Andrea Mazzari

Severe acute pancreatitis: advances and insights in assessment of severity and management.

The patients with acute pancreatitis are at risk to develop different complications from ongoing pancreatic inflammation. Often, there is no correlation between the degree of structural damage to pancreas and clinical manifestation of the disease. The effectiveness of any treatment is related to the ability to predict severity accurately, but there is no ideal predictive system or biochemical marker. Severity assessment is indispensable to the selection of proper initial treatment in the management of acute pancreatitis. The use of multiparametric criteria and the evaluation of severity index permit us to select high-risk patients. Furthermore, contrast-enhanced computed tomographic scanning and contrast-enhanced MRI play an important role in severity assessment. The adoption of multiparametric criteria proposed together with morphological evaluation consents the formulation of a discreetly reliable prognosis on the evolution of the disease a few days from onset.

Laparoscopic surgery for colorectal cancer is not associated with an increase in the circulating levels of several inflammation-related factors.

It has been hypothesized that inflammatory response triggered by surgery might induce the release of molecules that could promote proliferation, invasion and metastasis of surviving cancer cells. To test this hypothesis, the levels of multiple inflammation-related circulating factors were analyzed in patients undergoing surgery for colorectal cancer. A Luminex xMAP system was used to simultaneously assess levels of IL-1β, IL-1ra, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-9, IL-10, IL-12, IL-13, IL-15, IL-17, FGF, eotaxin, G-CSF, GM-CSF, IFN-γ, IP-10, MCP-1, MIP-1α, MIP-1β, PDGF-BB, RANTES, TNF-α and VEGF in 20 colorectal cancer patients and 10 age-matched non-neoplastic patients. In cancer patients analyses were performed at baseline (before surgery) and at different time points (up to 30 days) following laparoscopic surgery. Significantly higher levels of IL-1β, IL-7, IL-8, G-CSF, IFN-γ and TNF-α were detected in colorectal cancer patients compared to controls at baseline. In colorectal cancer patients, circulating levels decreased progressively following surgery and after day 30 post-surgery were no longer different from controls. These findings suggest that expression levels of several cytokines are higher in colorectal cancer patients compared to control subjects and no significant increase in several inflammation-related circulating factors is observed following laparoscopic surgery for cancer. Confirmation and validation in a different and larger cohort of patients are warranted.

Food residue granuloma mimicking metastatic disease on FDG-PET/CT

A 31-year-old woman presenting with acute abdomen underwent an emergency Hartmann’s procedure for fecal peritonitis due to perforated adenocarcinoma of the left colon. Shortly after a 7-month course of adjuvant chemotherapy, follow-up contrast-enhanced CT showed multiple peritoneal and hepatic nodules, showing focal intense and homogeneous FDG uptake on FDG-PET/CT, highly suspected for recurrence of disease. Excisional biopsy of the nodules revealed foreign body granulomas made up of alimentary materials surrounded by a fibrous wall. We report a unique case of a false-positive finding secondary to food residues mimicking metastatic disease on FDG-PET in a patient with colon cancer.

Extended or limited lymph node dissection? A gastric cancer surgical dilemma

W e read with great interest the article by Memon and coworkers1 reporting the outcome of a meta-analysis of randomized controlled trial evaluating the efficacy and drawbacks of limited (D1) versus extended (D2) lymphadenectomy for proven gastric carcinoma. This is a very excellent article; the basic organization of this report is clear and convincing, and the associated conclusions and recommendations are based on a review by investigators with long-standing interest in gastric disorders.2–4 Worldwide, gastric cancer is one of the top-3 leading causes of cancer mortality, but their incidence and presentation vary geographically. Currently, surgery is the only possible cure. Nodal status is an important prognostic indicator for gastric cancer, and despite results of randomized controlled trials, debate continues over the importance of aggressive lymphadenectomy. On the basis of the results of the meta-analysis, the authors conclude that D1 gastrectomy is associated with significant fewer anastomotic leaks, postoperative complication rate, and reoperation rate, decreased length of hospital stay, and 30-day mortality rate. Finally, the 5-year survival in patients who underwent D1 gastrectomy was similar to the D2 cohort.1 Similar results have been founded in recent meta-analysis.5 Overall, 14 randomized controlled trials (3432 patients) were included in the meta-analysis. Of the D1 and D2 surgery groups, the operative mortality and postoperative morbidity were higher in the D2 group than in the D1 group, but the 3and 5-year survival rates were not statistically different. Also, the operative time was shorter in the D1 group than in the D2 group. In the D2 versus D3 surgical group, the operative mortality, percentage of postoperative complications, operative time, and hospital stay were not significantly different. The results suggest that D2 and D3 surgical

Laparoscopic Splenectomy for Atraumatic Splenic Rupture

A traumatic splenic rupture (ASR) is a rare clinical entity. Several underlying benign and malignant conditions have been described as a leading cause. We report on a case of ASR in a 41-year-old man treated with laparoscopic splenectomy. Considering ASR as a life-threatening condition, a prompt diagnosis can be life saving.

Surgical treatment of gastric cancer in elderly patients

Gastric adenocarcinoma is considered a disease of the elderly, with a peak incidence in the seventh and eighth decades of life. In the elderly, biochemical changes in tissues and in organ physiology, in association with Helicobacter pylori infection, lead to atrophic gastritis, with an increased risk of developing cancer. Gastric cancer in the elderly is often diagnosed at an advanced stage and is associated with a poor prognosis in terms of disease-free and overall survival. Surgical treatment of gastric cancer in these patients remains controversial due to the increased perioperative risk; instead, subtotal gastrectomy is preferred when feasible. Total gastrectomy with or without combined resections of adjacent organs is associated with higher rates of postoperative morbidity and mortality. For advanced cancer, palliative resection is preferable, whenever possible, to gastroenterostomy. Morbidity and mortality are higher in the elderly, probably related to the comorbidities in these patients. T stage, lymph node metastases, and depth of invasion of the primary tumor are recognized as independent prognostic factors in terms of overall survival. The impact of multimodality treatment in the elderly cannot be clearly evaluated; currently, adjuvant chemotherapy is recommended in otherwise healthy patients. In general, age alone has not been definitively confirmed as a negative prognostic factor in patients with gastric cancer and should not preclude gastric resection. After radical resection, elderly patients have the same chance of survival as middle-age patients.

Surgical Management of Colorectal Cancer in the Elderly Patient

In both Europe and the United States, approximately 50% of colorectal cancer patients are older than 70 years of age, and, among these, colorectal cancer is the second leading cause of cancer death. Moreover, life expectancy has lengthened in elderly patients.

Heterotopic Pancreas Presenting as a Jejunal Nodule in a Young Patient with Breast Cancer

Heterotopic pancreas (HP) is defined as the presence of pancreatic tissue in an aberrant location, without any vascular or anatomical continuity with the normal pancreas. HP is a rare condition occurring in 0.11%‡0.21% at autopsy, with a male to female ratio of 3:1 and a peak age incidence between the 4th and 6th decades of life. Up to 90% of HPs are found in the upper gastrointestinal tract, involving the stomach, duodenum or jejunum. We report a case of HP presenting as a jejunal nodule found in a young girl during the staging of breast cancer.

Surgery for Small-Bowel Disease

The small bowel can be involved by several pathologic conditions whose diagnosis is often difficult. Current diagnostic tools include enteric NMR, double-balloon ileoscopy, and PillCam, all of which are helpful for decision-making in many cases.The prompt diagnosisof congenital malformations, inflammatory diseases, ischemia, diverticulosis, and neoplasms allows successful treatment. In considering the different modalities of resection and reconstruction, surgeons must also take into account the small bowel’s nutritional functions. The increasing use of a laparoscopic approach remains controversial despite reported successes. This chapter is a short but nonetheless thorough description of the surgical management of small-bowel diseases.