Roberto Caronna

Small intestine contrast ultrasonography (SICUS) for the detection of small bowel complications in crohn's disease: A prospective comparative study versus intraoperative findings

Background: In Crohns disease (CD) patients, small intestine contrast ultrasonography (SICUS) accurately assesses small bowel lesions. Its diagnostic role is not known in the assessment of intraabdominal CD complications. The aim was to assess the value of SICUS to detect intestinal complications in patients with CD. Methods: Forty‐nine CD patients (21 female, mean age 37.7 years; range 12–78 years) underwent resective bowel surgery and were included in this study. The accuracy of SICUS to preoperatively detect number, site, and length of strictures, fistulas, and abscesses was compared with surgical and pathological findings by kappa statistics. Results: SICUS identified at least one stricture in 39/40 and excluded it in 9/9 (97.5% sensitivity, 100% specificity, k = 0.93); two or more strictures in 9/12 (75% sensitivity, 100% specificity, k = 0.78). The agreement by k‐statistics between SICUS and surgery in identifying proximal and distal small intestine site of stricture was 1 and 0.92, respectively. The extension of strictures was 6.8 ± 5.4 cm at surgery, 6.6 ± 5.4 cm at SICUS (NS). Fistulas were correctly identified in 27/28 patients and excluded in 19/21 patients (96% sensitivity, 90.5% specificity, k = 0.88). Intraabdominal abscesses were correctly detected in 10/10 patients and excluded in 37/39 patients (100% sensitivity, 95% specificity, k = 0.89). Conclusions: SICUS is an accurate method for the detection of small intestinal complications in CD. Noninvasive SICUS is valuable as a primary investigative method for evaluating and planning proper treatment in patients with severe CD of the small bowel. (Inflamm Bowel Dis 2011;)

Impaired human gallbladder lipid absorption in cholesterol gallstone disease and its effect on cholesterol solubility in bile

BACKGROUND & AIMS The role of the gallbladder in gallstone pathogenesis is still unclear. We examined the effects of gallbladder mucosal lipid absorption on lipid composition and cholesterol crystallization in bile. METHODS The in vitro-isolated, intra-arterially perfused gallbladder model was used (1) to compare the absorption rates of lipids from standard bile by gallbladders obtained from 7 patients with cholesterol gallstones and 6 controls; and (2) to measure the microscopic cholesterol crystal detection time in cholesterol-enriched pig bile before and after lipid absorption by the pig gallbladder. RESULTS Control gallbladders, but not cholesterol gallstone gallbladders, significantly reduced cholesterol (P < 0.02) and phospholipid (P < 0.01) and increased bile salt (P < 0.01) molar percentages in bile over a 5-hour period by efficient and selective cholesterol and phospholipid absorption. A histomorphometric study of the epithelial cells showed significantly higher values for nuclear density (P < 0.01) and nuclear (P < 0.05) and cytoplasmic (P < 0.05) areas in the cholesterol gallstone than the control group. Sequential microscopy of cholesterol-enriched pig bile showed significantly shorter cholesterol filament (P < 0.01) and typical cholesterol plate (P < 0. 02) detection times before than after exposure of bile to the gallbladder lipid absorption. CONCLUSIONS In cholesterol gallstone disease, the human gallbladder epithelium loses its capacity to selectively and efficiently absorb cholesterol and phospholipids from bile, even if it is hyperplastic and hypertrophic. This epithelial dysfunction eliminates the positive effect that the normal gallbladder exerts on cholesterol solubility in bile and might be a pathogenetic cofactor for cholesterol gallstone formation.

Gastrointestinal Emergencies in Patients with Acute Intestinal Graft-Versus-Host Disease

Acute intestinal graft-versus-host disease (GVHD) develops in about 30-50% of allogeneic bone-marrow transplant recipients: 10-20% have gastrointestinal emergencies (hemorrhage or perforation). Mortality reaches 30-60% in patients with acute, grade 2-4 GVHD. We studied 36 bone marrow recipients in whom acute intestinal GVHD developed. Seven had gastrointestinal emergencies: 4 severe gastrointestinal bleeding and 3 acute peritonitis. Three patients with gastrointestinal bleeding and one patient with peritonitis responded to medical therapy. Three needed surgery: one with bleeding and two with peritonitis, while 1 patient had embolization. Of the 7, two patients died, one after embolization and one after surgery. Two of the three surgically-treated cases are still alive several years after operation. From this experience we feel that surgery for gastrointestinal bleeding in acute GVHD is indicated only when medical treatment fails. Severe neutropenia, thrombocytopenia (<10.000 x mm3) and blood cultures positive for CMV have an unfavorable prognostic value.

Pancreaticojejunostomy with Applicationof Fibrinogen/Thrombin-Coated Collagen Patch (TachoSil®) in Roux-en-Y Reconstruction after Pancreaticoduodenectomy

To the Editor We read with great interest the article by Wellner and colleagues about the comparison between pancreaticogastrostomy (PG) and Roux-en-Y pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD) with regard to postoperative pancreatic fistula (POPF) and other complications. The authors concluded that PG was superior to PJ in terms of clinically relevant POPF; although this study is retrospective, the use of a large case number and standardized measures in evaluation of the surgical outcome makes the results not negligible. Instead, the results of our previously described technique of Roux-en-Y reconstruction show that PJ may have a lower prevalence of POPF than that reported by Wellner and colleagues and suggest that outcome after Roux-en-Y reconstruction with regard to POPF can be further improved using fibrinogen/thrombincoated collagen patch (TachoSil®, Nycomed, UK Ltd.) in carrying out PJ. Briefly, we reviewed the clinical records of 54 consecutive patients who underwent PD by one surgeon (P.C.) at “La Sapienza” University (Rome, Italy) from January 1995 to December 2008. The underlying diseases were: pancreatic carcinoma in 31 cases; pancreatic serous cystadenoma in six cases; mucinous cystadenoma in one case; pancreatic endocrine tumor in two cases; ampullar carcinoma in seven cases; distal bile duct carcinoma in six cases; and chronic pancreatitis in one case. In all patients, the surgical procedure comprised PD with suprapyloric gastric resection and Roux -en-Y reconstruction with anastomosis of the isolated Roux limb to the stomach and single Roux limb to both the pancreatic stump and hepatic duct. Small catheters were inserted in the main duct, passed through the anastomosed bowel loop and fixed to the abdominal wall (Fig. 1a, b). A drainage tube was placed near to the pancreaticojejunostomy; external biliary drainage was not used. Pancreaticojejunal end-to-end anastomosis was done by simple invagination of the pancreatic stump into the jejunal loop for 2 cm and sutured all around with a singlelayer interrupted pledget-supported Ticron stitches between the seromuscularis of the jejunum and the pancreatic capsule. From January 2005, TachoSil® has been layered on suture line of pancreaticojejunal anastomosis (Fig. 1c, d). All 27 consecutive patients had pancreaticojejunostomy without TachoSil® (group A) whereas 27 consecutive patients had pancreaticojejunostomy with TachoSil®. All patients in our study received octreotide during the first six postoperative days. The postoperative surgical outcome within 60 postoperative days was assessed. POPF, postoperative hemorrhage J Gastrointest Surg (2009) 13:1396–1398 DOI 10.1007/s11605-009-0894-7

Pancreato-jejunostomy versus hand-sewn closure of the pancreatic stump to prevent pancreatic fistula after distal pancreatectomy: a retrospective analysis

BackgroundDifferent methods of pancreatic stump closure after distal pancreatectomy (DP) have been described to decrease the incidence of pancreatic fistula (PF) which still represents one of the most common complications in pancreatic surgery. We retrospectively compared the pancreato-jejunostomy technique with the hand-sewn closure of the pancreatic stump after DP, and analyzed clinical outcomes between the two groups, focusing on PF rate.MethodsThirty-six patients undergoing open DP at our institution between May 2005 and December 2011 were included. They were divided in two groups depending on pancreatic remnant management: in 24 cases the stump was closed by hand-sewn suture (Group A), while in 12 earlier cases a pancreato-jejunostomy was performed (Group B). We analyzed postoperative data in terms of mortality, morbidity and length of hospital stay between the two groups.ResultsPF occurred in 7 of 24 (29.1%) cases of group A (control group) compared to zero fistula rate in group B (anastomosis group) (p=0.005). Operative time was significantly higher in the anastomosis group (p=0.024). Mortality rate was 0% in both groups. Other postoperative outcomes such as hemorrhages, infections, medical complications and length of hospital stay were not significant between the two groups.ConclusionDespite a higher operative time, the pancreato-jejunostomy after DP seems to be related to a lower incidence of PF compared to the hand-sewn closure of the pancreatic remnant.

Pancreaticojejuno Anastomosis after Pancreaticoduodenectomy: Brief Pathophysiological Considerations for a Rational Surgical Choice

Introduction. The best pancreatic anastomosis technique after pancreaticoduodenectomy (PD) is still debated. Pancreatic fistula (PF) is the most important complication but is also related to postoperative bleedings and pancreatic remnant involution. We support pancreaticojejuno anastomosis (PJ) advantages describing our technique with brief technical considerations. Materials and Methods. 89 consecutive patients underwent PD with suprapyloric gastric resection and double loop reconstruction. Pancreaticojejunal end-to-end anastomosis was done by simple invagination with a single layer of interrupted pledget-supported Ticron stitches. Results. Pancreatic fistula occurred in seven patients (7.8%): six cases of grade A fistula resolved spontaneously, and in only one case of grade B fistula percutaneous drainage was necessary. Postoperative hemorrhage occurred in only two (2.2%) of 89 patients. Conclusion. Pancreaticojejunostomy with minor changes in anastomotic techniques can contribute to improvement of the outcome of Roux-en-Y reconstruction regarding PF and other related complications. The particular reconstruction reported seems also to preserve the pancreatic exocrine function.

Roux-en-Y end-to-end and end-to-side double pancreaticojejunostomy: application of the reconstructive method of the Beger procedure to central pancreatectomy

PurposesCentral pancreatectomy is indicated for treatment of traumatic lesions and benign or low-grade tumors of the pancreatic neck and proximal body. After central pancreatectomy, the proximal pancreatic stump is usually closed, and pancreaticojejunostomy or pancreaticogastrostomy carried out with the distal pancreas. Adopting these reconstructive techniques in most series revealed a prevalence of postoperative fistula that was higher than after pancreaticoduodenectomy or left pancreatectomy. We present a case treated by novel application of the reconstructive method of the Beger procedure.MethodsReconstruction by Roux-en-Y double pancreaticojejunostomy after central pancreatectomy was done in a 71-year-old female suffering from insulinoma of the proximal pancreatic body.ResultsPostoperative complications were not observed. No alteration of pancreatic endocrine and exocrine function occurred at 22-month follow-up.ConclusionsDouble pancreaticojejunostomy is a promising method for treating the proximal pancreatic stump after central pancreatectomy.

Effect of Surgery on Pancreatic Tumor-Dependent Lymphocyte Asset: Modulation of Natural Killer Cell Frequency and Cytotoxic Function

Objectives Tumor burden and invasiveness establish a microenvironment that surgery could alter. This study shows a comprehensive analysis of size, dynamics, and function of peripheral lymphocyte subsets in pancreatic cancer patients before and at different times after duodenopancreatectomy. Methods Lymphocyte frequency and natural cytotoxicity were evaluated by flow cytometry and in vitro assay on peripheral blood from initial and advanced-stage pancreatic cancer patients before (BS), at day 7 (PS7), and at day 30 (PS30) after surgery. Results An increase in natural killer (NK) cells and the diminution of B-cells occurred at PS30, whereas cytotoxicity decreased at PS7. The positive correlation between NK frequency and cytotoxicity at BS and PS7 revealed an altered NK behavior. The elevation of NK cell frequency at PS30, an initial defect in CD56bright NK, and the aberrant correlation between NK frequency and cytotoxicity remained significant in advanced-stage patients, whereas the diminution of NK cytotoxicity only affected initial stage patients. Conclusions The NK cell functional ability is altered in presurgery patients; duodenopancreatectomy is associated with short-term impairment of NK function and with a long-term NK cell augmentation and reversion of the aberrant NK behavior, which may impact on immunosurveillance against residual cancer.

Inflammatory myoglandular polyp of the cecum: case report and review of literature

BackgroundInflammatory myoglandular polyp (IMGP) is a rare non-neoplastic polyp of the large bowel, commonly with a distal localization (rectosigmoid), obscure in its pathogenesis. Up till now, 60 cases of IMGP have been described in the literature, but none located in the cecum.Case presentationWe report a case of a 53-year-old man who was admitted to our hospital for further evaluation of positive fecal occult blood test associated to anemia. A colonoscopy identified a red, sessile, lobulated polyp of the cecum, 4.2 cm in diameter, partially ulcerated. The histological examination of the biopsy revealed the presence of inflammatory granulation tissue with lymphocytic and eosinophil infiltration associated to a fibrous stroma: it was diagnosed as inflammatory fibroid polyp. Considering the polyps features (absence of a peduncle and size) that could increase the risk of a polypectomy, a surgical resection was performed. Histological examination of the specimen revealed inflammatory granulation tissue in the lamina propria, hyperplastic glands with cystic dilatations, proliferation of smooth muscle and multiple erosions on the polyp surface: this polyp was finally diagnosed as IMGP. There was also another little polyp next to the ileocecal valve, not revealed at the colonoscopy, 0.8 cm in diameter, diagnosed as tubulovillous adenoma with low grade dysplasia.ConclusionsThis is the first case of IMGP of the cecum. It is a benign lesion of unknown pathogenesis and must be considered different from other non-neoplastic polyps of the large bowel such as inflammatory cap polyps (ICP), inflammatory cloacogenic polyps, juvenile polyps (JP), inflammatory fibroid polyps (IFP), polyps secondary to mucosal prolapse syndrome (MPS), polypoid prolapsing mucosal folds of diverticular disease. When symptomatic, IMGP should be removed endoscopically, whereas surgical resection is reserved only in selected patients as in our case.

Adrenocortical carcinoma extending into the inferior vena cava in a patient with right kidney agenesis: Surgical approach and review of literature

INTRODUCTION Adrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis and the association with tumor thrombus into the inferior vena cava (IVC) is not common. The best treatment is represented by radical surgery. PRESENTATION OF CASE We describe a case of a large ACC of the left adrenal gland extending into the IVC through the left renal vein in a young patient with agenesis of the right kidney and signs of acute renal failure. A midline laparotomy was performed, subsequently extended by a left thoracophrenotomy through the 7th intercostal space in order to control the proximal surface of the mass and the thoracic aorta. The tumor was completely excised preserving the kidney, and thrombectomy was performed by a cavotomy with a temporary caval clamping, without cardiopulmonary by-pass (CPB). DISCUSSION We discuss surgical approaches reported in literature in case of ACC with intracaval extension. The tumor must be completely resected and the thrombectomy can be performed by different approaches: cavotomy with direct suture, partial resection of caval wall without reconstruction, resection of vena cava with graft reconstruction. These procedures could require a CPB, with an increased mortality. In our case we preserved the kidney and a thrombectomy without CPB was performed. CONCLUSION Intracaval extension of ACC does not represent a contraindication to surgery. The best treatment of intracaval thrombus should be the cavotomy with direct suture. The CPB is not always required. In presence of renal agenesis, the preservation of the kidney is mandatory.