Francesco Monari

Total pancreatectomy: indications, operative technique, and results: a single centre experience and review of literature.

The aims of this study were to identify the indications to perform a total pancreatectomy and to evaluate the outcome and quality of life of the patient who underwent this operation. A retrospective analysis of a prospective database, regarding all the patients who underwent total pancreatectomy from January 2006 to June 2009, was carried out. Perioperative and outcome data were analyzed in two different groups: ductal adenocarcinoma (group 1) and non-ductal adenocarcinoma (group 2). Twenty (16.9%) total pancreatectomies out of 118 pancreatic resections were performed. Seven (35.0%) patients were affected by ductal adenocarcinoma (group 1) and the remaining 13 (65.0%) by pancreatic diseases different from ductal adenocarcinoma (group 2) [8 (61.5%) intraductal pancreatic mucinous neoplasms, 2 (15.4%) well-differentiated neuroendocrine carcinomas, 2 (15.4%) pancreatic metastases from renal cell cancer and, finally, 1 (7.7%) chronic pancreatitis]. Eleven patients (55%) underwent primary elective total pancreatectomy; nine (45%) had a completion pancreatectomy previous pancreaticoduodenectomy. Primary elective total pancreatectomy was significantly more frequent in group 2 than in group 1. Early and long-term postoperative results were good without significant difference between the two groups except for the disease-free survival that was significantly better in group 2. The follow-up examinations showed a good control of the apancreatic diabetes and of the exocrine insufficiency without differences between the two groups. In conclusion, currently, total pancreatectomy is a standardized and safe procedure that allows good early and late results. Its indications are increasing because of the more frequent diagnose of pancreatic disease that involved the whole gland as well as intraductal pancreatic mucinous neoplasm, neuroendocrine tumors and pancreatic metastases from renal cell cancer.

Radiofrequency Ablation for Advanced Ductal Pancreatic Carcinoma: Is this Approach Beneficial for Our Patients? A Systematic Review

To the Editor:Radiofrequency ablation (RFA) is a local ablative method used for the palliative treatment of solid tumors, and it should be an attractive approach in patients with unresectable, locally advanced, and nonmetastatic pancreatic cancer. We aimed to systematically review the results of RFA

The Problems of Radiofrequency Ablation as an Approach for Advanced Unresectable Ductal Pancreatic Carcinoma

Advanced ductal pancreatic carcinoma (PC) remains a challenge for current surgical and medical approaches. It has recently been claimed that radiofrequency ablation (RFA) may be beneficial for patients with locally advanced or metastatic PC. Using the MEDLINE database, we found seven studies involving 106 patients in which PC was treated using RFA. The PC was mainly located in the pancreatic head (66.9%) with a median size of 4.6 cm. RFA was carried out in 85 patients (80.1%) with locally advanced PC and in 21 (19.9%) with metastatic disease. Palliative surgical procedures were carried out in 41.5% of the patients. The average temperature used was 90 °C (with a temperature range of 30–105 °C) and the ratio between the number of passes of the probe and the size of the tumor in centimeters was 0.5 (range of 0.36–1). The median postoperative morbidity and mortality were 28.3% and 7.5%, respectively; the median survival was 6.5 months (range of 1–33 months). In conclusion, RFA is a feasible technique: however, its safety and long-term results are disappointing; Thus, the RFA procedure should not be recommended in clinical practice for a PC patient.

Asymptomatic Cholecystocolonic Fistula: A Diagnostic and Therapeutic Dilemma

Cholecystocolonic fistulas (CCF) are rare complications of gallstones with a variable clinical presentation. Despite modern diagnostic tools, cholecystocolonic fistulas are often asymptomatic and it is difficult to diagnose them preoperatively. Biliary-enteric fistulae have been found in 0.9% of patients undergoing biliary tract surgery. The most common site of communication of the fistula is the cholecystoduodenal (70%), followed by the cholecystocolic (10–20%), and the least common is the cholecystogastric fistula. Herein, we report a case of female patient with multiple episodes of acute recurrent cholangitis due to common bile duct and gallbladder stones in which preoperative imaging studies were negative for cholecystocolonic fistula that was incidentally discovered and treated during surgery and was appropriately treated. A review of the literature is reported too.

Laparoscopic appendectomy: Which factors are predictors of conversion? A high-volume prospective cohort study

UNLABELLED Appendicitis represents one of the most frequent condition requiring surgery. In Italy almost 0.2% of the population will be affected by acute appendicitis every year. Laparoscopic appendectomy (LA) has gained acceptance over the past years and despite several meta-analyses, randomized studies and retrospective studies have been conducted, the indications and results are still conflicting especially in cases of complicated appendicitis. The aim of our study is to evaluate which factors are related to conversion to open appendectomy (OA) during laparoscopic appendectomy (LA). MATHERIALS AND METHODS From September 2011 to May 2013, appendectomy for acute appendicitis was performed on 434 patients in our Surgical Unit at S. Orsola-Malpighi Hospital, Bologna, Italy. Of these, 369 patients (85%) underwent LA. The clinical, demographic, surgical and pathological data of these patients were included in a prospective database. To note, only laparoscopic appendectomies were considered to be included in the analysis. The following factors were analyzed in order to identify which were associated with the conversion: age, sex, body mass index (BMI), previous abdominal surgery, comorbidities, clinical and laboratory parameters including Alvarado score, PCR, intraoperative findings such as anatomy and degree of inflammation. During our study period, laparoscopic appendectomies were performed by different surgeons both residents and attending surgeons. The decision to convert the intervention in an open procedure was taken by the individual surgeon. Regarding the postoperative period, were considered the time of hospitalization and related costs, time of oral intake of liquid and solid, time of passage of stool, readmissions and reoperations. RESULTS At univariate analysis, the factors significantly related to the conversion were the presence of comorbidities (p < 0.001) and, among these, the presence of arterial hypertension (p = 0.006) or other cardiovascular diseases (p = 0.031) and the history of previous abdominal surgery (p = 0.023). Patients with higher mean age (33.9 ± 15.4 vs. 46.0 ± 19.3, p = 0.001) and higher body mass index (BMI) (23.5 ± 4.3 vs 25.8 ± 4.9 kg/m(2), p = 0.006) had a higher risk of conversion. Multivariate analysis finally showed that factors significantly related to the conversion were the presence of comorbidities (p = 0.029), the presence of an appendiceal perforation (p = 0.003), a retrocecal appendix (p = 0.004), the presence of appendicular abscess (p = 0.023) and the presence of diffuse peritonitis (p = 0.008). CONCLUSION The majority of patients with acute appendicitis can be successfully managed with laparoscopy. We found that the only preoperative independent factor related to conversion during laparoscopic appendectomy is the presence of comorbidities. Nevertheless surgeons should take into account that presence of peri-appendicular abscess and diffuse peritonitis are both independently related not only to higher rate of conversion but also to higher risk of postoperative complication.

Treatment of advanced gastric cancer with cetuximab plus chemotherapy followed by surgery. Report of a case.

The prognosis of patients affected by advanced gastric cancer who did not undergo non-curative resection is extremely poor. We report a case of a 26-year-old woman affected by gastric cancer with peritoneal carcinosis in whom surgical treatment was not considered. The patient was enrolled in the Italian phase II trial of cetuximab (Erbitux, Merck KGaA, Darmstadt, Germany), a monoclonal antibody, in combination with docetaxel and cisplatin chemotherapy. Restaging of the tumor showed progressive regression, so the patient underwent a total gastrectomy. The patient is alive, well and disease-free ten months after surgery. The good result achieved in this patient provides interesting prospects for chemotherapy combined with cetuximab, followed by surgery.

Safety of Pancreatic Resections in Octogenarians

Context The safety of pancreatic resections in very elderly patients is still controversial. Objective To evaluate postoperative mortality, morbidity, type of discharge and length of hospital stay (LOS) in octogenarians who underwent pancreatic resections for malignancy. Methods From 2004 to 2013, 213 patients underwent pancreatic resections and were recorded in a prospective data base. They were divided in three groups: <70 years, 70-80 years and ≥80 years and were analyzed regarding postoperative course. Multivariate analysis was carried out to verify the impact of age on postoperative results. Results Mortality rate was higher (P=0.029) in patients ≥80 years (16.7%) only when compared with patients <70 years (3.4%). Morbidity rate was similar in the three groups. The discharge home was more frequent in patients <70 years (94.6%) and in those 70-80 years (92.3%) respect on patients ≥80 years (55%; P<0.001). LOS was similar in patients <70 years and in those 70-80 years, while it results higher in those aged ≥80 years (P=0.021). At multivariate analysis, patients aged 70-80 and ≥80 years had an increased risk of postoperative mortality (OR=7.1, P=0.022 and OR=6.3, P=0.050, respectively) as well as malnourishment (OR=4.5, P=0.029). Age did not influence morbidity while ASA score 4 increased risk of complications (OR=7.0, P=0.018). Distal pancreatectomy (DP) or an atypical resection reduced the risk (OR=0.4, P=0.008 and OR=0.1, P=0.049, respectively) respect on major procedures. Discharge to health care facility was more frequent in patients ≥80 years (OR=74.5, P<0.001), with ASA score 4 (OR=48.9, P=0.023), comorbidities (OR=25.4, P=0.011) or jaundice (OR=119.2, P=0.004) and in those performing DP (OR=26.7, P=0.039). Biliary stenting reduced the odds to health care facility (OR=0.1, P=0.041). LOS was increased by comorbidities, chronic renal failure and jaundice by 25% (P=0.039), 64% (P=0.003) and 36% (P=0.010), respectively. Total pancreatectomy reduced LOS by 14% (P=0.036). Conclusions Age ≥80 years increased the risk of postoperative mortality and discharge to health care facility after pancreatic resections.

Are Pancreatic Resections Cost-Effective in Elderly Patients?

Context The impact on heath care service of pancreatic resections in elderly patients is unknown. Objective To evaluate the costs of postoperative stay in elderly patients undergone pancreatic resections for malignancy. Methods From 2004 to 2013, 213 patients underwent pancreatic resections and were recorded in a prospective data base. They were divided in three groups (<70 years, 70-80 years and ≥80 years) and analyzed regarding the costs and overall long-term survival (OS). Multivariate analysis was carried out to verify the impact of age, on postoperative costs and long-term results. Results The total costs of postoperative stay of pancreatic resections was higher in patients aged 70-80 years (11,461±9,352€; P=0.050) and in those ≥80 years (13,130±10,000€; P=0.032) in comparison to patients <70 years (8,855±8,479€). The cost of ordinary stay was higher in patients aged ≥80 yrs (9,325±8,855€) when compared with both patients <70 years (5,726±3,866€; P=0.002) and 70-80 years (5,856±4,769€; P=0.016). ICU stay costs were increased in patients aged 70-80 years (5,605±7,352€; P=0.020) respect on those <70 years (3,129±6,895€). Age, presence of comorbidities, jaundice and chronic renal failure increased the total costs by 15% (P=0.031), 25% (P=0.011), 29% (P=0.004), and 80% (P=0.001), respectively, at multivariate analysis. Total pancreatectomy reduced total costs by 12% (P=0.033). Age did not influence ordinary costs while cardiac disease, chronic renal failure, and jaundice increased them by 12% (P=0.044), 78% (P=0.002) and 17% (P=0.049), respectively. Total pancreatectomy and presence of hard pancreatic stump reduced ordinary costs by 18% (P=0.001) and 79% (P=0.048), respectively. Comorbidities and ductal adenocarcinoma increased ICU costs by 40% (P=0.033) and 18% (P=0.018), respectively. Age ≥80 years (HR=3.2; P=0.003), ASA score=3 (HR=2.2; P=0.011), comorbidities (HR=1.7; P=0.015), jaundice (HR=2.6; P=0.004), tumor-related pain (HR=1.8; P=0.001) and reoperation (HR=2.9; P=0.015) reduced the OS. Malignant cystic and endocrine tumors were related to a longer OS (HR=0.17; P=0.019 and HR=0.18; P=0.001, respectively). Conclusions Pancreatic resections in elderly patients with comorbidities affected by ductal adenocarcinoma were not cost-effective.

Serous Cystic Tumor of the Pancreas: Are There Indications to Operate?

Context Serous cystic tumours (SCTs) of the pancreas are regarded as a benign entity with rare malignant potential. Surgical resection is generally considered curative. It was usually performed in large, symptomatic tumours or in cases in which the diagnosis was not clear. Objective To evaluate factors related to the surgical indication. Methods From 2000 to 2013, data of 43 patients affected by SCTs were collected in a prospective database. Demographics, clinical, radiological, surgical and pathological data were considered as factors related to surgical indication. After 2000 all patients were observed by a dedicated team including radiologists, surgeons, gastroenterologists and pathologists. Thus, patients were divided in two periods, before and after the 2000, to assess if there had been difference over the time in the management of this type of tumours. Univariate and multivariate analysis were performed. Results Thirty-three patients (76.7%) underwent surgical resection, while 10 (23.3%) entered in a surveillance program. At univariate analysis, factors related to surgery were: symptoms (P=0.026), radiological presence of microcysts of diameter <1 mm (P=0.020) and radiological diagnosis different from a SCTs (P=0.018). The multivariate analysis confirmed that symptoms increased the risk of surgery (OR=34.0; 95% CI: 2.1-545.1; P=0.013). The period in which the patients were enrolled, before and after 2000, did not influence the indication to surgery. Conclusions In our experience the only factor related to surgery was the presence of symptoms.

Locally Advanced Pancreatic Cancer: Is It Possible Pancreatic Resection? A Case Report

Context Patients with locally advanced pancreatic cancer are usually treated with chemoradiotherapy and rarely they became resectable. Herein, we present the case of a patient with locally advanced pancreatic cancer. Case report A 56-year-old man was observed in October 2011 because of high blood levels of CA 19.9 (>230 U/mL) and the presence of a pancreatic mass of the uncinate process (diameter 3.8x3.5 cm) revealed by US and CT scan. An US-guided biopsy allowed the diagnosis of well differentiated pancreatic adenocarcinoma, biliopancreatic type. CT scan showed a vascular involvement of both superior mesenteric vein and artery. The disease was defined as locally advanced unresectable pancreatic cancer. The patient started chemotherapy with gemcitabine and oxaliplatin. Five months later, CT scan re-evaluation of the disease showed a stable disease. Thus, a protocol of radio-chemotherapy was suggested. Eight months later from diagnosis, the mass was still unresectable. Other eight cycles of gemcitabine and oxaliplatin were performed. In February 2013 a further CT scan evaluation demonstrated a smaller lesion (3.5x2.2 cm) and also the vascular involvement was decreased, still without a normal fat plane between the tumor and the vessels. Another cycle of gemcitabine and oxaliplatin was completed. At the end of May 2013, the 18 FDG-PET was negative; CT scan demonstrated a further decreased of the mass (maximum diameter: 2.5 cm) while the mesenteric vessels involvement still remained. Moreover, the genomic characteristics of the patient DNA were different from other the pancreatic cancer. Because of the long-term survival of the young patient, the partial regression of the disease and the genomic characteristics of the tumor, a surgical approach was indicated. The patient underwent to a total pancreatectomy with splenectomy plus segmental resection of portal mesenteric trunk. Pathological diagnosis confirmed a well-differentiated ductal pancreatic carcinoma, biliopancreatic type (T4), with R0 resection. Conclusion Our case suggests that there are locally advanced pancreatic cancers in which chemoradiotherapy can allow surgical pancreatic resection probably because they have particular genomic characteristics.