing them.

Definitive Surgery for Liver Trauma in a Tertiary HPB Center (with video).

Background: Surgery for severe liver trauma remains challenging even for HPB surgeons, mainly due the hemodynamical instability, involvement of major vascular and biliary elements, impaired background liver and frequent anatomical variants. In this setting, despite conservative policy, major liver resection is still required in selected cases. Also salvage liver transplantation may be needed. Our study aims to analyze the results after definitive surgery for hepatic injury (HI) in a tertiary HPB center. Methods: Sixty-six patients with HI were admitted and treated in our center between June 2000 and June 2021. The median age was 29 years (mean 35, range 10-76). The male/female ratio was 50/16. According to the American Association for the Surgery of Trauma (AAST) system, HIs were grade II in one patient (1.5%), grade III in 11 pts (16.7%), grade IV in 25 pts (37.9%), and grade V in 29 pts (43.9%); no patient had grade I or VI HI. Results: Fifty-two pts (78.8%) benefitted from surgery and 14 pts (21.2%) from non-operative treatment (NOT). Perihepatic packing was previously performed in 38 pts (73.1%). Surgery consisted in hepatic resections (HR) in 51 pts (77.3%) and liver transplantation in one patient (1.5%). The rate of major HR was 51.9% (27 HRs). The overall major morbidity and mortality rates were 33.3% (20 pts) and 13.6% (9 pts), respectively. For surgery, the major complication rate was 35.3% (18 pts), while for major and minor HR were 40.7% (11 pts) and 29.2% (7 pts), respectively; the mortality rate was 15.7% (8 pts). After NOT, the major morbidity and mortality rates were 14.3% (2 pts) and 7.1% (1 pt), respectively. Conclusions: Hepatic resections, especially major ones and/or involving vascular and biliary reconstructions, as well as non-operative treatment for severe hepatic injuries, are to be carried out in tertiary HPB centers, thus minimizing the morbidity and mortality rates, while having the liver transplantation as salvage option.

Major Hepatectomy En Bloc with Cava Vein Resection for Locally Invasive Caudate Lobe Hepatocarcinoma.

BACKGROUND/AIM: Locally advanced liver tumours with vascular invasion have been considered for a long period of time as unresectable lesions, so the patient was further deferred to oncology services for palliation. However, improvement of the surgical techniques and the results reported so far came to demonstrate that extended hepatic and vascular resections might be safely performed in such cases and might significantly improve the long-term outcomes. MATERIALS AND METHODS: A 61-year-old patient was diagnosed with a caudate lobe tumour invading the inferior cava vein and the right hepatic pedicle. RESULTS: The patient was successfully submitted to surgery, and an extended right hepatectomy en bloc with cava vein resection was performed; the continuity of the cava vein was re-established by the placement of a synthetic graft. The postoperative outcome was uneventful. CONCLUSIONS: Although initially considered as a formal contraindication for resection, vascular invasion of the greater vessels should not preclude surgery if complete resection is achievable.

Infra-hepatic caval resection en bloc with right nephrectomy followed by caval reconstruction for locally advanced caval leiomyosarcoma: A case report and literature review.

Retroperitoneal sarcomas often require complex surgical procedures in order to achieve complete resection; in such cases both vascular and visceral resections are needed. When it comes to the need for vascular reconstruction, the type of graft as well as the type of reconstructive process are chosen according to the length and location of the resected segment. Meanwhile, depending on the location of the resected segment, other vascular reconstructions may be needed such as the reimplantation of the renal veins. However, in certain cases, this reimplantation is not mandatory, an adequate renal outflow being reported through the collateral network at this level. We present the case of a 43-year-old patient diagnosed with a large retroperitoneal sarcoma originating from the cava vein invading the right kidney. Resection of the tumor was performed en bloc with caval resection and right nephrectomy, without reimplantation of the left renal vein at the level of the graft. Extended visceral and vascular resections might be needed in order to achieve complete resection of inferior cava vein sarcomas; re-implantation of the left renal vein being not mandatory if rich collateral circulation is present.

Distal Pancreatectomy With Celiac Axis Resection for Locally Advanced Pancreatic Body Cancer - A Case Report and Literature Review.

BACKGROUND: Locally advanced pancreatic cancer invading the surrounding vascular structures has long been considered as unresectable and, therefore, patients were usually submitted to palliative chemotherapy. CASE REPORT: We present the case of a 44-year-old male investigated for weight loss and abdominal pain and diagnosed with a locally advanced pancreatic tumor invading the celiac axis. An endoscopic ultrasound was performed and a biopsy was retrieved demonstrating the presence of a moderately differentiated pancreatic adenocarcinoma. After discussing with the patient the risks and the benefits of performing an extended surgical procedure, the patient consented to distal pancreatectomy en bloc with celiac axis resection. Postoperatively, the patient was submitted to low-molecular-weight heparin therapy for 3 weeks followed by oral anticoagulant for 2 months. Histopathological studies confirmed the presence of a moderately differentiated pancreatic adenocarcinoma invading the celiac axis and described negative resection margins. CONCLUSION: Although celiac axis invasion has been considered for a long period of time as a sign of unresectable disease due to the high rates of perioperative complications, it seems that in selected cases, surgery can be safely performed with curative intent, especially if negative resection margins are achieved.

Superior Mesenteric Vein Resection Followed by Porto-Jejunal Anastomosis During Pancreatoduodenectomy for Borderline Resectable Pancreatic Cancer - A Case Report and Literature Review.

BACKGROUND/AIM: Pancreatic cancer represents the most lethal abdominal malignancy, the only chance for achieving an improvement in terms of survival being represented by radical surgery. Although it has been considered that venous invasion represents a contraindication for resection, recently it has been demonstrated that in regards to overall survival after radical resection, it is similar to the one reported after standard pancreatoduodenectomy. CASE REPORT: A 53-year-old patient with no significant medical past was diagnosed with a borderline resectable pancreatic adenocarcinoma invading the superior mesenteric vein. The patient was submitted to pancreatoduodenectomy en bloc with superior mesenteric vein resection; the two jejunal veins were further anastomosed to the remnant portal vein. The postoperative outcome was favorable; the patient was discharged in the 10th postoperative day. CONCLUSION: Although technically more demanding, pancreatoduodenectomy en bloc with superior mesenteric vein resection and jejunal portal anastomosis is feasible and might offer a chance for long-term survival in borderline pancreatic head carcinoma invading the superior mesenteric vein.

Extended Venous Resections for Borderline Resectable Pancreatic Head Adenocarcinoma-A Retrospective Studies of Nine Cases.

BACKGROUND: pancreatic cancer is one of the most lethal malignancies and a leading cause of cancer-related death worldwide. The only chance to improve the long-term outcomes of patients with pancreatic cancer is surgery with radical intent. METHODS: in the present paper, we aim to describe a case series of 9 patients submitted to radical surgery for borderline resectable pancreatic cancer. RESULTS: in all cases, negative resection margins were achieved. The types of venous resection consisted of tangential portal vein resection in four cases, circumferential portal vein resection with direct reanastomosis in one case and circumferential resection with graft placement in another four cases; postoperatively, one patient developed a vascular surgery-related complication consisting of graft thrombosis and thus necessitated prolonged anticoagulant therapy. CONCLUSIONS: extended venous resections can be a safe and efficient way to maximize the benefits of radical surgery in locally advanced, borderline resectable pancreatic cancer.

Hepatic artery reconstruction after extended resection for borderline resectable pancreatic head cancer: A case report.

Pancreatic head cancer is frequently associated with invasion of the surrounding vascular structures, such cases being considered for a long period of time as unresectable. Improvement of the vascular surgery techniques allowed association of extended vascular resections and reconstructions, increasing in this way the percentage of patients benefiting from radical surgery. We present the case of a 47-year-old male patient with no significant medical history diagnosed with a large pancreatic head tumor invading the common and proper hepatic artery as well as the portal vein. The venous reconstruction was performed using a synthetic prosthesis while the left hepatic artery was sutured to the left gastric artery; meanwhile the right hepatic artery was reconstructed using the splenic artery. In conclusion, extended hepatic artery resection followed by arterial reconstruction in association with portal vein resection and prosthetic replacement might be needed in cases presenting large pancreatic head tumors with vascular invasion.

Gastrointestinal stromal tumors of the colon and rectum.

Gastrointestinal stromal tumors (GISTs) are rare neoplasms, colorectal location being met in less than 5% of cases. Knowledge about this site related particularities are limited. The aim of this study is to present our experience with colorectal GISTs between 2005 and 2018 from the clinical, morphological, and immunohistochemical perspectives, with emphasis on prognostic factors. From a total of 203 gastrointestinal stromal tumors registered, 12 were colorectal (6%). The number of colonic tumors surpassed that of the rectum (9 : 3) and on the right side were registered more cases than on the left side (6/3). 9 were primary tumors and 3 were recurrences. Men and women were represented equally and the age range was between 22 and 76. Tumor dimensions varied between 0.5 and 14 cm. Microscopically, spindle cell type was dominant. Mitotic rate was variable between 1 and 115/50HPFs. Accordingly, for primary tumors progression risks were assigned (low risk: 2 cases, intermediate risk: 3 cases and high risk: 4 cases). All GISTs were CD117 and DOG1 positive. Four of the patients died of the disease.

A Morphological and Immunohistochemical Study of the Tumoral and Inflammatory Cells in Pancreatic Ductal Adenocarcinoma.

This study is aimed at investigating tumoral and inflammatory cells and the significance of the prognostic factors of pancreatic ductal adenocarcinoma (PDAC); it is also aimed at determining the role of immunohistochemistry in the diagnosis and prognosis of this neoplasm. Materials and Methods. 230 cases of pancreatic ductal adenocarcinoma were included in the study group; these cases were selected from the archives of the Department of Pathology of the Fundeni Clinical Institute over a ten-year period. Immunohistochemistry was performed using the following antibodies: MUC 1, CD 34, Factor VIII, CD 68, MMP-7, CEA, p21, p53, and Ki 67. Results. There were 133 male (57.8%) and 97 female (42.2%) patients included in this study, with ages between 20 and 81 years old (mean age: 58.2 years) and with tumors located in the pancreatic head (n = 196; 85.2%), pancreatic body (n = 12; 5.2%), and pancreatic tail (n = 20, 8.7%), as well as panpancreatic tumors (n = 2; 0.9%). Patients presented with early stages (IA and IB), with low pathologic grade (G1), with small size tumors (less than 1-1.5 cm), with tumors located in the head of the pancreas, (p53: negative; p21: positive; and CD 68: positive in peritumoral tissue), with low nuclear index (Ki 67 < 10%), without metastases at the time of surgery (had a better prognosis), and with a survival rate of about 7 months. Conclusions. Immunohistochemistry is useful for an accurate diagnosis, differential diagnosis, and establishment of additional factors that might have a prognostic importance. It is recommended to study peritumoral tissue from the quantitative and qualitative points of view to increase the number of prognostic factors. This study represents a multidisciplinary approach, and it is a result of teamwork; it presents histopathological methods of examination of this severe illness and describes only a part of the scientific effort to determine the main pathological mechanisms of this neoplasm.

Pancreatectomy With Arterial and Portal Vein Reconstruction for Locally Advanced Pancreatic Cancer - A Case Report and Literature Review.

BACKGROUND/AIM: Pancreatic cancer is still associated with poor survival rates due to the fact that it is most often diagnosed at advanced stages of the disease when local invasion is present. However, improvements of surgical techniques have enabled extended resections with curative intent. We present the case of a 43-year-old patient diagnosed with locally invasive pancreatic adenocarcinoma invading the portal vein and the common hepatic artery. CASE REPORT: Surgery with curative intent consisting of pancreatoduodenectomy en bloc with hepatic artery resection and portal vein resection was successfully performed. The right hepatic artery was further anastomosed with the remaining common hepatic artery while the left hepatic artery was reconstructed using a reversed splenic artery patch. The continuity of the portal vein was re-established by placing a synthetic prosthesis. CONCLUSION: Combined arterial and venous resections might be useful in order to achieve a good local control of disease in patients with locally advanced pancreatic cancer.

Reconstruction of superior mesenteric artery by prostheses placement in a case of chronic mesenteric ischemia: A case report and literature review.

Although superior mesenteric artery stenosis is a relatively common situation, it is rarely symptomatic due to the fact that in a significant number of cases an adequate collateral circulation exists. The aim of this study is to report a case in which arterial reconstruction was needed due to the absence of such a patent collateral circulation. The 47-year-old patient was investigated for chronic postprandial pain and was diagnosed with superior mesenteric artery stenosis. Percutaneous treatment was the initial option of choice but the patient rapidly became symptomatic again. Therefore surgery was performed, the segment of arterial stenosis was resected and the arterial continuity was re-established by using a synthetic prosthesis. The postoperative outcome was uneventful, the patient was discharged in the seventh postoperative day under anticoagulant therapy. In conclusion, superior mesenteric artery reconstruction by using a synthetic prosthesis can be useful in cases presenting chronic mesenteric ischemia and failure of percutaneous treatment.

Distal Pancreatectomy En Bloc With Splenectomy, Celiac Axis and Portal Vein Resection Followed by Arterial Reconstruction Using a Cadaveric Graft - A Case Report and Literature Review.

BACKGROUND/AIM: Locally advanced pancreatic body tumors invading the celiac axis and the portal vein have been considered since long as unresectable lesions; however, due to improvement of surgical techniques, in certain cases surgery with curative intent might be taken in consideration. CASE REPORT: We present the case of a 48-year-old female investigated for epigastric pain that was diagnosed with a locally invasive pancreatic body tumor. The patient was submitted to computed tomography which revealed the presence of a locally advanced pancreatic tumor with no demarcation line with the celiac axis and the portal vein. The endoscopic ultrasound raised the suspicion of malignancy and retrieved a biopsy which demonstrated the presence of a pancreatic adenocarcinoma. The patient was submitted to surgery, distal pancreatectomy en bloc with splenectomy, celiac axis and portal vein resection was performed; the hepatic artery was reconstructed by placing a cadaveric graft while the portal vein was sutured per primam by an end to end anastomosis. The postoperative outcome was favorable, and the patient was discharged in the 10th postoperative day. CONCLUSION: Multiple vascular resections followed by reconstructions might be needed in order to achieve resection with negative margins in patients with pancreatic body tumors.