Nicola Marrano

Pancreatic Metastases: Observations of Three Cases and Review of the Literature

Background: The aim of the study is to analyze pancreatic metastases and their clinical, radiological, therapeutic and prognostic features. Methods: Three cases of pancreatic metastases observed and a world literature review of 333 cases were recorded. Results: Pancreatic metastases are due more frequently to renal cell carcinoma; they are usually metachronous and characterized by a long period of time between the resection of the primary tumor and their detection. The differential diagnosis with other pancreatic masses is difficult, but an accurate anamnesis, some peculiar findings of imaging techniques and percutaneous fine needle aspiration could allow preoperative diagnosis. Pancreatic resections are the treatment of choice allowing the better palliation and improving survival. 150/234 pancreatic metastases underwent pancreatic resections (resectability index = 64.1%); 88/132 patients are alive with a mean follow-up of 27.1 months; of the 44 dead patients the mean survival time was 21.3 months. Among pancreatic metastases the primary tumor with better prognosis is renal cell carcinoma. Conclusion: Pancreatic metastases are rare; their preoperative diagnosis is difficult but useful and possible. Surgical resection is suggested because the patient still may have a prolonged survival.

Combined Aldosterone and Cortisol Secretion by Adrenal Incidentaloma

A 70-year-old woman was referred to the authors’ unit following hospitalization for cardiac failure, high urinary free cortisol concentrations and severe hypokaliemia. A computed tomography scan of the abdomen showed an adrenal adenoma. The 24-hour urinary free cortisol values were high and plasma cortisol levels failed to suppress following 1 mg dexamethasone test. Aldosterone to plasma renin activity ratio was also pathologic, confirmed by saline load. She showed no symptoms of glucocorticoid excess. She was diagnosed with combined primary hyperaldosteronism and Cushing’s syndrome. Cases of adrenal incidentalomas co-secreting cortisol and aldosterone are rare; they should be addressed in patients undergoing adrenal surgery for Conn’s syndrome to avoid adrenal insufficiency after removal of the tumor.

Laparoscopic Left Pancreatectomy: Does Exist a Learning Curve?

Context Surgeons are performing laparoscopic left pancreatectomy (LLP) with increasing frequency. To our knowledge do not exist studies which defines learning curve (LC). Objectives To define a number of procedures needed to achieve LC in LLP. Methods From January 2008 to June 2012 data regarding 25 patients, undergoing LLP for pancreatic lesions, were collected in a prospective database. All procedures were performed by a single high volume surgeon in advanced laparoscopic and open pancreatic surgery. Decrease of the operative time (OT) was used as parameter to establish the achievement of LC. A preliminary multivariate analysis was carried out to establish which factors influenced OT. Correlation between OT and cumulative sum of procedure (CUSUM) was evaluated to calculate the LC cut-off. Finally multivariate analysis was repeated including LC cut-off. ANOVA test was used to estimate correlation and to calculate multivariate model. Results There were 18 (72%) females and 7 (28%) males with mean age of 55±16 years and mean BMI of 27±5 kg/m 2 . Patients were more frequently ASA II (64%). Thirteen patients (52%) presented one or more co-morbidity and had a previous surgical abdominal procedure. Splenectomy was carried out in 18 (72% ) cases. An extended resection was conducted in 5 cases (20%). Mean operative time was 219±52 min. Rate of conversion was 16%. Pathological examination showed only in 11 (44%) cases a malignant disease and none ductal adenocarcinoma. Preliminary multivariate analysis showed that splenectomy significantly decreased OT while size of lesion increased OT (P=0.033 and P=0.041, respectively). A significant inverse correlation was found between OT and CUSUM (P=0.050) and the LC cut-off was 14 procedures. Final analysis including LC cut-off showed that the achievement of LC cut-off reduced significantly OT (P=0.047). Instead BMI and extended resection independently increased OT (P=0.030 and P=0.022, respectively) Conclusion In our experience the number of procedure needed to achieve LC was 14 LLP. BMI and extended resection influenced OT even after the achievement of LC.

Infected Necrosis and Pancreatic Abscess

Infected necrosis (IN) and pancreatic abscess (PA) are septic complications of acute pancreatitis (AP), and are characterised by a severe prognosis and high mortality rates (20–40%). The overall incidence is 3–8% and can reach 60% in cases of acute necrotizing pancreatitis. In our experience, the overall incidence was 7,1% for IN and 6,7% for AP, with mortality rates of 30 and 14,8%, respectively. Bacterial superinfection is generally caused by enteric Gram-negative germs that reach the pancreas by translocation through the gut and the colon. These conditions produce a very bad prognosis, and require both adequate medical and intensive care as well as surgical treatment, which must be provided as early as possible. In AP, the treatment is based on surgical or, in selected cases, radiological drainage of pus. For IN, the surgical treatment is based on necrosectomy, debridement and removal of infected tissue, by using either a closed procedure and continuous postoperative lavage, or by means of laparostomy (open treatment). In this paper, we shall consider the complex diagnostic tests required in these conditions, as well as the advantages and disadvantages of different surgical procedures. Our series of 29 surgical cases of infected acute pancreatitis will also be presented.