Giulio Di Candio

Long-term survival in pancreatic cancer: Pylorus-preserving versus Whipple pancreatoduodenectomy

BACKGROUND This study compared long-term survival in pancreatic or periampullary cancer treated with Whipple pancreatoduodenectomy (PD) and pylorus-preserving pancreatoduodenectomy (PPPD). METHODS Two hundred twenty-one patients with pancreatic head or periampullary cancer were treated. Prognostic variables included age, gender, type and period of operation, and tumor stage. In the ductal adenocarcinomas variables also included tumor and node status, type of lymphadenectomy, pathologic grade, and presence of microscopic residual tumor. The end point was death as a result of neoplastic recurrence. Survival curves were estimated by using the Kaplan-Meier method, and multifactorial analysis was also performed on the data from the ductal adenocarcinoma group. RESULTS The mortality rate was 8.2% in the PD group versus 7.0% in the PPPD group. Morbidity rates were 34.4% for PD and 45.8% for PPPD. Five-year survival was 9.6% in the ductal adenocarcinoma and 63.8% in the periampullary carcinoma groups. Univariate analysis failed to show statistically significant differences in survival curves between the two treatments in either patient group. Correcting for multiple variables in the ductal adenocarcinoma group did not reveal any significant differences in survival rates between the two treatments. CONCLUSIONS PPPD was as successful as classic PD in the treatment of ductal adenocarcinoma and periampullary cancer of the pancreas. Long-term survival was not influenced by the type of resection.

Endosonographic staging of rectal carcinoma.

Transrectal ultrasonography (US) scanning facilitates the ultrastructural differentiation of the various histologic layers of the rectal wall. In particular, the muscularis propria is represented by the 4th sonographic layer. Rectal carcinoma appears on US as a low echogenic area that suddenly interrupts the regular sequence of parietal layers.Sixty-five patients suffering with carcinoma of the lower two-thirds of the rectum underwent pre-operative linear endosonography for staging. The reliability of such a method in assessing the extra-rectal spread was evaluated in our study, at the end of which 55 sonographic/histologic correlations were obtained. Four false-negative and 1 false-positive determinations of the presence or absence of extrarectal spread proved that sonography has a sensitivity and specificity of 91%, with a positive predictive value of 97% and a negative predictive value of 71%. Lower results are obtained in lymph node staging: enlarged lymph nodes are seen in only 11/22 C1/C2 patients (11 false negatives) while we were aware of 3 false positives.

Robotic right colectomy using the Da Vinci Single‐Site® platform: case report

While single‐port laparoscopy for abdominal surgery is technically challenging, the Da Vinci Single‐Site® robotic surgery platform may help to overcome some of the difficulties of this rapidly evolving technique. The authors of this article present a case of single‐incision, robotic right colectomy using this device.

Laparoscopic distal pancreatomy: are we ready for a standardized technique?

This paper describes and discusses the surgical steps needed to perform a laparoscopic distal pancreatectomy. The current lack of standardization of the operative technique can account for the limited diffusion of this procedure. The issue of spleen preservation, which cannot be overemphasized, always demands an accurate surgical technique that results from proficiency both in open pancreatic surgery and advanced laparoscopy. The preservation of the splenic vessels or short gastric-vessel salvage is feasible, yet with different indications. Also, the splenic-vessels preservation procedure has two distinct technical options. The technique of occlusion of the pancreatic stump is crucial for reducing the risk of a post-operative fistula and should be tailored to the structural features of the gland at the transection line. Finally, the hand-assisted approach can provide distinctive advantages over the pure laparoscopic technique in selected circumstances.

Use of the new da Vinci Xi® during robotic rectal resection for cancer: a pilot matched-case comparison with the da Vinci Si®

The aim of this study was to compare the short‐term outcomes of robotic rectal resection with total mesorectal excision (TME) for rectal cancer, with the use of the new da Vinci Xi® (Xi‐RobTME group) and the da Vinci Si® (Si‐RobTME group).

Use of the new Da Vinci Xi® during robotic rectal resection for cancer: technical considerations and early experience

Dear Editor: Robotic rectal resection with the Da Vinci Si System (Intuitive Surgical, Sunnyvale, CA, USA) is a well-defined approach to rectal cancer. The tremor filter, three-dimensional vision, and wrist-like movements facilitate the preparation of autonomic nerves in a narrow space such as the pelvis. These technical advantages translate into clinical and surgical benefits as suggested by a reduced conversion rate, a shorter learning curve, and good functional outcomes compared with the same parameters applied to standard laparoscopy. Nevertheless, there are still several limitations in robotic rectal surgery, such as the reduced skill to perform a multi-quadrant operation, which could result in difficulty performing a complete splenic flexure mobilization. Additionally, a fixed position of the patient after docking limits the possibility to change it during the procedure. These characteristics may require multiple undocking and re-docking, repositioning the entire platform, or use of conventional laparoscopy. Recently, Intuitive Surgical marketed a new product called Da Vinci Xi®, which is expected to overcome some of the limitations of the previous platform, thereby increasing the acceptance of its use for minimally invasive techniques in all surgical fields. Whereas increasingly more studies are being published about the use of the Da Vinci Si® System for robot-assisted proctectomy to treat rectal cancer, the Da Vinci Xi® is still in its infancy. Hence, correct standardization is required for all surgical procedures but explicitly for rectal resection. Rectal cancer surgery could be a valid benchmark for testing the new robotic platform because of its multi-quadrant approach for splenic and left colon mobilization and the need to deal with the risks of external collision and problems related to rectal transection down the pelvis. Additionally, the technique for full robotic rectal resection with total mesorectal excision (TME) using the new Da Vinci Xi® is not yet well defined. Particularly, patient and port positions have not yet been standardized. We describe our successful experience with robot, patient, and trocar positioning that allowed us to perform ten consecutive full robotic rectal resections for a low-lying cancer using Da Vinci Xi® between January and May 2015. For the first phase of the procedure (left colon mobilization, ligation of the inferior mesenteric vessels, and complete mobilization of the splenic flexure), the patients were placed in a modified lithotomy position, with 30° Trendelenberg, and tilted to the right side. After establishing the pneumoperitoneum at 12 mmHg, the first 8-mm robotic trocar was placed in the umbilical region along the right pararectal line. More trocars were then placed following the Universal Port Placement Guidelines provided by Intuitive Surgical for Bleft lower^ abdominal procedures. Four trocars were then inserted under visualization: an 8-mm port in the right iliac fossa, a 12-mm assistant trocar in the right flank, and two 8-mm robotic ports in the periumbilical region and the left hypochondriac space, respectively. A modified version of the Universal Port Placement Guidelines for Bleft lower^ abdominal procedures^ was the same as just described but translating all the trocars of 2–5 cm to the right side. BPatient-left^ was the selected approach, and the surgical cart was driven to position the * Gregorio Di Franco gregoriodifranco@yahoo.it

Prognostic value of histological grading in ductal adenocarcinoma of the pancreas - Klöppel vs TNM grading

SummaryA new histological grading system with prognostic correlation for pancreatic cancer was proposed by Klöppel et al. in 1985. Histological sections from 60 ductal adenocarcinomas operated on between January 1980 and December 1990 were retrospectively reviewed in order to compare Klöppels grading with standard TNMs grading and assess their prognostic value. Klöppel grading was determined through the following histologic and cytologic factors: number duct-like structures, mucus production, neoplastic epithelium, arrangement and pleomorphism of nuclei, and mitotic activity. A score from 0 (well differentiated) to 2 (poorly differentiated) was given to each factor. The mean value obtained dividing the sum of the different values by the number of parameters was used to construct a malignancy scale and therefore allocate each patient to his Klöppel grading. The concordance index K between the two grading systems was relevant (K=0.85p<0.001). There was no relation either between gradings (Klöppel or TNM) and preoperative duration of symptoms or between gradings and UICC stages. TNMs G2 grades of malignancy, N status, and tumor stage were significantly related to survival time (p<0.05). Klöppels grading does not show any advantage over the classical and simpler TNMs grading, even though it can be considered more objective and therefore more easily reproducible. This characteristic further should be enhanced by the introduction of a malignancy scale such as the “mean value”.

Different Impact of Essential Hypertension on Structural and Functional Age-Related Vascular Changes.

We evaluated whether vascular remodeling is present in physiological aging and whether hypertension accelerates the aging process for vascular function and structure. Small arteries from 42 essential hypertensive patients (HT) and 41 normotensive individuals (NT) were dissected after subcutaneous biopsy. Endothelium-dependent vasodilation (pressurized myograph) was assessed by acetylcholine, repeated under the nitric oxide synthase inhibitor N-nitro-L-arginine methylester or the antioxidant tempol. Structure was evaluated by media–lumen ratio (M/L). Intravascular oxidative generation and collagen deposition were assessed. Inhibition by N-nitro-L-arginine methylester on ACh was inversely related to age in both groups (P<0.0001) and blunted in HT versus NT for each age range. In NT, tempol enhanced endothelial function in the oldest subgroup; in HT, the potentiating effect started earlier. HT showed an increased M/L (P<0.001) versus control. In both groups, M/L was directly related to age (P<0.0001). M/L was greater in HT, starting from 31 to 45 years range. A significant age–hypertension interaction occurred (P=0.0009). In NT, intravascular superoxide emerged in the oldest subgroup, whereas it appeared earlier among HT. Among NT, aged group displayed an increment of collagen fibers versus young group. In HT, collagen deposition was already evident in youngest, with a further enhancement in the aged group. In small arteries, ageing shows a eutrophic vascular remodeling and a reduced nitric oxide availability. Oxidative stress and fibrosis emerge in advanced age. In HT, nitric oxide availability is early reduced, but the progression rate with age is similar. Structural alterations include wide collagen deposition and intravascular reactive oxygen species, and the progression rate with age is steeper.

Fibrotic and Vascular Remodelling of Colonic Wall in Patients with Active Ulcerative Colitis

BACKGROUND AND AIMS Intestinal fibrosis is a complication of inflammatory bowel disease [IBD]. Although fibrostenosis is a rare event in ulcerative colitis [UC], there is evidence that a fibrotic rearrangement of the colon occurs in the later stages. This is a retrospective study aimed at examining the histopathological features of the colonic wall in both short-lasting [SL] and long-lasting [LL] UC. METHODS Surgical samples of left colon from non-stenotic SL [≤ 3 years, n = 9] and LL [≥ 10 years, n = 10] UC patients with active disease were compared with control colonic tissues from cancer patients without UC [n = 12] to assess: collagen and elastic fibres by histochemistry; vascular networks [CD31/CD105/nestin] by immunofluorescence; parameters of fibrosis [types I and III collagen, fibronectin, RhoA, alpha-smooth muscle actin [α-SMA], desmin, vimentin], and proliferation [proliferating nuclear antigen [PCNA]] by western blot and/or immunolabelling. RESULTS Colonic tissue from both SL-UC and LL-UC showed tunica muscularis thickening and transmural activated neovessels [displaying both proliferating CD105-positive endothelial cells and activated nestin-positive pericytes], as compared with controls. In LL-UC, the increased collagen deposition was associated with an up-regulation of tissue fibrotic markers [collagen I and III, fibronectin, vimentin, RhoA], an enhancement of proliferation [PCNA] and, along with a loss of elastic fibres, a rearrangement of the tunica muscularis towards a fibrotic phenotype. CONCLUSIONS A significant transmural fibrotic thickening occurs in colonic tissue from LL-UC, together with a cellular fibrotic switch in the tunica muscularis. A full-thickness angiogenesis is also evident in both SL- and LL-UC with active disease, as compared with controls.

Nonoperative management of pancreatic pseudocysts. Problems in differential diagnosis.

CONCLUSION The evaluation of pancreatic cystic lesions entails a misdiagnosis risk. Awareness of the problem, knowledge of the natural history of these lesions, and meticulous posttreatment follow-up can reduce the consequences of diagnostic errors. If all these precautions are adopted, pancreatic pseudocysts can be safely treated nonoperatively. BACKGROUND The accurate diagnosis of pancreatic cystic lesions remains a problem. The aim of this study was to ascertain the incidence of and the reasons the diagnostic errors occurred in a series of pseudocysts drained percutaneously and to compare these data to those reported in the literature. METHODS Data from 70 patients bearing one or more pseudocysts who underwent a percutaneous drainage were reviewed. The pretreatment workup included medical history, physical examination, ultrasound (US) and computed tomography (CT) scans, amylase assay in both the serum and the cystic fluid, culture and cytology of the cystic fluid. After removal of the drainage, the minimum follow-up period was 12 mo. RESULTS Four patients died, and two cancer-associated pseudocysts were identified before removal of the drainage. Sixty-four patients were followed up for a mean of 51.9 mo (range 12-154 mo). A third cancer and a mucinous cystic tumor, fully communicating with the main duct, were further detected during this period.SummaryBackground. The accurate diagnosis of pancreatic cystic lesions remains a problem. The aim of this study was to ascertain the incidence of and the reasons the diagnostic error occurred in a series of pseudocysts drained percutaneously and to compare these data to those reported in the literature.Methods. Data from 70 patients bearing one or more pseudocysts who underwent a percutaneous drainage were reviewed. The pretreatment workup included medical history, physical examination, ultrasound (US) and computed tomography (CT) scans, amylase assay in both the serum and the cystic fluid, culture and cytology of the cystic fluid. After removal of the drainage, the minimum follow-up period was 12 mo.Results. Four patients died, and two cancer-associated pseudocysts were identified before removal of the drainage. Sixty-four patients were followed up for a mean of 51.9 mo (range 12–154 mo). A third cancer and a mucinous cystic tumor, fully communicating with the main duct, were further detected during this period.Conclusion. The evaluation of pancreatic cystic lesions entails a misdiagnosis risk. Awareness of the problem, knowledge of the natural history of these lesions, and meticulous posttreatment follow-up can reduce the consequences of diagnostic errors. If all these precautions are adopted, pancreatic pseudocysts can be safely treated nonoperatively.