Modified "Blumgart-Type" Suture for Wirsung-Pancreaticogastrostomy: Technique and Results of a Pilot Study.

INTRODUCTION: Postoperative pancreatic fistula (POPF) represents the principal determinant of morbidity and mortality after pancreaticoduodenectomy. Since 1994 we have been performing pancreaticogastrostomy with duct-to-mucosa anastomosis (Wirsung-pancreaticogastric anastomosis [WPGA]), but postoperative morbidity, although limited, was still a concern. An original pancreas-transfixing suture technique, named "Blumgart's anastomosis" (BA), has shown efficacy at reducing fistula rates from pancreaticojejunostomy. Few cohort studies have shown that WPGA with pancreas-transfixing stitches may help reduce the rate of POPF. We designed a novel "Blumgart-type" modification of WPGA (B-WPGA) aiming at harnessing the full potential of the Blumgart design. METHODS: A prospective development study was designed around the application of B-WPGA after pancreaticoduodenectomy for primary periampullary tumors. It focused on describing the early iterations of this technique and on assessing the rate of POPF and delayed post-pancreatectomy hemorrhage (DPH) (primary outcomes), along with other perioperative outcomes. Technically, after mobilizing the pancreatic remnant for a few centimeters, the Wirsung duct is cannulated. A lozenge of seromuscular layer is excised from the posterior gastric wall, matching the shape and size of the pancreas's cut surface. Two to four transparenchymal pancreatic-to-gastric submucosa U stitches with 4/0 Gore-Tex are positioned cranially and caudally to the Wirsung duct, respectively, mounted on soft clamps, and tied onto the gastric serosa only after duct-to-mucosa anastomosis. Postoperative follow-up was standardized by protocol and included a pancreatic enzyme check on the drain output. RESULTS: From February 2018 to June 2019, in 15 continuous cases, B-WPGA was performed after pancreaticoduodenectomy. Indications for pancreaticoduodenectomy were mainly ampulla of Vater and pancreatic head adenocarcinomas. There was no operative mortality and no pancreatic anastomosis-related morbidity. Two events (13%) of transiently elevated amylase in the drain fluid, not matching the definition of POPF, were identified in patients with a soft pancreas on postoperative day 2. No DPHs were recorded after a minimum follow-up of 18.6 months. DISCUSSION/CONCLUSION: The principles of BA may be safely applied to the WPGA model. B-WPGA allows (1) gentle compression and closure of the small secondary ducts in the pancreatic remnant; (2) partial invagination of the pancreatic body in the gastric wall, with the pancreatic cut surface protected by the gastric submucosa; and (3) prevention of parenchymal fractures, as the pancreaticogastric stitches are tied onto the gastric serosa. Despite the limited number of cases in this study, the absence of mortality and anastomosis-related complications supports further reproduction of this technical variant. Larger studies are necessary to determine its efficacy.

Robotic Versus Laparoscopic Minimally Invasive Surgery for Rectal Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

OBJECTIVE: The aim of this study was to evaluate the safety and efficacy of elective rectal resection for rectal cancer in adults by robotic surgery compared with conventional laparoscopic surgery. SUMMARY OF BACKGROUND DATA: Technological advantages of robotic surgery favor precise dissection in narrow spaces. However, the evidence base driving recommendations for the use of robotic surgery in rectal cancer primarily hinges on observational data. METHODS: We searched MEDLINE, Embase, and CENTRAL for randomized controlled trials (until August 2016) comparing robotic surgery versus conventional laparoscopic surgery. Data on the following endpoints were evaluated: circumferential margin status, mesorectal grade, number of lymph nodes harvested, rate of conversion to open surgery, postoperative complications, and operative time. Data were summarized as relative risks (RR) or weighted mean differences (WMDs) with 95% confidence intervals (95% CIs). Risk of bias of studies was assessed with standard methods. RESULTS: Five trials were eligible, including 334 robotic and 337 laparoscopic surgery cases. Meta-analysis showed that RS was associated with lower conversion rate (7.3%; 4 studies, 544 participants, RR 0.58; 95% CI 0.35-0.97, P = 0.04, I = 0%) and longer operating time (MD 38.43 minutes, 95% CI 31.84-45.01: P < 0.00001) compared with laparoscopic surgery. Perioperative mortality, rate of circumferential margin involvement (2 studies, 489 participants, RR 0.82, 95% CI 0.39-1.73), and lymph nodes collected (mean 17.4 Lymph Nodes; 5 trials, 674 patients, MD -0.35, 95% CI -1.83 to 1.12) were similar. The quality of the evidence was moderate for most outcomes. CONCLUSION: Evidence of moderate quality supports that robotic surgery for rectal cancer produces similar perioperative outcomes of oncologic procedure adequacy to conventional laparoscopic surgery. Robotic surgery portraits lower rate of conversion to open surgery, while operating time is significantly longer than by laparoscopic approach.

Emergency pancreaticoduodenectomy: When is it needed? A dual non-trauma centre experience and literature review.

INTRODUCTION: Emergency pancreaticoduodenectomy (EPD) has been very rarely reported in literature as a lifesaving procedure for complex pancreatic injury, uncontrollable hemorrhage from ulcers and tumors, descending duodenal perforations, and severe infection. The aim of this study was to analyze the experience of two non-trauma centers and to review the literature concerning emergency pancreaticoduodenectomy. METHODS: From January 2005 to December 2014, from a population of 169 PD (92 females and 77 males; mean age: 61.3, range 23-81) 5 patients (3%; 2 females and 3 males; mean age: 57.8, range: 42-74) underwent EPD for non-traumatic disease performed at two Academic Units of the University of Bari. RESULTS: The emergency pancreaticoduodenectomy subgroup of patients showed an overall morbidity of 80%, and mortality of 40%. In 80% (4/5) of patients treated by emergency pancreaticoduodenectomy, the pancreatic remnant was not reconstructed, and in 20% (1/5) a pancreaticojejunostomy was performed. CONCLUSION: Emergency pancreaticoduodenectomy is an effective life-saving operation reservable to pancreatoduodenal trauma, perforations, and bleeding, unmanageable by a less invasive approach. It should be preferentially approached by surgeons with a high level of experience in hepatobiliary and pancreatic surgery and in trauma centers too, but it should also be in the armamentarium of general surgeons performing hepato-pancreato-biliary surgery.

Laparoscopic primary repair and isoperistaltic endoluminal drain for Boerhaave's Syndrome.

Spontaneous oesophageal rupture, also known as Boerhaave syndrome (BS), is a rare and potentially lethal pathological condition. BS recognition is difficult, while rapidity of diagnosis, along with extension of the lesion, affects type and outcome of treatment. BS was classically treated by thoracotomy, but laparoscopic (LS), thoracoscopic (TS) surgery, and nonsurgical procedures as endoscopic stent positioning or use of glues have been described. Still, there is no model treatment, and selection of the most appropriate therapeutic procedure is complex in the absence of standardised criteria. We successfully managed a patient affected with BS by LS approach and present our experience along with a review of treatment options so far described. Our treatment integrated positioning of an oesophageal isoperistaltic endoluminal drain (IED), that we routinely use in oesophageal sutures at risk of leakage, and of which there is no previous report in the setting of BS. A 68 year old man presented to our attention with true BS, suspected on chest-abdominal CT scan and confirmed by upper GI contrast swallow test, showing leakage of hydro-soluble contrast from the lower third of the oesophagus. Of note, pleural cavities appeared intact. We performed an urgent laparoscopy 12 hours after the onset of symptoms. Laparoscopic toilet of the inferior mediastinum and dual layer oesophageal repair with pedicled omental flap were complemented by positioning of IED, feeding jejunostomy and two tubular drains. The patient had a slow but consistent recovery where IED played as a means of oesophageal suture protection, until he could be discharged home. We think that, when integrity of the pleura is documented, LS should be priority choice to avoid contamination of the pleural cavities. We have to consider every type of oesophageal repair in BS at risk of failure, and every means of protection of the suture is opportune. In our patient the oesophageal suture, covered with a flap of omentum isolated on a pedicle, has also been protected from excessive oesophageal endoluminal pressures by means of a multi-fenestrated two way endooesophageal drain (IED, two way tube type Salem). Oesophageal drain has the finality of relieving tension and monitoring the healing of the oesophageal repair.

Analysis of telomere dynamics in peripheral blood cells from patients with Lynch syndrome.

BACKGROUND: In patients with Lynch syndrome, germline mutations in DNA mismatch repair (MMR) genes cause a high risk of developing a broad spectrum of cancers. To date, the management of patients with Lynch syndrome has represented a major challenge because of large variations in age at cancer onset. Several factors, including genetic anticipation, have been proposed to explain this phenotypic heterogeneity, but the molecular mechanisms remain unknown. Telomere shortening is a common event in tumorigenesis and also has been observed in different familial cancers. In this study, the authors investigated the possibility of a relation between telomere length and cancer onset in patients with Lynch syndrome. METHODS: The mean telomere length was measured using quantitative polymerase chain reaction in peripheral blood samples from a control group of 50 individuals, from 31 unaffected mutation carriers, and from 43 affected patients, and the results were correlated with both gene mutation and cancer occurrence. In affected patients, telomere attrition was correlated with age at cancer onset. In all patients, a t test was used to assess the linearity of the regression. RESULTS: A significant correlation between telomere length and age was observed in both affected and unaffected mutation carriers (P = .0016 and P = .004, respectively) and in mutS homolog 2 (MSH2) mutation carriers (P = .0002) but not in mutL homolog 1 (MLH1) mutation carriers. Telomere attrition was correlated significantly with age at onset in MSH2 carriers (P = .004), whereas an opposite trend toward longer telomeres in patients with delayed onset was observed in MLH1 carriers. CONCLUSIONS: The current data suggested that telomere dynamics differ between MLH1 and MSH2 mutation carriers. It is possible that subtle, gene-specific mechanisms can be linked to cancer onset and anticipation in patients with Lynch syndrome.

The mckittrick-wheelock syndrome: a rare cause of severe hydroelectrolyte disorders and acute renal failure.

The McKittrick-Wheelock syndrome is a rare cause of severe hydroelectrolyte disorders and fluid depletion as a result of rectal tumor hypersecretion, which can lead to acute renal failure. We report the case of a 70-year-old female who presented with hyponatremia, hypokalemia, hypochloremia, and acute renal failure, due to a watery, mucinous diarrhea. A large rectal villous adenoma was discovered on ileocolonoscopy, and definitive management was achieved by removal of the tumor. In conclusion, reversal of the biochemical derangement is the cornerstone of successful management of the McKittrick-Wheelock syndrome. Then, immediate surgical resection of the tumor is the treatment of choice.

[Isoperistaltic endoluminal drainage (IED) in the surgical treatment of upper digestive tract dehiscence]. / Il drenaggio endoluminale isoperistaltico nel trattamento chirurgico delle deiscenze nel tratto alimentare superiore.

Dehiscence of upper gastrointestinal sutures still remains a severe clinical problem and often requires complex surgical repair. Despite its multifactorial aetiopathogenesis, endoluminal pressure seems to play an important role in the onset and maintenance of this complication. The efficacy of isoperistaltic endoluminal drainage (IED) in the operative treatment or prevention of upper gastrointestinal surgical dehiscence was assessed in a retrospective study. The IED procedure is obtained by means of a two-way nasogastric tube inserted in the proximal jejunum through the abdominal and advanced to the site of the leak in order to achieve low endovisceral pressure, normal intestinal free flow downstream of the lesion and monitoring of the healing process. Over the past decade 31 patients (mean age 62 years; 52.9% male) with postoperative dehiscences of the thoraco-abdominal oesophagus, stomach or duodenum underwent reintervention. During the surgical repair an IED was inserted in 17, while no IED was inserted in 14 (NOIED): the two groups were well matched for age, gender, primary pathology, site and type of leak. The overall operative mortality (30 days) was 16% (12.5% IED vs. 20% NOIED), and morbidity was 45% (37.5% IED vs. 53.3% NOIED). The rate of leak relapse was significantly different: 6% IED vs. 20% NOIED. In the last 5 years the IED procedure has also been used preventively with promising outcomes in another 16 other high-risk upper gastrointestinal suture patients. The results of this retrospective study appear to support the use of the IED procedure to minimize the risk of failure of the suture/anastomosis in upper gastrointestinal surgery. Other studies are needed to validate the efficacy of this supplementation of surgical treatment.

[Evolution of surgery for cancer of the anorectal junction]. / Evoluzione chirurgica per i tumori del giunto ano-rettale.

Certain aspects of the epidemiology, classification and therapy of adenocarcinoma of the anorectal junction (< 5 cm from the anal verge) are not well standardised to date. To evaluate the recent advances in the surgical management we reviewed our database, focusing on the oncological and functional results of intersphincteric resection. From 1989 to 2005 we treated 183 adenocarcinomas of the anorectal junction with a curative intent by 106 total proctetomies (84 of which by intersphinteric resection), 54 abdominoperineal resections, 22 transanal local excision and 1 Hartmann procedure. Intersphincteric resections were performed in 51 males and 33 females, mean age 62, with the following clinical stages: 28 stage 1, 55 stages II and III, 1 stage IV; radiotherapy was administered preoperatively to 27 patients and postoperatively to 18. Fifty-five intersphinteric resections were performed by open surgery and 29 by laparoscopy (since 2001). All the procedures were R0 except for 2 R1 (readily converted to abdominoperineal resections). Perioperative mortality (30 days) was 1.1% and the overall morbidity was 27.7% (including a 6% leakage rate). Assessment of anal sphincter function recovery one year after restoration of bowel continuity showed good continence in 76% of the patients; 2 patients have a permanent ostomy. After an average 60-month follow-up (min. 30 months) the local recurrence rate was 2.4% and the actuarial 5-year survival rate 81.7%. Our experience shows a drop in abdominoperineal resections in the last 5 years from 56.5% to 17.8%, while the intersphincteric resection rate has increased from 32.6% to 66%. The oncological results of intersphincteric resection compare favourably with those of abdominoperineal resection and functional recovery appears satisfactory.

The Italian Registry of Laparoscopic Surgery of the Spleen (IRLSS) A retrospective review of 379 patients undergoing laparoscopic splenectomy.

In December 2000, the Italian Registry of Laparoscopic Surgery of the Spleen (IRLSS) was formally launched under the auspices of the Italian Society for Endoscopic Surgery and New Technologies (SICE). The aim of this multicentre study was to analyse various aspects of the treatment that are still under discussion, such as the extension of the laparoscopic indications in cases of malignancy, independently of the associated splenomegaly, patient selection and operative techniques. A retrospective review of 379 patients undergoing laparoscopic splenectomy for haematological diseases from February 1, 1993, to September 15, 2005, was conducted. Data were collected from the 18 italian centres participating in the IRLSS. The mean length of surgery was 140 minutes (range: 25-420). Conversion was necessary in 25 cases (6.6%), and at least one accessory spleen was found in 30 patients (8%). The mean spleen weight was 1200 g (range: 85-4500). Perioperative death occurred in two cases (0.5%). There were no complications in 312 patients (82.3%), with a mean hospital stay of 5.5 days (range: 2-30). Morbidity occurred in 67 patients (17.8%), mainly consisting in transient fever (n = 22), pleural effusions (n = 16), and actual or suspected haemorrhage (n = 14), requiring re-intervention in 7 patients. This first study carried out on the IRLSS data shows that laparoscopic splenectomy may constitute the gold standard for haematological diseases with a normal-sized spleen. The low morbidity and mortality rates suggest that laparoscopic splenectomy can be successfully proposed also for splenomegaly in haematological malignancies.

[Carney's syndrome: a case report]. / Sindrome di Carney: un contributo casistico.

The peculiar aspects of the clinico-pathological picture and surgical treatment of Carney's syndrome, a rare morbid association of multiple non-epithelial neoplasms of the stomach, lung and chromaffin tissue, are focused on and discussed on the basis of the observation of a clinical case. The patient was a 22-year-old male with a multiple stromal tumour of the stomach, oesophageal leiomyoma, a left thoracic terato-chondroid neoplasm and gallbladder adenomyoma, surgically treated in two stages: laparotomy for gastric resection and cholecystectomy followed by left thoracotomy for resection of the intrathoracic neoplasm and excision of the oesophageal leiomyoma. The postoperative course was characterised by low morbidity and healing was monitored by means of thorough follow-up examinations. The case reported here is classed among the variants of Carney's classical triad. A knowledge of the pathological associations of these uncommon tumours and their natural history is of great importance for implementing appropriate diagnostic and therapeutic protocols.