Intraoperative radio-guided localization of parathyroid adenomas using 3D freehand SPECT technology.

Parathyroidectomy for primary hyperparathyroidism (PHPT) could have poor outcomes, even with accurate preoperative localization of the adenomas, because their intraoperative localization can be challenging. Freehand single photon emission computed tomography (fhSPECT) is a new technique for radio-guided intraoperative navigation. Its use during parathyroidectomy could be useful and such data are limited. We herein present our experience on the feasibility of fhSPECT for intraoperative detection of abnormal parathyroid glands. We retrospectively reviewed the clinical data of 55 patients (30-77 years old) with PHPT due to parathyroid adenomas, that were subjected to parathyroidectomy from 12/2017 to 7/2022. In average, 111 ± 74 MBq of Tc-99 m Sestamibi were injected intravenously, approximately 2 h before the operation and fhSPECT was used to generate 3D images during parathyroidectomy. Measurements of PTH and calcium levels were performed preoperatively, postoperatively and 4-6 months after the procedure. FhSPECT successfully identified the parathyroid adenoma in all the patients. It took 3 min (median time) for fhSPECT to detect at least one radioactive spot in all patients. The mean duration of the operation was 66.6 ± 7.3 min. Forty-nine patients out of 55 had solitary and 6/55 had multiple adenomas, whereas 6/55 had ectopic abnormal parathyroid glands. None of the patients had persistent hyperparathyroidism during follow-up. To the best of our knowledge, this is the largest series of patients with PHPT that underwent fhSPECT assisted parathyroidectomy. Our data suggest that this navigation system is helpful in identifying parathyroid adenomas intraoperatively.

Epithelial to mesenchymal transition (EMT) in metaplastic breast cancer and phyllodes breast tumors.

Epithelial-mesenchymal transition (EMT), a transdifferentiation program whereby epithelial cells acquire mesenchymal phenotype, is essential during embryonic development. EMT has also been implicated in cancer progression by conferring migratory and metastatic potential, as well as cell plasticity and stem cell like traits, to cancer cells. Metaplastic breast carcinoma (MBC) is a rare aggressive type of breast cancer characterized by the presence of heterologous elements, typically by the existence of epithelial and mesenchymal components. Phyllodes tumors (PTs) are uncommon fibroepithelial neoplasms consisting of epithelial and mesenchymal elements. Although various hypotheses have been proposed on the pathogenesis of these biphasic tumors, there is growing evidence supporting the theory that PTs and MBC could both correlate with cancer related EMT. This review summarizes the existing literature on the emerging role of EMT in the pathogenesis of MBC and PTs. Both malignant PTs and MBC are characterized by poor prognosis. Therefore, several anti-EMT targeting strategies such as blocking upstream signaling pathways, targeting the molecular drivers of EMT and targeting mesenchymal cells and the extracellular matrix, could potentially represent a promising therapeutic approach for patients suffering from these aggressive neoplasms.

Mid-term outcomes in the treatment of retroperitoneal sarcomas: a 12-year single-institution experience.

Aim To present the experience from collective data regarding patients with retroperitoneal sarcomas that have been operated in and followed up by the University General Hospital of Patras in Rion, Greece, between 2009 and 2020. Methods A retrospective analysis of adult patients treated at our hospital with a diagnosis of primary retroperitoneal sarcoma who underwent tumour resection. Results Data from 29 patients were analysed. The mean age at diagnosis was 56.1 years; 55.2% of patients were male (n=16). Liposarcomas (on histology) were identified in 19 (65.5%) patients, leiomyosarcoma six (20.7%), and other histologic subtypes in four (13.8%) patients. Tumours >5cm were presented in 27 (93.1%) patients. Negative margins were attained in 13 (44.8%) of all patients who underwent surgical resection. Five (17.2%) patients received neoadjuvant radiation, four (13.8%) postoperative radiation, and three (10.3%) patients received both chemotherapy and radiation prior to surgery with the rest of the patients being treated with surgical excision alone. A 3-year follow-up was successful in 21 (72.4%) patients; five (23.8%) patients died. In total, 16 (55.2%) patients were found to have a local recurrence, with no significant difference in patients' age, gender, tumour size, histology, negative surgical margin (Ro) resection, neoadjuvant chemotherapy, or radiation therapy. There was a significant difference in the 3-year survival rate between patients having positive or negative surgical margins (p=0.027). Conclusion The higher 3-year survival rate in patients with retroperitoneal sarcomas when achieving Ro resection warrant further investigation with a larger sample size across different institutions.

Chyle leak after major pancreatic surgery. Is this an underestimated complication? A narrative review of the literature.

PURPOSE: Postoperative chyle leak, termed 'chylous ascites', is a rare complication with a reported frequency of only one in 20464 abdominal operations. The purpose of this study was to summarize the available scientific data reviewing the most relevant studies for this type of postoperative complication after pancreatic surgery, highlighting at the same time the necessity for pancreatic surgeons to retain a high level of clinical suspicion for the early diagnosis and its therapeutic management. METHODS: A thorough literature search in Pubmed and Google Scholar, under the terms' chylous ascites OR chyle leak AND pancreas OR pancreatic', since the year of inception until 19th of February 2021 was conducted by the authors and the associated results are presented in this narrative review. RESULTS: Chyle leak is a rare complication following pancreatic surgery. Patients may suffer from exudative enteropathy and malnutrition leading to repeated infections and impaired wound healing or even death secondary to sepsis. Several studies have highlighted the issue of increased hospital stay, while others failed to reach statistical significance as far as hospital stay or survival are concerned. Researchers found that patients with diffuse chyle leak tended to have a worse 3-year survival rate (18.8%), which can be attributed to postoperative complications and early demise due to immunosuppression associated with the leak, or delayed adjuvant chemotherapy Conclusion: Further clinical research is needed to enhance prevention, diagnosis, treatment and long-term prognosis of this relevant surgical problem that shows trends of increase due to the great number of major operations which are performed nowadays.

A gelatinous veil inside the abdomen of a pancreatic cancer patient. What lies beneath it?

Chylous ascites following pancreatic surgery results from surgical damage to the cisterna chyli or tributaries, with an incidence in pancreatic surgery of 1.8%-11%. Usually, conservative treatment is effective.

Laparoscopic versus open approach to neurolytic celiac plexus block in inoperable pancreatic cancer.

BACKGROUND: Neurolytic celiac plexus block (NCPB) is an effective method of palliative pain control. The purpose of this study was to evaluate the feasibility and effectiveness of the laparoscopic NCPB versus open approach. METHODS: Eight patients (Group A) underwent diagnostic laparoscopy which revealed an inoperable pancreatic cancer. Forty millilitres of solution (20 mL of 95% ethanol mixed with 20 mL of xylocaine) was injected into either side of para-aortic soft tissue. The same solution was injected in 10 patients (Group B), with inoperable pancreatic body cancer diagnosed during laparotomy. RESULTS: There were no intraoperative or post-operative, NCPB related, complications. Patients in both groups, reported significant pain relief in the early post-operative period. Using the visual analogue scale preoperatively, in second post-operative day, first and third post-operative month, no significant different was observed between the two groups. The mean hospital stay in both groups was 2.1 versus 5.2 (P = 0.0005) and the mean survival 8.1 versus 7.9 months (ns). CONCLUSIONS: The NCPB is feasible method for palliation in inoperable pancreatic cancer. Laparoscopic NCPB gives excellent results and could still be considered in selected cases, as an effective alternative during staging laparoscopy.

Prognostic factors and survival after surgical resection of pancreatic neuroendocrine tumor with validation of established and modified staging systems.

BACKGROUND: Pancreatic neuroendocrine tumors (PNETs) display wide heterogeneity with highly variable prognosis. This study aimed to identify variables related to survival after surgical resection of PNET. METHODS: A total of 143 patients were identified from a prospectively maintained database. Patient characteristics were analyzed and prognostic factors for overall survival and progression-free survival were evaluated. The WHO, ENETS and AJCC scoring systems were applied to the cohort, and their ability to predict patient outcomes were compared. RESULTS: Multivariate analysis found that female gender, lymph node metastases and increasing WHO 2010 grade to be independently associated with reduced overall survival (P < 0.05). Patients requiring multi-visceral resection or debulking surgery found to be associated with shortest survival. ROC analysis found the ENETS and AJCC scoring systems to be similarly predictive of 5-year overall survival. Modified Ki67 significantly improved its accuracy in predicting 5-year overall survival (AUROC: 0.699 vs 0.605; P < 0.01). CONCLUSIONS: Multi-visceral or debulking surgery is associated with poor outcomes. There seems to be no significant difference between enucleation and anatomical segmental resection. Available scoring systems have reasonable accuracy in stratifying disease severity, with no system identified as being superior. Prognostic stratification with modified grading systems needs further validation before applied in clinical practice.

Complex outflow anatomy in left lateral lobe graft and modified venous reconstruction in pediatric living donor liver transplantation.

Hepatic venous outflow reconstruction is of critical significance in pediatric patients undergoing living donor liver transplantation. Accurate knowledge of the anatomical variations is important to obtain appropriate size segmental grafts. The diameter of the hepatic veins and the potential risk of complications at the level of the anastomosis require an adequate primary vascular reconstruction. We describe a venous outflow reconstruction technique, in a living related left lateral lobe graft, with unfavorable hepatic venous anatomy.

Laparoscopic pancreas-preserving total duodenectomy for familial adenomatous polyposis.

Patients with duodenal polyps associated with familial adenomatous polyposis (FAP) have a considerable risk of developing duodenal carcinoma. Prophylactic resection of the duodenum for Spigelman stage III disease is the treatment of choice to prevent progression to cancer. Pancreaticoduodenectomy and pancreas-preserving total duodenectomy (PPTD) are the techniques that have been described for the surgical treatment of duodenal polyposis. We report the first case of laparoscopic PPTD in a patient with previous total colectomy for FAP and Spigelman stage III duodenal polyposis. A laparoscopic total dissection of the duodenum was carried out and the restoration was achieved performing pancreatico-biliary-jejunostomy and gastrojejunostomy. The postoperative period was uneventful. Laparoscopic PPTD can be performed safely in selected cases for the management of FAP.

Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial.

BACKGROUND: The attempt to further reduce operative trauma in laparoscopic cholecystectomy has led to new techniques such as natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS). These new techniques are considered to be painless procedures, but no published studies investigate the possibility of different pain scores in these new techniques versus classic laparoscopic cholecystectomy. In this randomized control study, we investigated pain scores in SILS cholecystectomy versus classic laparoscopic cholecystectomy. PATIENTS AND METHODS: Forty patients (34 women and 6 men) were randomly assigned to two groups. In group A (n = 20) four-port classic laparoscopic cholecystectomy was performed. Patients in group B (n = 20) underwent SILS cholecystectomy. In all patients, preincisional local infiltration of ropivacaine around the trocar wounds was performed. Infusion of ropivacaine solution in the right subdiaphragmatic area at the beginning of the procedure plus normal saline infusion in the same area at the end of the procedure was performed in all patients as well. Shoulder tip and abdominal pain were registered at 2, 6, 12, 24, 48, and 72 h postoperatively using visual analog scale (VAS). RESULTS: Significantly lower pain scores were observed in the SILS group versus the classic laparoscopic cholecystectomy group after the first 12 h for abdominal pain, and after the first 6 h for shoulder pain. Total pain after the first 24 h was nonexistent in the SILS group. Also, requests for analgesics were significantly less in the SILS group, while no difference was observed in incidence of nausea and vomiting between the two groups. CONCLUSION: SILS cholecystectomy, as well as the invisible scar, has significantly lower abdominal and shoulder pain scores, especially after the first 24 h postoperatively, when this pain is nonexistent. (Registration Clinical Trial number: NTC00872287, www.clinicaltrials.gov ).

Laparoscopic Nissen fundoplication combined with posterior gastropexy in surgical treatment of GERD.

BACKGROUND: Laparoscopic Nissen fundoplication (LNF) has become established as the procedure of choice in the surgical management of the majority of patients suffering from gastroesophageal reflux disease (GERD). Postoperative paraesophageal herniation has an incidence range up to 7% in the immediate postoperative period. AIM: A prospective randomized trial was scheduled to study the role of posterior gastropexy, in combination with LNF, in prevention of paraesophageal herniation and improvement of postoperative results in surgical treatment of GERD. PATIENTS AND METHODS: Eighty-two patients with GERD were randomized to LNF combined with (group A, n = 40) or without (group B, n = 42) posterior gastropexy. Subjective evaluation using disease-specific and generic questionnaires and structured interviews, and objective evaluation by endoscopy, esophageal manometry, and 24-h pH monitoring, were performed before operation, at 2 and 12 months after surgery, and then every year. Crura approximation was performed by stitches if the diameter was less than 6 cm, or with a patch to reinforce the conventional crural closure or by tension-free technique to close the hiatus. Posterior gastropexy (group A) was performed with one stitch between the posterior wall of the wrap and the crura near the arcuate ligament. RESULTS: Sixteen patients of group A and 15 patients of group B with concomitant abdominal diseases had simultaneous procedures [cholecystectomy 25, vagotomy 2, ventral hernia repair 1, gastric polypectomy 1, gastric fundus diverticulectomy 1, gastrointestinal stromal tumor (GIST) wedge resection 1]. In mean follow-up of 48 +/- 26 months (range 7-94 months), one patient of group B presented with paraesophageal herniation in the first postoperative month (reoperation), while recurrent gastroesophageal reflux (Visick III or IV), successfully treated by medication, was noted in three patients of group B and in one patient of group A. Only mild dysphagia, during the first two postoperative months, was noted in nine patients of group A and eight patients of group B. Six patients of each group with Barrett's esophagus had endoscopic improvement after the second postoperative month. Visick score in groups A/B was I in 26/11 (P < 0.0001), II in 13/27 (P = 0.037), III in 1/2 (not significant, NS), and IV in 0/2. Generally, Visick score was I or II in 39/38 in groups A/B (97.5%/90.5%, NS) and III or IV in 1/4 (2.5%/9.5%, P < 0.0001). CONCLUSIONS: LNF combined with posterior gastropexy may prevent postoperative paraesophageal or sliding herniation in surgical treatment of GERD, providing better early and long-term postoperative results. (Registered Clinical Trial number: NCT00872755. www.clinicaltrials.gov .).