Benedetto Ielpo

Does robotic distal pancreatectomy surgery offer similar results as laparoscopic and open approach? A comparative study from a single medical center.

In the field of pancreatic surgery, robotic surgery has yet to be evaluated against open and laparoscopic approaches. The outcomes of robotic surgery for distal pancreatectomy were analysed and the results compared with those of laparoscopic and open procedures.

Robotic versus laparoscopic rectal resection: is there any real difference? A comparative single center study.

Robotic surgery has gained worldwide acceptance in the past decade, and several studies have shown that this technique is safe and feasible. The aim of this study is to compare main outcomes of laparoscopic and robotic rectal resection.

Proctalgia as a late complication of stapled hemorrhoidectomy. Report of our case series

INTRODUCTION Incidence and etiology of persistent pain after stapled hemorrhoidectomy remain uncertain. Characteristics, clinical course and management of this complication have not yet been assessed. Purpose of this essay is to describe our experience with persistent pain in our series of patients with this technique. METHODS This retrospective study evaluated 126 cases of stapled hemorrhoidectomy treated from 2006 to 2009. We gathered information on each patient regarding type of prolapsed hemorrhoids, number of haemostatic suture placed, histology of each doughnut and post operative complications. A close follow up was done in those patients complaining about pain. RESULTS Early and late complications occurred in 11.9% and 16.7% of patients respectively. At two weeks from surgery 18 patients (14.3%) were complaining of persistent pain. The average number of haemostatic sutured placed in this group and in all series is 4.5 and 2.5 respectively. Eight patients (6.34%), 3 (2.4%) and 2 (1.6%) patients were still complaining of persistent pain at 1 month, 4 months and 6 months of follow up, respectively. In these patients, endoanal manometry was normal at 4 months from surgery, while endoanal ultrasound showed retained staples in 3 of them. At 7 months from surgery a staples removal was performed in 2 patients that were still complaining of pain. CONCLUSIONS Incidence of pain at 2 weeks after surgery resulted in 14.3% of patients. In most patients its etiology remains unclear but we reckon it might be related to the high number of haemostatic sutures placed. Staples removal resulted successfully.

Alternative Arterial Reconstruction After Extended Pancreatectomy. Case Report and Some Considerations of Locally Advanced Pancreatic Cancer

CONTEXT The clinical benefits of distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic body cancer remains controversial and, therefore, declared unresectable in most cases. Appleby first described extended distal pancreatectomy with celiac axis resection for locally advanced gastric cancer. CASE REPORT We report a case of a 65-year-old female who presented a locally advanced pancreatic carcinoma with infiltration of celiac axis. After radio-chemo neoadjuvant treatment, the patient underwent exploratory laparoscopy and subsequent distal pancreatectomy with en bloc resection of celiac axis. Arterial reconstruction was necessary as hepatic flow was not adequate, determined by intraoperative Doppler ultrasonography. It consisted of end to end anastomosis with prosthetic graft between hepatic artery directly to the aorta, as an atheromatous plaque was at the origin of the celiac axis. The postoperative course was uneventful with a perfect relief of pain. She presents a long term survival of 36 months, very exceptional for this type of disease. CONCLUSION The particularity of this case is not only the surgical treatment, rarely offered to these patients, but also and especially the subsequent vascular reconstruction. To our knowledge, this is the first report of this type of arterial reconstruction. Besides, we briefly discuss the recent advances in results of extended distal pancreatectomy with arterial resection for locally advanced pancreatic carcinoma.

Bowel perforations in a patient affected by Churg–Strauss syndrome under high-dose steroid treatment: will alternative drugs reduce risk of surgery?

Churg–Strauss syndrome is a relapsing–remitting vasculitis that frequently involves digestive system. Ischemic perforation of the large bowel is relatively rare and potentially life threatening. We report a case treated with high dose of steroids for a relapsing of Churg–Strauss vasculopathy that underwent emergency surgery for multiple large-bowel perforations. Massive use of steroids is common for controlling relapse of this disease, but this increases the risk of intestinal perforation. A prompt switching to alternative drugs when intestinal tract is involved should be considered in order to prevent surgery.

Pearls and pitfalls on ALPPS procedure: new complications in a new technique

The Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) procedure is a new innovative surgical strategy aiming to potentially overcome the liver failure secondary to major liver resection. It represents a modification of the two-stage hepatectomy in which a complete parenchymal transection is associated along with the tumor clearance of one lobe along with the ligation of the contralateral portal vein, too. It allows increase in the future liver remnant (FLR) hypertrophy in a shorter time. Since the first report of this technique by Baumgart [1] a number of case reports have been published, gaining a wide interest and reactions from all over the world [2]. ALPPS benefits are mostly clear; however, its indications and postoperative morbidity/mortality are still under investigations. It is difficult to draw conclusions about it as only case reports and case series with heterogeneous groups have been reported. The aim of this letter is to describe the experience acquired with ALPPS procedure in our center in order to point out the ‘‘pearls’’ and ‘‘pitfalls’’ of this technique. Between January 2011 and May 2013, five ALPPS procedures were performed in our center. Four for colorectal liver metastases (3 metachronous, 1 synchronous) and received preoperative chemotherapy, one for intrahepatic cholangiocarcinoma (Table 1). One patient underwent concomitant right colectomy for colonic cancer. In the first stage we have cleared the FLR from malignancies, associating the liver partition and ligation of opposite portal vein. Planned CT scan volumetry was performed post-first ALPPS stage at 7 days, in order to calculate the FLR hypertrophy. Second stage is performed when an adequate FLR is reached, repeating CT scan every week. Parenchymal resection is performed with electrocautery and CUSA device. Post-hepatectomy liver failure was determined according to the International Study Group of Liver Surgery classification [3]. Complications are classified according to the Clavien-Dindo classification [4]. Along the first step of ALPPS procedure, in case 1 we noted a macroscopic liver turgidity and change in color of the FLR, maybe due to an hyper perfusion, confirmed by Doppler ultrasound (100 cm/s). A spleno-renal venous shunt was performed to reduce the portal inflow allowing normalization of previous macroscopic and ultrasound characteristics (20 cm/s). The patient had a severe liver insufficiency, later recovered with MARS therapy. In case 3 a longitudinal left supra-hepatic vein resection was necessary to complete the liver transection (Table 1). Severe postoperative morbidity (CIIIB) occurred in three patients (60 %); mortality was in one patient (20 %) (Table 1). Reviewing the recent literature [2], there are not yet clearly reliable data concerning the actual complications of this technique. However, it seems that severe complications are higher than in the standard ‘‘two-stage’’ hepatectomy [5] when compared with the ALPPS procedure. In the last E-AHPBA meeting at Belgrade, the ALPPS mean morbidity reported ranged 43.8–50 % with a mean mortality of 14.9 % [5]. Main conclusions were that ALPPS is better than conventional ‘‘two-stage’’ procedures to achieve complete resection but at the price of a higher morbidity and mortality. B. Ielpo (&) Y. Quijano E. Vicente Sanchinarro University Hospital, Calle Oña 10, 28050 Madrid, Spain e-mail: ielpo.b@gmail.com

Giant pancreatic insulinoma. The bigger the worse? Report of two cases and literature review

INTRODUCTION Giant pancreatic insulinomas are rare endocrine tumors. We describe 2 cases reviewing the current literature. PRESENTATION OF CASE We report herein 2 female patients affected by giant insulinomas of 14cm and 6cm, respectively. Symptomatic hypoglycemia episodes occurred during 4 months in first case and 3 years in the second one until diagnosis. Both patients were successfully treated performing a distal pancreatectomy with splenic preservation in the first case and a Whipples procedure in the second one. DISCUSSION Up to now only 7 cases have been reported previously. Insulinomas larger than 3cm accounts for less than 5% of all. This literature review shows that despite the size hypoglycemic symptoms varies from 1 day to 3 years and only 1 out of 9 cases reported presented lymph nodes metastases. No recurrences have been described. CONCLUSION One of the cases here described (14cm) is the largest presented in the literature. Despite the size, giant insulinoma is related apparently neither to metastases nor to the recurrences.

A case of metachronous splenic metastasis from renal cell carcinoma after 14 years

We present a case of a patient who developed a metachronous splenic metastasis from renal clear cell carcinoma, for which he has undergone a left nephrectomy 14 years earlier. During his routine follow up a CT scan showed a splenic mass which was considered an isolated metastasis possibly originating from the renal cancer. A splenectomy was performed and histopatological examination of the spleen confirmed the presence of clear cell carcinoma with infiltration of the capsule. Splenic metastases are uncommon and from the reported literature we understand that splenic metastasis from renal cell carcinoma is extremely rare. The optimal treatment seems to be splenectomy with a good long term outcome. With this report the authors would like to discuss the possibility that it could be a case of local recurrence rather than a real metastasis. A revision of previous reports in the literature is performed too.

Pancreatic disease, panniculitis, polyarthrtitis syndrome successfully treated with total pancreatectomy: Case report and literature review

Highlights • PPP (pancreatic disease, panniculitis, polyarthritis) syndrome is a rare disease caused by pancreatitis or pancreatic cancer.• Panniculitis and polyarthritis are the main characteristics of the syndrome.• A high mortality rate and chronic sequel are reported.• Surgical and endoscopic treatment may improve the prognosis of this condition.

Sigue representando la infiltración arterial un criterio de irresecabilidad en el carcinoma de páncreas

As surgical resection remains the only hope for cure in pancreatic cancer (PC), more aggressive surgical approaches have been advocated to increase resection rates. Venous resection demonstrated to be a feasible technique in experienced centers, increasing survival. In contrast, arterial resection is still an issue of debate, continuing to be considered a general contraindication to resection. In the last years there have been significant advances in surgical techniques and postoperative management which have dramatically reduced mortality and morbidity of major pancreatic resections. Furthermore, advances in multimodal neo-adjuvant and adjuvant treatments, as well as the better understanding of tumor biology and new diagnostic options have increased overall survival. In this article we highlight some of the important points that a modern pancreatic surgeon should take into account in the management of PC with arterial involvement in light of the recent advances.