C. Bassi

Prognostic factors at diagnosis and value of WHO classification in a mono-institutional series of 180 non-functioning pancreatic endocrine tumours

BACKGROUNDnNon-functioning pancreatic endocrine tumours (NF-PETs) are an aggressive gastroenteropancreatic neoplasm. The present study assessed survival, value of World Health Organisation (WHO) classification and prognostic utility of clinicopathological parameters at diagnosis.nnnPATIENTS AND METHODSnFrom 1990 to 2004, 180 patients with NF-PETs were entered in a prospective database, and predictors of prognosis were tested in uni- and multivariate models.nnnRESULTSnThere were 25 (14%) benign lesions, 38 (21%) neoplasms of uncertain behaviour, 100 well-differentiated carcinomas (56%) and 17 poorly differentiated carcinomas (9%). Radical resection was possible in 93 cases (51.6%). Overall 5-, 10- and 15-year survival rates were 67%, 49.3% and 32.8%, respectively, and were significantly higher in radically resected patients (93%, 80.8% and 65.2%, respectively; P < 0.00001). By multivariate analysis, poor differentiation [hazard ratio (HR) 7.3; P = 0.0001], nodal metastases (HR 3.05; P = 0.02), liver metastases (HR 3.29; P = 0.003), K(i)-67 >5% (HR 2.5; P = 0.012) and weight loss (HR 3.06; P = 0.001) were significantly associated with mortality.nnnCONCLUSIONnThis study confirms the good long-term survival of patients with NF-PETs and the prognostic value of WHO classification, liver metastases, poor differentiation, Ki-67, nodal metastases and weight loss. These latter two parameters have a prognostic value similar to that of liver metastases and Ki-67.

Practical guidelines for acute pancreatitis

Introduction: The following is a summary of the official guidelines of the Italian Association for the Study of the Pancreas regarding the medical, endoscopic and surgical management of acute pancreatitis. Statements: Clinical features together with elevation of the plasma concentrations of pancreatic enzymes are the cornerstones of diagnosis (recommendation A). Contrast-enhanced computed tomography (CT) provides good evidence for the presence of pancreatitis (recommendation C) and it should be carried out 48–72 h after the onset of symptoms in patients with predicted severe pancreatitis. Severity assessment is essential for the selection of the proper initial treatment in the management of acute pancreatitis (recommendation A) and should be done using the APACHE II score, serum C-reactive protein and CT assessment (recommendation C). The etiology of acute pancreatitis should be able to be determined in at least 80% of cases (recommendation B). An adequate volume of intravenous fluid should be administered promptly to correct the volume deficit and maintain basal fluid requirements (recommendation A); analgesia is crucial for the correct treatment of the disease (recommendation A). Enteral feeding is indicated in severe necrotizing pancreatitis and it is better than total parenteral nutrition (recommendation A). The use of prophylactic broad-spectrum antibiotics reduces infection rates in CT-proven necrotizing pancreatitis (recommendation A). Infected pancreatic necrosis in patients with clinical signs and symptoms of sepsis is an indication for intervention, including surgery and radiological drainage (recommendation B). Conclusions: The participants agreed to revise the guidelines every 3 years in order to re-evaluate each question on the management of acute pancreatitis patients according to the most recent literature.

Exocrine pancreatic insufficiency in adults: A shared position statement of the Italian association for the study of the pancreas

This is a medical position statement developed by the Exocrine Pancreatic Insufficiency collaborative group which is a part of the Italian Association for the Study of the Pancreas (AISP). We covered the main diseases associated with exocrine pancreatic insufficiency (EPI) which are of common interest to internists/gastroenterologists, oncologists and surgeons, fully aware that EPI may also occur together with many other diseases, but less frequently. A preliminary manuscript based on an extended literature search (Medline/PubMed, Cochrane Library and Google Scholar) of published reports was prepared, and key recommendations were proposed. The evidence was discussed at a dedicated meeting in Bologna during the National Meeting of the Association in October 2012. Each of the proposed recommendations and algorithms was discussed and an initial consensus was reached. The final draft of the manuscript was then sent to the AISP Council for approval and/or modification. All concerned parties approved the final version of the manuscript in June 2013.

Blunt Pancreatic Trauma: Role of CT

Purpose: To define the evolution patterns of blunt pancreatic trauma, and to point out the CT features most significant for the diagnosis. Material and Methods: Ten cases of pancreatic trauma, observed over a period of about 10 years, were analyzed in retrospect. The cases were divided into 3 groups according to the time that had elapsed between trauma and first CT: early phase (within 72 h: n=3/10); late phase (after 10 days: n=3/10); and following pancreatic drainage (n=4/10). Results: In the early phase, one case showed a blood collection surrounding the pancreatic head and duodenum, and displacing the mesenteric vessels to the left. In the 2 other cases it was possible to demonstrate a tear in the pancreas at the neck, perpendicular to the main pancreatic axis. In the late phase in all 3 cases, one cystic lesion was present at the site of the tear, either surrounding the gland or embedded - more or less deeply - within the parenchyma. One of the lesions subsided spontaneously; the 2 others required surgery. In the postoperative phase, an external fistula was demonstrated in 2 cases following percutaneous drainage of pancreatic cysts; the fistula was fed by a cystic lesion in the pancreatic neck. In the 2 other cases a pseudocyst developed. Conclusion: Early demonstration of a parenchymal tear was difficult. At a later stage the diagnosis was easier owing to the demonstration of cystic lesions within the parenchyma at the site of the tear. The surgical drainage of this lesion does not usually lead to healing since an external fistula or a pseudocyst may develop.

Management of Digestive Tract Fistulas

: Digestive tract fistulas are a complex subject in terms both of classification and management. There is still a lack of firm epidemiological data regarding the their incidence, though the prognostic factors conditioning the prognosis of these patients are now well known. They are related mainly to the nutritional status of the patients and to the presence or otherwise of sepsis. Instrumental investigations should be aimed not merely at identifying the complication, but also at guiding clinicians in their choice of therapeutic management. According to the various situations arising, the treatment will be surgical, endoscopic or conservative medical. In the latter case, the clinician should establish first of all whether, as a result of the site of the fistula or the nutritional status, the patient requires total parenteral or enteral artificial nutrition, whenever possible. In those cases in which parenteral nutrition is indicated, the ideal drug with the best proven ability to shorten healing times and reduce the number of complications when used in combination with parenteral nutrition is naturally occurring somatostatin at the dose of 250 micrograms/h over 24 h. In all other cases, if the fistula is clinically important, its synthetic analogue, octreotide, should be the drug of choice and can be administered subcutaneously. The amount of octreotide administered ranges from 300 to 600 micrograms/day in 3 or 4 daily doses.

Derivative Surgical Treatment

Most patients suffering from chronic pancreatitis are referred to the surgeon for the presence of disabling pain which fails to respond to conservative medical therapy [1]. In most medico-surgical patient series, from 30 % to 60 % of patients with chronic pancreatitis are treated surgically for this indication at some time in the course of the disease. Other indications for surgical treatment include pseudocysts, mechanical jaundice, bleeding oesophageal varices, duodenal stenosis, pancreatic ascites and suspected presence of carcinoma [2].

P.1.30: SECONDARY CANCERS IN PATIENTS WITH INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM OF THE PANCREAS (IPMN): PRELIMINARY RESULTS OF A PROSPECTIVE MULTICENTRE ITALIAN STUDY

and moderate-severe steatosis (OR 2.1; 95%CI, 1.1-4.1; p=0.03). SVR rates were not related to HOMA in the overall population [63% (220/351) vs 60% (29/48), p=0.75], nor in subgroup analysis by virus genotype [genotype 1: 43% (61/143) for ≤ 2 HOMA vs 53% (9/17) for > 2 HOMA (p=0.45); genotype 2 and 3: 83% (143/173) vs 80% (20/25), p=0.78, respectively]. In SVR patients, baseline and follow up HOMA values were similar (1.12±0.82 vs 1.17±1.1, p=0.25). Conversely, nonresponders had increased HOMA values trough 18 months follow up (from 1.17±0.7 to 1.49±1.3, p=0.007); IR de-novo occurred more frequently in non-SVR than in SVR patients [24% (25/106) vs 8% (16/198), p=0.0003]. Conclusions: While the outcome of Peg-IFN/Rbv therapy is not influenced by IR, the latter is prevented once SVR is achieved.

Non-Adenocarcinoma Pancreatic Tumors

Diagnosis, localization and surgical as well as medical treatment of most endocrine pancreatic tumors is nowadays clearly established and not a matter of debate. This is especially true for sporadic benign insulinomas, gastrinomas or more rare tumors like VIPomas or glucagonomas. Controversies still exist in hereditary tumors, mainly in symptomatic gastrinomas and insulinomas, occurring within the syndrome of multiple endocrine neoplasia type I (MEN I). Since the recent description of the mutation in chromosome 11 associated with MEN I [1] the question of how we should deal with asymptomatic patients detected by genetic and/or biochemical screening also became controversial.