Tommaso Bocchetti

Total mesorectal excision for surgical treatment of rectal cancer

The aim of our study was to retrospectively evaluate the results of 2 groups of patients admitted and treated for rectal cancer.

Recovery of immunological homeostasis positively correlates both with early stages of right-colorectal cancer and laparoscopic surgery.

Differences in postoperative outcome and recovery between patients subjected to laparoscopic-assisted versus open surgery for colorectal cancer (CRC) resection have been widely documented, though not specifically for right-sided tumors. We investigated the immunological responses to the different surgical approaches, by comparing postoperative data simultaneously obtained at systemic, local and cellular levels. A total of 25 right-sided CRC patients and controls were managed, assessing -in the immediate followup- the conventional perioperative parameters and a large panel of cytokines on plasma, peritoneal fluids and lipopolysaccharide (LPS)-stimulated peripheral blood mononuclear cells (PBMC) tissue cultures. A general better recovery for patients operated with laparoscopy compared to conventional procedure, as indicated by the analysis of typical pre- and post-surgical parameters, was observed. The synchronous evaluation of 12 cytokines showed that preoperative plasma levels of the proinflammatory cytokines IL-6, IL-8, IL-1β, TNFα were significantly lower in healthy donors versus CRC patients and that such differences progressively increase with tumor stage. After surgery, the IL-6 and IL-8 increases were significantly higher in open compared to laparoscopic approach only in CRC at early stages. The postsurgical whole panel of cytokine levels were significantly higher in peritoneal fluids compared to corresponding plasma, but with no significant differences depending on kind of surgery or stage of disease. Then we observed that, pre- compared to the corresponding post-surgery derived LPS-stimulated PBMC cultures, produced higher supernatant levels of the whole cytokine panel. In particular IL-6 in vitro production was significantly higher in PBMC derived from patients subjected to laparoscopic versus open intervention, but -again- only in CRC at early stages of disease. Our results thus show that laparoscopy compared to open right resection is associated with a shorter compromission of the immunological homeostasis, mainly in early stages of right-CRC patients.

Is entirely conservative management a correct strategy for hemodynamically stable patient with a grade IV blunt pancreatic injury

The first case of pancreatic injury was described by Travers in 1827, and long-held but uncertain opinions still surround this formidable disease. We commend Dr. Pata and colleagues for the notable information introduced into the nonoperative management for grade III blunt pancreatic injury [1] and raise one question with interest: As of the most recent follow-up, did you find any ‘‘upstream’’ chronic pancreatitis in this group of patients treated conservatively? Recently, we grappled with the case of a 20-year-old woman who sustained a road traffic accident. She was vigilant and hemodynamically stable all of the time, although a multidetector double-contrast computed tomography scan showed complete pancreatic transection to the right of the superior mesenteric vessels with no associated duodenal injury and a 4.7 cm hematoma in segment VI of the liver. The serum amylase level was 1097 U/l. Considering both the aforementioned hemodynamic stability and grade IV pancreatic disruption, we elected to manage the patient conservatively with bowel rest, total parenteral nutrition, gabexate mesylate, octreotide, meropenem, teicoplanin, and paracetamol. The patient made a full recovery on conservative treatment, resuming oral intake on day 10 and becoming dischargeable on day 23 after admission. At the 18-month follow-up, she maintained a satisfactory healthy state and magnetic resonance pancreatography revealed atrophy to the pancreatic body-tail together with dilated Wirsung and secondary ducts. In this era of damage control management, many endeavors have provided a unanimous consensus for an algorithm to follow for trauma to the spleen, liver, and kidney but not for the pancreas [2]. Each case seems unique and thus hinders us from drawing the basic outlines for a uniform diagnostic and therapeutic algorithm. Currently, conservative management of stable adults and children with blunt pancreatic injury is the norm in cases of low-grade (I–II) injuries, as such lesions resolve spontaneously within 4 to 10 days. Controversies arise in the presence of a main pancreatic duct injury, which is recognized as the main determinant of morbidity and mortality [3]. In the pediatric literature some successful cases of nonoperative care are described for high-grade (III–IV) injuries [4]; in the adult literature, conversely, an entirely expectant management for grade III injuries was first described in 2009 [1] and, except for some cases treated by ancillary techniques, is still unprecedented for grade IV injuries. Historical treatments for grade IV pancreatic injuries include distal pancreatectomy, pancreaticoenterostomy, debridement with surgical drainage, percutaneous drainage, and pancreatic duct stenting [5]. We addressed a case of grade IV blunt pancreatic injury with a nonoperative strategy, avoiding any surgical, endoscopic, or interventional procedure during both the early and later period of observation. We encourage use of this approach for stable patients with class III–IV pancreatic lesions to augment information about this topic and tailor the best clinical practice for each case. Our caveat is that the clinical status of the patient, rather than the grade of pancreatic injury, should be the principal determinant to guide the diagnostic and therapeutic decisions. Surgery P. Mercantini E. Virgilio (&) T. Bocchetti A. Kazemi Nava V. Ziparo Department of General Surgery 1, II Faculty of Medicine La Sapienza of Rome, Hospital S. Andrea, Rome, Italy e-mail: aresedo1992@yahoo.it

Colonic Perforations Caused by Migrated Plastic Biliary Stents

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RE: Hemangiopericytoma of the Greater Omentum: A Potential Imaging Pitfall and Cause of Repeatedly Unsuccessful Angiographic Embolization

We commend Kulkarni et al. (1) on their description of a rare case of aberrant splenic artery aneurysm treated with a combination of stent graft and coil embolization. Indeed, aneurysm of splenic artery is a protean disease as for the origin, location, size and clinical manifestations. Furthermore, what appears to be initially a splenic aneurysm can exceptionally turn out to be another vascular lesion as happened to us. In fact, a 74-year-old man with a history of prostate cancer was recently diagnosed as having an aneurysm of 1.7 x 2 cm arising from a short gastric artery on a surveillance CT scan (Fig. 1). Superselective arteriography confirmed the

Inclusion of Predeposit Autologous Blood Donation and 33 % Hypertonic Saline Solution in the Surgical Management of Patients with Peritoneal Echinococcosis

We praise Majbar and colleagues [1] for their brilliant and profitable attempt at classifying peritoneal echinococcosis (PE) into four main categories. However, we remain curious about whether they tackled the following two topics that so far have been overlooked by the pertinent literature: the potential eligibility for predeposit autologous blood donation (PABD) in patients with PE and the use of 33 % hypertonic saline solution during surgical or minimally invasive procedures [1]. Recently, in fact, we grappled with these issues in the surgical management of a 29-year-old male patient affected by a disseminated form of PE. Two echinococcal cysts were located in the greater and lesser omentum, three in the liver (segments II, IVa, and VII), one in the right subdiaphragmatic peritoneum, and one in the retrovesical pouch. Anticipating the risk of intraperitoneal bleeding due to extensive hydatid disease, we offered the patient a preoperative evaluation for PABD; however, the consulted transfusion practitioner did not alert us to the risk of recruiting the flatworm from the circulating blood and reconveying the infecting agent through the transfusion. At surgery, after walling off the operative field with packs soaked in 33 % hypertonic saline solution, we performed radical resection for three cysts and partial excision (deroofing plus drainage and chemical inactivation by means of the aforementioned scolicidal agent) for the remaining five cysts which could not be totally extirpated. Altogether, 6,500 mL of 33 % saline solution were used during the procedure and the postoperative course was uneventful. Surgery is the only curative treatment for patients with PE, but may expose the patient to bleeding complications, especially when the hydatid cysts involve or abut wellvascularized structures. In this regard, we know of some cases from the literature of uncontrollable intraoperative bleeding requiring prompt blood transfusions and resuscitation [2]. Surgical treatment of hydatidosis has reported mortality and morbidity rates up to 8 and 69 %, respectively; however, the real incidence of hemorrhagic events is unknown. The first and only case of PABD profitably performed in a patient with a liver hydatid cyst was reported by Roussel et al. [3]. The authors infer that PABD is a safe procedure in patients without signs of cystic crevice such as abdominal tenderness, hypereosinophilia, and serum IgE elevation. Our patient was thought not to be eligible for PABD, although none of the above-mentioned features were present. Of interest, the past current international guidelines for PABD do not include hydatidosis among the contraindications, rendering this subject more intriguing and baffling at the same time [4]. As for the scolicidal agent, the guidelines of the World Health Organization do not mention 33 % hypertonic saline solution, and only a few cases have reported on its use for hydatid disease, although none of them dealt with PE [5]. Even though some authors warn of potentially serious complications following the use of saline, such as injuries to the peritoneal surface and hypernatremia, it helped us permanently eradicate echinococcosis in our patient (follow-up is now 40 months) without any complications. We advocate the use for PABD in otherwise healthy patients with PE and encourage the use of 33 % saline solution in such patients as a safe and efficacious scolicidal agent. E. Virgilio (&) T. Bocchetti G. Balducci General Surgery Unit 1, Faculty of Medicine and Psychology La Sapienza, Hospital St. Andrea, via di Grottarossa 1035-39, 00189 Rome, Italy e-mail: aresedo1992@yahoo.it