Sorin Paun

The epithelial to mesenchymal transition in pancreatic cancer: A systematic review

BACKGROUND/OBJECTIVES The present article summarizes and analyzes the current knowledge about the role of the epithelial to mesenchymal transition (EMT) in the systemic invasiveness of pancreatic cancer. METHOD An electronic search of PubMed/MEDLINE, EMBASE, and the Web of Science was used to identify relevant original articles and reviews. RESULTS The EMT represents a key step during normal embryogenesis. However, increasing evidence reveals its essential role in the local progression and metastasis of pancreatic cancer. Areas of interest are the cross-linking between cells undergoing the EMT and pancreatic cancer stem cells, and the correlation between the EMT and chemoresistance to standard therapies. During carcinogenesis, malignant pancreatic cells at the primary site acquire the ability to undergo the EMT, a transformation associated with increased mobility. The reverse process at secondary sites, the mesenchymal to epithelial transition (MET), has devastating consequences, allowing neoplastic epithelial cells to invade surrounding tissues and spread to distant sites. Consequences of the EMT are the loss of E-cadherin expression and the acquisition of mesenchymal markers including fibronectin or vimentin. Detailed knowledge of the molecular processes underlying the EMT has opened possibilities for new therapeutic agents. These include an EMT approach for patients with early cancers, to prevent invasion and dissemination, and anti-MET therapy for patients with established metastasis. CONCLUSIONS The current literature shows a strong correlation between the EMT and the systemic aggressiveness of pancreatic tumors. Individualized therapy, targeting the process of EMT and its cross-linking with cancer stem cells, may increase survival of patients with pancreatic cancer.

Extralevator vs conventional abdominoperineal resection for rectal cancer—A systematic review and meta-analysis

BACKGROUND The aim of this study was to compare the short-term morbidity and long-term oncologic benefits of extralevator abdominoperineal excision (ELAPE) with conventional abdominoperineal resection (CAPR) for patients with rectal cancer. METHODS Electronic search of the Cochrane Library, MEDLINE, EMBASE, Korean Journal, and J-EAST database from 2007 until August 2015 was carried out. We considered randomized controlled trials and nonrandomized comparative studies comparing ELAPE with CAPR to be eligible, if they included patients with rectal cancers. RESULTS A total of 1 randomized controlled trials and 10 nonrandomized comparative studies met the inclusion criteria, involving 1,736 patients in the ELAPE group and 1,320 in the CAPR group. The ELAPE was associated with a significantly lower intraoperative perforation rate. There were no differences regarding the circumferential margin involvement, R0 resections, and local recurrence rate. There was less blood loss in ELAPE patients. CONCLUSIONS The ELAPE significantly lowered the intraoperative perforation rate, with no benefits regarding circumferential resection margin involvement and local recurrence rate.

Natural orifice translumenal endoscopic surgery (NOTES) second-look peritoneoscopy for staging of limited peritoneal carcinomatosis

BACKGROUND Over the past decades, staging laparoscopy evolved as a useful tool in multimodality treatment of patients with abdominal malignancies, especially for detection of incurable peritoneal and liver metastasis. Natural orifice translumenal endoscopic surgery (NOTES) is a new, evolving technique which represents the next logical progression in minimally invasive surgery and has theoretical advantages in comparison with standard laparoscopic surgery. A review of the current literature revealed a continuous increasing number of fundamental and clinical studies addressing NOTES approach in multimodal management of oncologic patients. Technical possibility to use this new minimally invasive approach for oncological resection of abdominal malignancies was proved by some investigators. HYPOTHESIS NOTES can be used as an alternative method for staging patients with limited peritoneal carcinomatosis and may have better results compared to current imaging techniques for small diameter metastatic disease. CONCLUSIONS With the continuous development of the NOTES techniques and technology, the second-look peritoneoscopy by NOTES may become an alternative method for staging in patients with peritoneal carcinomatosis. Nevertheless, NOTES is at a very early stage of its development, and its implementation in oncologic surgery should be made very caution, and only after careful evaluation.

Most small bowel cancers are revealed by a complication.

ABSTRACT Objective To characterize the pattern of primary small bowel cancers in a tertiary East-European hospital. Methods A retrospective study of patients with small bowel cancers admitted to a tertiary emergency center, over the past 15 years. Results There were 57 patients with small bowel cancer, representing 0.039% of admissions and 0.059% of laparotomies. There were 37 (64.9%) men, mean age of 58 years; and 72 years for females. Out of 57 patients, 48 (84.2%) were admitted due to an emergency situation: obstruction in 21 (38.9%), perforation in 17 (31.5%), upper gastrointestinal bleeding in 8 (14.8%), and lower gastrointestinal bleeding in 2 (3.7%). There were 10 (17.5%) duodenal tumors, 21 (36.8%) jejunal tumors and 26 (45.6%) ileal tumors. The most frequent neoplasms were gastrointestinal stromal tumor in 24 patients (42.1%), adenocarcinoma in 19 (33.3%), lymphoma in 8 (14%), and carcinoids in 2 (3.5%). The prevalence of duodenal adenocarcinoma was 14.55 times greater than that of the small bowel, and the prevalence of duodenal stromal tumors was 1.818 time greater than that of the small bowel. Obstruction was the complication in adenocarcinoma in 57.9% of cases, and perforation was the major local complication (47.8%) in stromal tumors. Conclusion Primary small bowel cancers are usually diagnosed at advanced stages, and revealed by a local complication of the tumor. Their surgical management in emergency setting is associated to significant morbidity and mortality rates.

Primary Aortoduodenal Fistula: First you Should Suspect it

A 59 year-old patient was admitted with upper gastrointestinal bleeding. The clinical exam showed mild hypotension and blood samples revealed acute anemia (hemoglobin = 7.5 g/dl). Emergency computed tomography showed an infrarenal abdominal aortic aneurysm and extravasation of the arterial contrast material toward the digestive tract. The patient was transported to the operating room for emergency laparotomy, which showed an aortoduodenal fistula. After proximal and distal aortic vascular control, the two anatomical structures were dissected with duodenorrhaphy, patch repair of the aortic tear and omentum interposition. The postoperative recovery was uneventful, with discharge after 12 days.

Resection of Large Metachronous Liver Metastasis with Gastric Origin: Case Report and Review of the Literature

Introduction: Increasing evidence suggests that surgical resection may be offered to a subgroup of patients with liver metastasis of gastric adenocarcinoma. The aim of this case report is to illustrate the surgical resection of a single liver metachronous recurrence twelve months after a radical total gastrectomy for cancer. Case report: A 63-year-old male patient with an Eastern Cooperative Oncology Group performance status of 1 was referred to our hospital for a single, large liver metastasis, twelve months after a radical total gastrectomy and DII lymphadenectomy for upper third gastric adenocarcinoma. As the adjuvant treatment, the patient received 12 cycles of FOLFOX chemotherapy. During the present admission, the abdominal computed tomography (CT) revealed a single liver metastasis located in the segments 5 and 6, of 105/85 mm in diameter. Surgical resection by an open approach of liver metastasis was decided. We performed a non-anatomical liver resection, without inflow control due to significant peritoneal adhesions in the liver hilum secondary to the previous lymphadenectomy. The patient was discharged after seven days, with an uneventful recovery. Six months after the second surgical procedure, the patient developed a local liver recurrence. The surgical resection of the liver recurrence was performed, with no postoperative morbidities, and the patient was discharged after eight days. Three months after the latest surgery, the patient is under adjuvant chemotherapy, with no imagistic signs of further recurrences. Conclusions: Hepatic resection for liver metastasis of gastric origin may offer satisfactory oncological outcomes in a very selected subgroup of patients.

Complex Perineal Trauma with Anorectal Avulsion

Introduction. The objective of this case report is to illustrate a severe perineal impalement injury, associated with anorectal avulsion and hemorrhagic shock. Results. A 32-year-old male patient was referred to our hospital for an impalement perineal trauma, associated with complex pelvic fracture and massive perineal soft tissue destruction and anorectal avulsion. On arrival, the systolic blood pressure was 85 mm Hg and the hemoglobin was 7.1 g/dL. The patient was transported to the operating room, and perineal lavage, hemostasis, and repacking were performed. After 12 hours in the Intensive Care Unit, the abdominal ultrasonography revealed free peritoneal fluid. We decided emergency laparotomy, and massive hemoperitoneum due to intraperitoneal rupture of pelvic hematoma was confirmed. Pelvic packing controlled the ongoing diffuse bleeding. After 48 hours, the relaparotomy with packs removal and loop sigmoid colostomy was performed. The postoperative course was progressive favorable, with discharge after 70 days and colostomy closure after four months, with no long-term complications. Conclusions. Severe perineal injuries are associated with significant morbidity and mortality. Their management in high volume centers, with experience in colorectal and trauma surgery, allocating significant human and material resources, decreases the early mortality and long-term complications, offering the best quality of life for patients.

Massive lower gastrointestinal bleeding after low anterior resection for middle rectal cancer – case report

Abstract Objective To emphasize the value of emergency diagnostic angiography and angioembolization in massive postoperative bleeding. Methods A case report was presented and electronic search of U.S. National Library of Medicine National Institutes of Health PubMed/MEDLINE, EMBASE, Google Scholar, ISI Web of Knowledge, to identify original articles and reviews about the subject. Results A 55 year-old male patient was addmited for rectal bleeding. ECOG index=2, digital rectal examination revealed the inferior pole of a middle rectal tumor. Colonoscopy exam validated the presence of a middle rectal tumor, 8 cm from the anal verge. CT scan showed rectal wall thickening up to 3 cm, that extends 9 cm proximally, whit infiltration of the perirectal fatty tissue and multiple enlarged lymph nodes up to 12 mm in dimension. There was a laparoscopic converted to open approach, with low anterior resection of the rectum and total mesorectal excision, an end to end stapled colorectal anastomosis and protective loop ileostomy. In the 5th postoperative day a massive lower gastrointestinal bleeding occured, with hypovolemic shock and a decrease in hemoglobin. Emergency angiography was performed. This revealed active bleeding from an internal iliac branch that was successfully angioembolized. Conclusions Angiography with angioembolization is an effective tool in emergency setting, avoiding the morbidity and associated mortality of a surgical reinervention. In early postoperative hemorrhages, only a rapid clinical recognition, a personalized diagnostic workup and an agressive intervention may offer the patient the best chances for cure.

Open to laparoscopic conversion in hemoperitoneum of unknown origin.

PurposeDemonstrating the potential, in spite of the current trend, of closing an open emergency surgical procedure and to convert it to a minimally invasive approach.MethodsCase report of an open converted to a laparoscopic approach in an emergency setting for hemoperitoneum of unknown origin.ResultsA 28-year-old-female patient was transported to the operating room for suspected acute appendicitis. Through McBurney’s incision, hemoperitoneum was found. She was hemodynamically stable. The open incision was closed and a laparoscopic approach established. The diagnosis was a ruptured right ectopic pregnancy with mild hemoperitoneum. After a laparoscopic salpingectomy, her recovery was uneventful.ConclusionsFor selected cases, the conversion of an open procedure to a laparoscopic approach offers a real benefit for the patient, avoiding a large laparotomy and its associated morbidity.