Andrea Kazemi Nava

Free peritoneal tumor cells detection in gastric and colorectal cancer patients

Free peritoneal tumor cells (FPTC) derive from the detachment of primary cancer and may result in peritoneal carcinomatosis. Since peritoneal lavage cytology has low sensitivity in detecting FPTC, our aim was to estimate the clinical relevance of FPTC detected using an approach based on multiple molecular techniques.

Is entirely conservative management a correct strategy for hemodynamically stable patient with a grade IV blunt pancreatic injury

The first case of pancreatic injury was described by Travers in 1827, and long-held but uncertain opinions still surround this formidable disease. We commend Dr. Pata and colleagues for the notable information introduced into the nonoperative management for grade III blunt pancreatic injury [1] and raise one question with interest: As of the most recent follow-up, did you find any ‘‘upstream’’ chronic pancreatitis in this group of patients treated conservatively? Recently, we grappled with the case of a 20-year-old woman who sustained a road traffic accident. She was vigilant and hemodynamically stable all of the time, although a multidetector double-contrast computed tomography scan showed complete pancreatic transection to the right of the superior mesenteric vessels with no associated duodenal injury and a 4.7 cm hematoma in segment VI of the liver. The serum amylase level was 1097 U/l. Considering both the aforementioned hemodynamic stability and grade IV pancreatic disruption, we elected to manage the patient conservatively with bowel rest, total parenteral nutrition, gabexate mesylate, octreotide, meropenem, teicoplanin, and paracetamol. The patient made a full recovery on conservative treatment, resuming oral intake on day 10 and becoming dischargeable on day 23 after admission. At the 18-month follow-up, she maintained a satisfactory healthy state and magnetic resonance pancreatography revealed atrophy to the pancreatic body-tail together with dilated Wirsung and secondary ducts. In this era of damage control management, many endeavors have provided a unanimous consensus for an algorithm to follow for trauma to the spleen, liver, and kidney but not for the pancreas [2]. Each case seems unique and thus hinders us from drawing the basic outlines for a uniform diagnostic and therapeutic algorithm. Currently, conservative management of stable adults and children with blunt pancreatic injury is the norm in cases of low-grade (I–II) injuries, as such lesions resolve spontaneously within 4 to 10 days. Controversies arise in the presence of a main pancreatic duct injury, which is recognized as the main determinant of morbidity and mortality [3]. In the pediatric literature some successful cases of nonoperative care are described for high-grade (III–IV) injuries [4]; in the adult literature, conversely, an entirely expectant management for grade III injuries was first described in 2009 [1] and, except for some cases treated by ancillary techniques, is still unprecedented for grade IV injuries. Historical treatments for grade IV pancreatic injuries include distal pancreatectomy, pancreaticoenterostomy, debridement with surgical drainage, percutaneous drainage, and pancreatic duct stenting [5]. We addressed a case of grade IV blunt pancreatic injury with a nonoperative strategy, avoiding any surgical, endoscopic, or interventional procedure during both the early and later period of observation. We encourage use of this approach for stable patients with class III–IV pancreatic lesions to augment information about this topic and tailor the best clinical practice for each case. Our caveat is that the clinical status of the patient, rather than the grade of pancreatic injury, should be the principal determinant to guide the diagnostic and therapeutic decisions. Surgery P. Mercantini E. Virgilio (&) T. Bocchetti A. Kazemi Nava V. Ziparo Department of General Surgery 1, II Faculty of Medicine La Sapienza of Rome, Hospital S. Andrea, Rome, Italy e-mail: aresedo1992@yahoo.it

Inferior vena cava resection with prosthesis replacement for recurrent leiomyosarcoma (with video)

Inferior vena cava (IVC) leiomyosarcoma (LY) is a rare tumor with poor prognosis and recurring in one third of patients, radical surgery represents the only chance of cure. Whether caval flow has to be re-established with IVC reconstruction is a matter of debate as well as neoadjuvant therapy. We herein present a case of recurrent IVC LY managed with caval resection and reconstruction with polyethylene terephthalate (PET) prosthesis and left lateral liver resection for suspected metastases. Although the patient experienced a prosthesis occlusion and transient renal failure, at 24 months’ follow-up is recurrence free with a normal renal function and no sign of lower limbs edema.