A retrospective analysis of bile duct injuries treated in a tertiary center: the utility of a universal classification-the ATOM classification.

BACKGROUND: Bile duct injuries (BDI) are the most feared complications that can occur after laparoscopic cholecystectomy (LC). BDI have a high variability and complexity, several classifications being developed along the years in order to correctly assess and divide BDI. The EAES ATOM classification encompasses all the important details of a BDI: A (for anatomy), To (for time of), and M (for mechanism) but have not gained universal acceptance yet. Our study intents to analyze the cases of BDI treated in our institution with a focus on the clinical utility of the ATOM classification. METHODS: We conducted a retrospective study, on a 10-year period (2011-2020), including patients diagnosed with BDI after LC, with their definitive treatment performed in our tertiary center. All injuries were retrospectively classified using the Strasberg, Hannover, and ATOM classifications. RESULTS: We included in our study 100 patients; 15% of the BDI occurred in our center. No classification system was used in 73% of patients; 23% of the BDI were classified by the Strasberg system, 3% were classified by the Bismuth classification, 1% being classified by the ATOM classification. After retrospectively assessing all BDI, we observed that especially the Strasberg classification, as well as Hannover, over-simplifies the characteristics of the injury, many types of BDI according to ATOM being included in the same Strasberg or Hannover category. Most main bile duct injuries underwent a bilio-digestive anastomosis (60%), as a definitive treatment. An important percentage of cases (31%) underwent a primary treatment in the hospital of origin, reintervention with definitive treatment being done in our department. CONCLUSION: The ATOM classification is the best suited for accurately describing the complexity of a BDI, serving as a template for discussing the correct management for each lesion. Efforts should be made toward increasing the use of this classification in day-to-day clinical practice.

Emergency pancreaticoduodenectomy for non-traumatic indications-a systematic review.

PURPOSE: Emergency pancreaticoduodenectomy (EPD) is an uncommon surgical procedure; usually, it is performed in traumatic cases, with non-traumatic indications being very rare. Our review aimed to offer a comprehensive descriptive overview of the characteristics of EPD in non-traumatic settings. METHODS: Our study is a review of individual participant data. PubMed, Cochrane, Google Scholar and Embase databases were searched. The last search was conducted in March 2022; studies that reported EPD for non-traumatic indications were included in the analysis. RESULTS: Twenty-six articles were identified, twenty-five providing individual participant data; 17 articles (68%) were case reports. One article was a large retrospective study on the NSQIP (American College of Surgeons National Surgical Quality Improvement) database, which enrolled 409 patients that underwent EPD for malignant causes. From the other studies, we extracted individual participant data for a total of 66 patients. The patients were divided in subgroups, based on the indication for surgery: malignant causes (39.39%), uncontrollable bleeding (19.69%), iatrogenic injuries (30.3%), perforations (4.54%), or ischemic causes (6.06%). The postoperative morbidity was higher for the perforation subgroup. Postoperative pancreatic fistula is the most common complication reported (21.21%); higher rates were reported in the malignant and bleeding subgroups, with no special mention of this complication in the NSQIP database study. Mortality rate was 10.3% in the NSQIP database and higher, 19.69% in the 66-patient cohort; the highest mortality rates were registered in the perforation and ischemic subgroup. CONCLUSION: EPD is a complex surgical intervention, with important associated morbidity and mortality rates, higher than that in elective settings, although it can be a life-saving procedure in selected cases and should be performed only in high-experience centres.

The role of systemic immuno-inflammatory factors in resectable pancreatic adenocarcinoma: a cohort retrospective study.

BACKGROUND: Pancreatic cancer is an aggressive malignancy, surgery being the only potentially curative treatment. The systemic inflammatory response is an important factor in the development of cancer. There is still controversy regarding its role in pancreatic cancer. METHODS: Our study is a retrospective observational cohort study. We included patients diagnosed with pancreatic ductal adenocarcinoma (PDAC), who underwent surgical resection in our hospital, between January 2012 and December 2019. We gathered information from preoperative and postoperative blood tests. Neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), lymphocyte to monocyte ratio (LMR), prognostic nutritional index (PNI) and systemic immune-inflammation index (SII) were determined. RESULTS: We included 312 patients. All the immune-inflammatory scores assessed significantly changed after the surgery. The impact on overall survival of these markers showed that only some of the postoperative scores predicted survival: high PLR had a negative prognostic impact, while high lymphocyte and PNI values had a positive effect on overall survival. DISCUSSION: The circulating immune cells and their values integrated in the assessed prognostic scores suffer statistically significant changes after curative pancreatic surgery. Only the postoperative values of lymphocyte count, PLR, and PNI seem to influence the overall survival in PDAC. TRIAL REGISTRATION: ClinicalTrials.gov-identifier NCT05025371 .

The role of artificial intelligence in pancreatic surgery: a systematic review.

Artificial intelligence (AI), including machine learning (ML), is being slowly incorporated in medical practice, to provide a more precise and personalized approach. Pancreatic surgery is an evolving field, which offers the only curative option for patients with pancreatic cancer. Increasing amounts of data are available in medicine: AI and ML can help incorporate large amounts of information in clinical practice. We conducted a systematic review, based on PRISMA criteria, of studies that explored the use of AI or ML algorithms in pancreatic surgery. To our knowledge, this is the first systematic review on this topic. Twenty-five eligible studies were included in this review; 12 studies with implications in the preoperative diagnosis, while 13 studies had implications in patient evolution. Preoperative diagnosis, such as predicting the malignancy of IPMNs, differential diagnosis between pancreatic cystic lesions, classification of different pancreatic tumours, and establishment of the correct management for each of these lesions, can be facilitated through different AI or ML algorithms. Postoperative evolution can also be predicted, and some studies reported prediction models for complications, including postoperative pancreatic fistula, while other studies have analysed the implications for prognosis evaluation (from predicting a textbook outcome, the risk of metastasis or relapse, or the mortality rate and survival). One study discussed the possibility of predicting an intraoperative complication-massive intraoperative bleeding. Artificial intelligence and machine learning models have promising applications in pancreatic surgery, in the preoperative period (high-accuracy diagnosis) and postoperative setting (prognosis evaluation and complication prediction), and the intraoperative applications have been less explored.

Surgical technique in the laparoscopic repair of Morgagni hernia in adults. How do we do it?

INTRODUCTION: Adult Morgagni hernias are rare congenital diaphragmatic hernias, which can present with an array of symptoms based on the size and the contents of it. This article focuses primarily on the laparoscopic repair with transfascial suturing. METHODS: A number of five patients over the course of 10 years were admitted in our clinic, one of them being admitted with emergency symptoms. Four of the patients were treated laparoscopically, one of them requiring conversion to open approach. RESULTS: The median age was 53 (range 44-71), 80% of the patients being females. Four of the patients received laparoscopic treatment with transfascial suturing, the fifth being converted, but respecting the same technique. The median surgery duration was 110 min, with a median blood loss of 30 ml. Removal of the sac was attempted in two cases. Median hospitalization stay was 3 days, with a median follow-up of 21 months, with no postoperative complications reported. CONCLUSIONS: Laparoscopic repair with transfascial suturing provides an feasible and efficient repair, compared to the other laparoscopic techniques. Although no postoperative complications were reported, the removal of the sac still remains an controversial issue.

Influence of dietary fatty acid concentration and geometric configuration on murine mammary tumorigenesis and experimental metastasis.

To investigate the influence of fatty acid geometric isomers on the growth and experimental metastasis of mammary tumors, mice were fed diets containing fat high in either cis or trans fatty acids. The cis fat was prepared to have a fatty acid composition similar to that of the trans fat; both were provided at 5 or 20% (by weight) of the diet. Line 168 mammary tumor cells were transplanted: 1) subcutaneously into female BALB/c mice to observe the effects of dietary fat on latency and local tumor growth, and 2) intravenously to observe influences on experimental metastasis. No differences in the latency or rate of primary tumor growth were observed among the groups fed the diets containing cis or trans fatty acids. In addition, there were no differences in fatty acid composition except the levels of trans-C18:1 in the primary tumor cells among the groups fed the experimental diets. Livers and spleens from animals fed both the 5 and 20% cis diet contained significantly more viable radiolabeled tumor cells than those fed the trans diets. Although body weight and composition were not significantly different among the groups, livers from animals fed the diets containing trans fatty acids were significantly heavier than those fed diets containing only cis fatty acids. Thus, trans fatty acids behaved similarly to cis fatty acids with respect to promotion of transplantable mammary tumor growth but trans fatty acids were less effective than cis fatty acids in promoting the blood-borne implantation and distant survival of the tumor cells.