Roberto Luca Meniconi

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.

Clinical effects of laparotomy with perioperative continuous peritoneal lavage and postoperative hemofiltration in patients with severe acute pancreatitis

BackgroundThe elevated serum and peritoneal cytokine concentrations responsible for the systemic response syndrome (SIRS) and multiorgan failure in patients with severe acute pancreatitis lead to high morbidity and mortality rates. Prompted by reports underlining the importance of reducing circulating inflammatory mediators in severe acute pancreatitis, we designed this study to evaluate the efficiency of laparotomy followed by continuous perioperative peritoneal lavage combined with postoperative continuous venovenous diahemofiltration (CVVDH) in managing critically ill patients refractory to intensive care therapy. As the major clinical outcome variables we measured morbidity, mortality and changes in the Acute Physiology and Chronic Health Evaluation (APACHE II) score and cytokine concentrations in serum and peritoneal lavage fluid over time.MethodsFrom a consecutive group of 23 patients hospitalized for acute pancreatitis, we studied 6 patients all with Apache II scores ≥19, who underwent emergency surgery for acute complications (5 for an abdominal compartment syndrome and 1 for septic shock) followed by continuous perioperative peritoneal lavage and postoperative CVVDH. CVVDH was started within 12 hours after surgery and maintained for at least 72 hours, until the multiorgan dysfunction syndrome improved. Samples were collected from serum, peritoneal lavage fluid and CVVDH dialysate for cytokine assay. Apache II scores were measured daily and their association with cytokine levels was assessed.ResultsAll six patients tolerated CVVDH well, and the procedure lasted a mean 6 days (range, 3-12). Five patients survived and one died of Acinetobacter infection after surgery (mortality rate 16.6%). The mean APACHE II score was ≥ 19 (range 19-22) before laparotomy and decreased significantly during peritoneal lavage and postoperative CVVDH (P = 0.013 by matched-pairs Students t-test). The decrease in cytokine concentrations in serum and lavage fluid was associated with the decrease in APACHE II scores and high interleukin 6 (IL-6) and tumor necrosis factor (TNF) concentrations in the hemofiltrate.ConclusionIn critically ill patients with abdominal compartment syndrome, septic shock or high APACHE II scores related to severe acute pancreatitis, combining emergency laparotomy with continuous perioperative peritoneal lavage followed by postoperative CVVHD effectively reduces the local and systemic cytokines responsible for multiorgan dysfunction syndrome thus improving patients outcome.

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.

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

INTRODUCTIONnAdrenocortical 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.nnnPRESENTATION OF CASEnWe 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).nnnDISCUSSIONnWe 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.nnnCONCLUSIONnIntracaval 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.

Left hepatectomy with concomitant cavo-atrial and biliary tumor thrombectomy for invasive hepatocellular carcinoma: a video report

Representing the prevalent primary hepatic malignancy, hepatocellular carcinoma (HCC) is concurrently the sixth most common cancer worldwide and the third dominant cause of mortality due to cancer (1,2).

Lessons learned from 300 consecutive pancreaticoduodenectomies over a 25-year experience: the “safety net” improves the outcomes beyond surgeon skills

Pancreaticoduodenectomy (PD) is associated with high postoperative morbidity. The management of postoperative complications is paramount for reducing the mortality rate. The aim of this study was to evaluate the importance of surgical and hospital experience on outcomes by comparing postoperative results in three different hospitals with increasing resources for supporting the same surgical team. Patients data and surgical outcome of 300 consecutive patients undergoing PD were collected prospectively in the department database and divided into three periods (Axa0=xa01990–2000, Bxa0=xa02001–March 2007, Cxa0=xa0April 2007–2015). Pancreatico-jejunostomy was the procedure of choice between 1995 and 2004, and pancreatico-gastrostomy was performed afterwards. In the periods A, B and C, a total of 78, 85 and 137 PD were performed, respectively, and the number of PDs per year increased from 5 to 25. Between the three periods, the death rate (10.4 vs. 6 vs. 1.6%, pxa0=xa00.01) and intraoperative RBC transfusion rate (84.9 vs. 42.4 vs. 6.5%, pxa0=xa00.01) decreased significantly, whereas the vascular resection rate increased significantly (1.2 vs. 7 vs. 14.5, pxa0<xa00.002). Morbidity and reoperation rates did not change significantly between the three periods as well as operative time and median length of stay. Infectious complications and sepsis represented the most frequent major complication. Massive bleeding associated with uncontrolled pancreatic leak represented the major cause of morbidity and reoperation in the three periods, however, the relative mortality rate decreased significantly with no deaths in the last period. PD remains a challenging procedure with high morbidity and mortality rate. A multidisciplinary pancreatic team represents the “safety net” of pancreatic surgeon because it improves the results beyond the surgeon skills and experience.

Massive pelvic recurrence of uterine leiomyomatosis with intracaval-intracardiac extension: video case report and literature review

BackgroundUterine leiomyomas represent the gynecological neoplasm with the highest prevalence worldwide. This apparently benign pathological entity may permeate into the venous system causing the so-called intravenous leiomyomatosis of the uterus (IVL). IVL may seldom extend to large caliber veins and reach the right cardiac chambers or pulmonary arteries and cause signs of right sided congestive heart failure and sudden death. Due to its low incidence, however, IVL with intracardiac extension is often misdiagnosed resulting in deferred treatment. No consensus has been obtained regarding the standard surgical approach to be used for this rare condition. We describe the case of a massive pelvic recurrence of uterine leiomyomatosis with intracardiac extension and provide a review of the literature, analyzing management and surgical outcomes.Case presentationWe present the case of a 46-year-old premenopausal woman presenting with lower-extremity edema, recurrent syncopes and a history of subtotal hysterectomy for multiple uterine fibroids. She was diagnosed with pelvic recurrence of uterine leiomyomatosis and IVL with cardiac involvement. A two-stage surgical excision of the intracardiac-intracaval mass and pelvic leiomyomatosis was performed. The patient had an uneventful recovery and no evidence of recurrence was observed on follow-up.ConclusionsBy virtue of the rarity of the present pathology, awareness is widely scarce and diagnosis is often delayed. Early recognition is difficult due to initial aspecific and subtle clinical manifestations. Nevertheless, suspicion should be held high in premenopausal women with known history of uterine leiomyomata, presenting with cardiovascular symptoms and evidence of a free-floating mass within the right cardiac chambers. In-depth imaging is crucial for defining its anatomical origin and relations. Prompt surgical treatment with radical excision of pelvic and intravenous leiomyomatosis guarantees favorable outcomes and excellent prognosis with low rates of recurrence, whereas delayed diagnosis and treatment exposes to increased risk of congestive heart failure and sudden death.

Preoperative and Intraoperative Evaluation of Pancreatic Cancer with Vascular Involvement

Context Pancreatic carcinoma, even though distant metastases are not detectable, extends directly into the retroperitoneal spaces and involves the superior mesenteric vein (SMV) or portal vein (PV) in 25% of cases. Evidences show that patients who underwent pancreatectomy with PV and/or SMV resection and those who underwent radical resection for localized tumors, may have a comparable long term survival. Multidetector computed tomography (CT) with three-dimensional (3-D) reconstruction is an essential tool to accurately stage the disease in an attempt to identify patients who would benefit from attempted curative resection. Objective The aim of this study is to compare the results of preoperative radiological (multislice CT) evaluation with the intraoperative and histopathological findings in terms of mesenteric vessels involvement. Methods Between 2006 and 2013 we performed 130 pancreatic resections. Preoperatively, all patients underwent clinical staging with multislice CT with contrast and multiplanar reconstruction (MPR). Radiological findings were compared with surgical and histopathological results. Results Twenty cases (15.4%) radiologically showed a vascular involvement. However at laparotomy, a venous vascular resection was only performed in 10/20 cases (50%). As regard the vascular reconstruction, we performed in 3 cases a continuous suture after a tangential resection, in 7 cases a segmental resection with autologous graft interposition (with right internal jugular vein in 4 cases and with left renal vein in 1), and in 2 case a segmental resection with direct suture previous hepatic mobilization. The postoperative course had no major complications. Histological examination of resected vein wall showed: in 3 case a neoplastic infiltration limited to tunica adventitia, in 5 cases an involvement of tunica media, in 1 case an extension to intima and in 1 case there was no neoplastic infiltration. Conclusions When there are no distant metastasis, surgical radical resection provides the only chance for cure or long-term survival. In pancreatic tumors with PV/SMV involvement (borderline pancreatic cancers), oncologic radicality (negative resection margins: R0) must provide a vascular resection that actually have low morbidity and mortality. We also must consider that in more than 50% of patients the radiological vascular involvement is not confirmed at laparotomy.

Double inferior vena cava does not complicate para-aortic nodal dissection for the treatment of pancreatic carcinoma

Duplication of the inferior vena cava (IVC) involves large veins on both sides of the aorta that join anteriorly at the level of the renal arteries to become the suprarenal IVC. We report CT scan and intraoperative images of a patient with duplication of the IVC who underwent pancreaticoduodenectomy with para-aortic lymphadenectomy for carcinoma of the pancreatic head: nodal dissection along the left caval vein was not carried out. The anatomical background of the lymphatic flow to the para-aortic lymph nodes and the theoretic basis for lymph node dissection of the para-aortic area in cases of double IVC are highlighted. Lymphadenectomy along the left caval vein is not necessary in patients with double IVC who undergo pancreaticoduodenectomy with extended lymphadenectomy for carcinoma of the pancreatic head in the absence of preoperative appearance of para-aortic disease.