Perioperative management of patients undergoing pancreaticoduodenectomies (PD). Surgical clinic no. III Cluj expertise

Clinica Chirurgie III, Institutul Regional de Gastroenterologie si Hepatologie, UMF “Iuliu Hatieganu” Cluj-Napoca, România, Al XIII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” și al III-lea Congres al Societății de Endoscopie, Chirurgie miniminvazivă și Ultrasonografie ”V.M.Guțu” din Republica MoldovaIntroducere: În 2009, în Clinica Chirurgie III Cluj-Napoca a fost introdus un protocol care cuprinde aspecte legate de pregătirea preoperatorie a pacienților pentru DPC, de tactica și tehnica intraoperatorie, și tratament postoperator. Material si metode: Studiul înrolează 444 pacienti cu DPC operați în clinica între 2009-2018, împărțiți în două loturi: 2009-2015 și 2016-2018. Au fost urmăriți factorii incriminați în apariția principalelor complicații postoperatorii, rezultatele fiind comparate cu cele obținute înainte de 2009. Informaţiile s-au colectat utilizând Excel 2009, analiza statistică efectuandu-se cu software-ul R v3.2.4. Rezultate: Nu am obtinut reducerea semnificativă a morbidității (53% înainte de 2009, 45,6% între 2009-2015 și 42% între 2016- 2018), însă a scăzut rata de apariție a fistulei pancreatice (de la 10% la 9,06%, respectiv 7,5%) și a stazei gastrice (de la 43% la 20,47%, respectiv 12,8%). Hemoragia bontului pancreatic a apărut mai frecvent (de la 2%, la 6,71%, respectiv 7,2%). Mortalitatea s-a redus semnificativ (de la 11,9%, la 6,04%, respectiv 3,99%), datorită scăderii fistulelor pancreatice grad C. Concluzie: Implementarea protocolului de pregătire a DPC și-a dovedit utilitatea, iar preocuparea de îmbunătațire a acestuia, prin adaptarea la literatură și la propria experiență rămâne o prioritate.Introduction: In 2009, a protocol was introduced at the Surgical Clinic III Cluj-Napoca, which included aspects related to preoperative preparation of patients for PD, intraoperative tactics and technique, and postoperative treatment. Material and Method: The study includes 444 patients with PD operated in the clinic between 2009-2018, divided into two batches: 2009-2015 and 2016-2018. We followed the factors involved in the occurrence of the main postoperative complications and the results were compared with those we obtained before 2009. The information was collected using Excel 2009, the statistical analysis being performed with the software R v3.2.4. Results: We have not achieved a significant decrease in morbidity (53% before 2009, 45.6% between 2009-2015 and 42% between 2016-2018), but decreased the rate of pancreatic fistula (from 10% to 9, 06% and 7.5% respectively) and gastric stasis (from 43% to 20.47% and 12.8% respectively). Pancreas bleeding occurred more frequently (from 2% to 6.71% and 7.2%, respectively). Mortality was significantly reduced (from 11.9% to 6.04% and 3.99%, respectively) due to the reduce rate of grade C pancreatic fistulae. Conclusion: Implementation of the protocol has proven useful and the concern for improvement by adapting it to literature and our experience remains a priority

Laparoscopic rectal resections: practical aspects

Abordul laparoscopic in chirurgia cancerului de rect este o considerat standardul de aur ce ofera rezultate oncologice similar cu o recuperare postoperatorie imbunatatita, si o rata minimala de complicatii. Pe fondul complexitatii crescute, cu toate astea, abordul laparoscopic ar trebui efectuat in centre tertiare, fiind rezervat chirurgilor cu o curba de invatare adecvata. O selectie atenta a cazurilor si o planificare adecvata ar trebui luata in considerare in cadrul acestui abord. Prezentarea de fata surprinde aspectele practice de baza precum si variatii tatice in cadrul rezectiilor de rect laparoscopice, precum si pasii potentiali in atingerea curbei de invatare.Laparoscopic approach is an already established procedure in rectal cancer which offers a similar oncological outcome, with improved postoperative recovery and fewer complications. Due to its increased complexity, however, the laparoscopic approach should be reserved for high-volume centers and for experienced surgeons with an adequate learning curve. Appropriate patient selection and planning must be carefully considered when opting for this approach. In this presentation, the primary practical aspects as well as certain tactical approaches will be covered regarding the laparoscopic rectal resections as well as the potential steps in achieving the learning curve

Classic vs laparoscopic approach in colorectal cancer. Experience of a tertiary center, Surgery No 3 Clinic, Cluj-Napoca

Clinica Chirurgie 3, Cluj-Napoca, România, Al XIII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” și al III-lea Congres al Societății de Endoscopie, Chirurgie miniminvazivă și Ultrasonografie ”V.M.Guțu” din Republica MoldovaIntroducere: Cancerul colorectal este unul dintre cele mai frecvente cancere și cu tendință în creștere la nivel global. Majoritatea studiilor recente au demonstrat non inferioritatea și chiar o ușoară superioritate în abordul laparoscopic prin prisma rezultatelor obținute și a supraviețuirii la distanță. Material și metode: Au fost selectate retrospectiv 2186 de cazuri din baza de date completată prospectiv a Clinicii Chirurgie 3 pentru perioada ian 2013-dec 2018 (6 ani). Din acestea s-au exclus 76 cazuri laparoscopie/laparotomie exploratorie, 154 cazuri colostomii, 51 derivații interne; în final au fost analizate 1905 cazuri de cancer colorectal. Rezultate: Din 1905 cazuri s-au efectuat rezecții laparoscopice la un număr de 310 (16.27%) și clasice la un număr de 1595 cazuri (83.73%). Au fost analizați între cele două loturi următorii parametri: pregătire preoperatorie, durata operației, pierderi sangvine, complicații postoperatorii (fistulă, abces, hemoragie, ocluzie, complicații generale), supurații de plagă, zile spitalizare, necesar antibiotic, mobilizare postoperatorie, mortalitate. Concuzii: Abordul laparoscopic prezintă avantaje privind recuperarea postoperatorie, pierderi sangvine, zile spitalizare, necesar antialgice/antibiotic, lipsa supurațiilor de plagă. Dezavantajele sunt curba de învățare, aparatura specifică și dificultatea păstrării principiilor oncologice.Introduction: Colorectal cancer remains one of the most frequently diagnosed malignant pathologies with a continuously increasing rate worldwide. Most of the recent studies have shown the non-inferiority and slight superiority in the laparoscopic approach through obtained results. Material and methods: 2186 cases were selected retrospectively from a prospectively completed database of the Surgical no 3 Clinic in Cluj-Napoca over the course of 6 years (ian 2013 – dec 2018). Out of these cases, 76 cases were excluded for exploratory laparoscopy/laparotomy, 154 which underwent only colostomy, and 51 which underwent internal derivation. At the end of the study, 1905 cases were eligible. Results: Out of 1905 cases, 310 underwent a laparoscopic approach (16.27%) and 1595 cases underwent a classic approach (83.73%). Between the two approaches, a series of parameters were analyzed: preoperative care, duration of the surgery, intraoperative blood loss, postoperative complications (fistula, abscess, hemorrhage, occlusion, general complications), antibiotic necessity, postoperative mobilization, mortality, prevalence of surgical site infection. Conclusions: The laparoscopic approach proves many advantages regarding postoperative care, blood loss, hospitalization care, necessity of antibiotics and painkillers, and surgical site infection, cosmetic advantages. Disadvantages are the learning curve, specific instruments requirements, difficulty of maintaining the oncology principles

Resection margin in liver metastasectomy secondary colorectal cancer

Clinica Chirurgie 3, Cluj-Napoca, România, Al XIII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” și al III-lea Congres al Societății de Endoscopie, Chirurgie miniminvazivă și Ultrasonografie ”V.M.Guțu” din Republica MoldovaIntroducere: Rezectia hepatică este gold standardul în tratamentul metastazelor hepatice. Marginea de rezectie hepatica în cazul metastazelor hepatice a fost si este un subiect des dezbătut. Unii chirurgi considerau marginea de siguranță oncologică de 1 cm, în timp ce în ultima vreme se acceptă tot mai des marginea de rezecție de 1 mm. Materiale și metode: În studiul prezent au fost analizați 140 de pacienți internați din 01.01.2011 pana in 30.06.2018 si s-au comparat rezultatele obținute în funcție de marginile de rezecție R0 si R1. Rezultate și concluzii: Concluziile acestui studiu sunt că lipsa tratamentului neoadjuvant se corelează cu apariția mai frecventă marginii de rezecție microscopic pozitive, nu sunt diferențe semnificativ statistice de supraviețuire între pacienții cu R0 și R1, supraviețuirea acestora la 5 ani fiind de 45% vs. 33%, pe termen scurt și mediu, supraviețuirea estimată este mai mică în grupul pacienților cu metastaze mai mari de 5 cm, metastazele din hemificatul stang prezic un prognostic mai lung al supraviețuirii, iar supraviețuirea este influențată de gradul de diferențiere tumoral - biologia tumorală.Introduction: Liver resection is the gold standard in the treatment of liver metastases. The hepatic resection margin for liver metastases has been and is a frequently debated topic. Some surgeons considered the 1 cm margin of oncology safety, whereas lately, the 1 mm resection margin is increasingly accepted. Material and methods: In the current study, 140 patients were admitted from January 01, 2011 to June 30, 2018 and the results obtained according to the resection edges R0 and R1 were compared. Results and conclusion: The conclusion of this study is that the lack of neoadjuvant treatment correlates with the more frequent occurrence of the positive microscopic resection margin, there are no statistically significant survival differences between patients with R0 and R1, their survival at 5 years being 45% vs. 33%, in the short and medium term, the estimated survival is lower in the patients with metastases greater than 5 cm, the left hemi-liver metastases predict a longer prognosis of survival, and survival is influenced by the degree of tumor differentiation - tumor biology

R1 incidence in pancreatoduodenectomy for pancreatic ductal adenocarcinoma of the pancreatic head

Universitatea de Medicină și Farmacie “Iuliu Hațieganu”, Institultul Regional de Gastroenterologie și Hepatologie “Prof. O. Fodor”, Institutul Regional de Gastroenterologie și Hepatologie “Prof. O. Fodor,” Departamentul de Anatomie Patologică, Cluj-Napoca, Romănia, Al XIII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” și al III-lea Congres al Societății de Endoscopie, Chirurgie miniminvazivă și Ultrasonografie ”V.M.Guțu” din Republica MoldovaIntroducere: Gold standardul duodenopancreatectomiei cefalice (DPC) este obținerea unor margini de rezecție tumorală negative (R0). Având în vedere datele din literatură, în care unii autori au demonstrat ca incidența marginilor R1 crește după folosirea unor protocoale histopatologice standardizate de colorare și preparare a piesei de duodenopancreatectomie cefalica (DPC), am considerat necesar efectuarea unui studiu, în acest sens, în Institutul nostru. Material și metode: Au fost studiate 116 cazuri de adenocarcinom ductal pancreatic cefalic la care s-a efectuat DPC cu intenție de radicalitate. Cele 116 cazuri au fost împarțite în două loturi: un lot de 59 de cazuri (retrospectiv) la care marginile de rezecție nu au fost preparate și un lot de 57 de cazuri (prospectiv) la care piesele au fost preparate și colorate conform unui protocol standardizat. Astfel dacă în cazul lotului retrospectiv marginea circumferențiala nu a fost detaliată, în cazul lotului prospectiv această margine a fost imparțită în: medială, anterioară, superioară și posterioară. Rezultate: Incidența marginii R1 în lotul retrospectiv a fost de 39%, iar în lotul prospectiv a fost de 68.6% (p-value=0.0016). Marginea de rezecție cea mai des R1 a fost marginea circumferențială (87%) în cazul lotului retrospectiv, iar marginea mediala (mezopancreasul) (74.35%) în lotul prospectiv. Marginile R1 au fost multifocale în 13.04% în grupul retrospectiv vs 51.28% în grupul prospectiv (p-value=0.003). Supraviețuirea generală nu a fost influențată de tipul margini de rezecție (R0/R1). Concluzii: Folosirea unor protocoale standardizate de preparare și colorare a pieselor de DPC duce la creșterea incidenței marginilor R1. Mezopancreasul reprezintă locul de elecție pentru apariția marginilor R1 în DPC.Utilizarea unor protocoale standardizate pentru colorarea marginilor de rezecție în DPC crește incidența marginilor R1 multifocale. Supraviețuirea generală este influențată de tipul margini de rezecție (R0/R1).Introduction: Obtaining "clear" margins (R0) in pancreatoduodenectomy is the gold standard for this surgery. We sought to determine whether a standardized histopathological protocol (SHP) would increase the R1 rate. Material and methods: We analyzed 116 cases who had received surgery to treat pancreatic ductal adenocarcinoma (PDAC) of the pancreatic head. We separated the cases into two groups: the first group included 59 cases (retrospective) with no standardized histopathological protocol (NSHP), while the second one included 57 cases (prospective), for which we used an SHP for the tumor margins. The circumferential margins were not defined in detail in the NSHP group, while SHP margins were defined as medial (mesopancreas), anterior, superior and posterior. R1 was defined as the distance between the tumor and the resection margin of ≤1 mm. Results: The R1 rate increased significantly from 39% in the NSHP group to 68.6% in the SHP group (p-value=0.0016). The circumferential margin was closest to the R1 definition in the NSHP group (87%); the closest to R1 in the SHP group was a medial margin (74.35%). The margin positivity was multifocal (13.04% retrospective vs 51.28% prospective, p-value=0.003) in the SHP group. There was no significant difference in overall survival (OS) between R0 and R1 resections (p-value=0.348). Conclusions: The R1 incidence rate in PD for PDAC of the pancreatic head is influenced by SHP, but OS is not influenced by margin positivity when R1 is defined as 1 mm. The mesopancreas represents the primary site for positive resection margins. SHP can determine multifocal margin positivity

Further investigation of confirmed urinary tract infection (UTI) in children under five years: a systematic review.

Background: Further investigation of confirmed UTI in children aims to prevent renal scarring and future complications. Methods: We conducted a systematic review to determine the most effective approach to the further investigation of confirmed urinary tract infection (UTI) in children under five years of age. Results: 73 studies were included. Many studies had methodological limitations or were poorly reported. Effectiveness of further investigations: One study found that routine imaging did not lead to a reduction in recurrent UTIs or renal scarring. Diagnostic accuracy: The studies do not support the use of less invasive tests such as ultrasound as an alternative to renal scintigraphy, either to rule out infection of the upper urinary tract (LR- = 0.57, 95%CI: 0.47, 0.68) and thus to exclude patients from further investigation or to detect renal scarring (LR+ = 3.5, 95% CI: 2.5, 4.8). None of the tests investigated can accurately predict the development of renal scarring. The available evidence supports the consideration of contrast-enhanced ultrasound techniques for detecting vesico-ureteric reflux (VUR), as an alternative to micturating cystourethrography (MCUG) (LR+ = 14.1, 95% CI: 9.5, 20.8; LR- = 0.20, 95%CI: 0.13, 0.29); these techniques have the advantage of not requiring exposure to ionising radiation. Conclusion: There is no evidence to support the clinical effectiveness of routine investigation of children with confirmed UTI. Primary research on the effectiveness, in terms of improved patient outcome, of testing at all stages in the investigation of confirmed urinary tract infection is urgently required

Plasminogen binding and activation at the breast cancer cell surface: the integral role of urokinase activity

INTRODUCTION: The regulation of extracellular proteolytic activity via the plasminogen activation system is complex, involving numerous activators, inhibitors, and receptors. Previous studies on monocytic and colon cell lines suggest that plasmin pre-treatment can increase plasminogen binding, allowing the active enzyme to generate binding sites for its precursor. Other studies have shown the importance of pre-formed receptors such as annexin II heterotetramer. However, few studies have used techniques that exclusively characterise cell-surface events and these mechanisms have not been investigated at the breast cancer cell surface. METHODS: We have studied plasminogen binding to MCF-7 in which urokinase plasminogen activator receptor (uPAR) levels were upregulated by PMA (12-O-tetradecanoylphorbol-13-acetate) stimulation, allowing flexible and transient modulation of cell-surface uPA. Similar experiments were also performed using MDA-MB-231 cells, which overexpress uPAR/uPA endogenously. Using techniques that preserve cell integrity, we characterise the role of uPA as both a plasminogen receptor and activator and quantify the relative contribution of pre-formed and cryptic plasminogen receptors to plasminogen binding. RESULTS: Cell-surface plasminogen binding was significantly enhanced in the presence of elevated levels of uPA in an activity-dependent manner and was greatly attenuated in the presence of the plasmin inhibitor aprotinin. Pre-formed receptors were also found to contribute to increased plasminogen binding after PMA stimulation and to co-localise with uPA/uPAR and plasminogen. Nevertheless, a relatively modest increase in plasminogen-binding capacity coupled with an increase in uPA led to a dramatic increase in the proteolytic capacity of these cells. CONCLUSION: We show that the majority of lysine-dependent plasminogen binding to breast cancer cells is ultimately regulated by plasmin activity and is dependent on the presence of significant levels of active uPA. The existence of a proteolytic positive feedback loop in plasminogen activation has profound implications for the ability of breast cancer cells expressing high amounts of uPA to accumulate a large proteolytic capacity at the cell surface, thereby conferring invasive potential

Transmission and evolution of the Middle East respiratory syndrome coronavirus in Saudi Arabia:a descriptive genomic study

BACKGROUND: Since June, 2012, Middle East respiratory syndrome coronavirus (MERS-CoV) has, worldwide, caused 104 infections in people including 49 deaths, with 82 cases and 41 deaths reported from Saudi Arabia. In addition to confirming diagnosis, we generated the MERS-CoV genomic sequences obtained directly from patient samples to provide important information on MERS-CoV transmission, evolution, and origin. METHODS: Full genome deep sequencing was done on nucleic acid extracted directly from PCR-confirmed clinical samples. Viral genomes were obtained from 21 MERS cases of which 13 had 100%, four 85-95%, and four 30-50% genome coverage. Phylogenetic analysis of the 21 sequences, combined with nine published MERS-CoV genomes, was done. FINDINGS: Three distinct MERS-CoV genotypes were identified in Riyadh. Phylogeographic analyses suggest the MERS-CoV zoonotic reservoir is geographically disperse. Selection analysis of the MERS-CoV genomes reveals the expected accumulation of genetic diversity including changes in the S protein. The genetic diversity in the Al-Hasa cluster suggests that the hospital outbreak might have had more than one virus introduction. INTERPRETATION: We present the largest number of MERS-CoV genomes (21) described so far. MERS-CoV full genome sequences provide greater detail in tracking transmission. Multiple introductions of MERS-CoV are identified and suggest lower R0 values. Transmission within Saudi Arabia is consistent with either movement of an animal reservoir, animal products, or movement of infected people. Further definition of the exposures responsible for the sporadic introductions of MERS-CoV into human populations is urgently needed. FUNDING: Saudi Arabian Ministry of Health, Wellcome Trust, European Community, and National Institute of Health Research University College London Hospitals Biomedical Research Centre

How does study quality affect the results of a diagnostic meta-analysis?

Background: The use of systematic literature review to inform evidence based practice in diagnostics is rapidly expanding. Although the primary diagnostic literature is extensive, studies are often of low methodological quality or poorly reported. There has been no rigorously evaluated, evidence based tool to assess the methodological quality of diagnostic studies. The primary objective of this study was to determine the extent to which variations in the quality of primary studies impact the results of a diagnostic meta-analysis and whether this differs with diagnostic test type. A secondary objective was to contribute to the evaluation of QUADAS, an evidence-based tool for the assessment of quality in diagnostic accuracy studies. Methods: This study was conducted as part of large systematic review of tests used in the diagnosis and further investigation of urinary tract infection (UTI) in children. All studies included in this review were assessed using QUADAS, an evidence-based tool for the assessment of quality in systematic reviews of diagnostic accuracy studies. The impact of individual components of QUADAS on a summary measure of diagnostic accuracy was investigated using regression analysis. The review divided the diagnosis and further investigation of UTI into the following three clinical stages: diagnosis of UTI, localisation of infection, and further investigation of the UTI. Each stage used different types of diagnostic test, which were considered to involve different quality concerns. Results: Many of the studies included in our review were poorly reported. The proportion of QUADAS items fulfilled was similar for studies in different sections of the review. However, as might be expected, the individual items fulfilled differed between the three clinical stages. Regression analysis found that different items showed a strong association with test performance for the different tests evaluated. These differences were observed both within and between the three clinical stages assessed by the review. The results of regression analyses were also affected by whether or not a weighting (by sample size) was applied. Our analysis was severely limited by the completeness of reporting and the differences between the index tests evaluated and the reference standards used to confirm diagnoses in the primary studies. Few tests were evaluated by sufficient studies to allow meaningful use of meta-analytic pooling and investigation of heterogeneity. This meant that further analysis to investigate heterogeneity could only be undertaken using a subset of studies, and that the findings are open to various interpretations. Conclusion: Further work is needed to investigate the influence of methodological quality on the results of diagnostic meta-analyses. Large data sets of well-reported primary studies are needed to address this question. Without significant improvements in the completeness of reporting of primary studies, progress in this area will be limited

Under- treatment and under diagnosis of hypertension: a serious problem in the United Arab Emirates

BACKGROUND: Hypertension, notably untreated or uncontrolled, is a major risk factor for cardiovascular diseases (CVD) morbidity and mortality. In countries in transition, little is known about the epidemiology of hypertension, and its biochemical correlates. This study was carried out in Al Ain, United Arab Emirates, to characterize self-reported (SR) normotensives and hypertensives in terms of actual hypertension status, demographic variables, CVD risk factors, treatment, and sequalae. METHODS: A sample, stratified by SR hypertensive status, of 349 SR hypertensives (Mean age ± SD; 50.8 ± 9.2 yrs; Male: 226) and 640 SR normotensives (42.9 ± 9.3 yrs, Male: 444) among nationals and expatriates was used. Hypertensives and normotensive subjects were recruited from various outpatient clinics and government organizations in Al-Ain city, United Arab Emirates (UAE) respectively. Anthropometric and demographic variables were measured by conventional methods. RESULTS: Both under-diagnosis of hypertension (33%) and under-treatment (76%) were common. Characteristics of undiagnosed hypertensives were intermediate between normotensives and SR hypertensives. Under-diagnosis of hypertension was more common among foreigners than among nationals. Risk factors for CVD were more prevalent among SR hypertensives. Obesity, lack of exercise and smoking were found as major risk factors for CVD among hypertensives in this population. CONCLUSION: Hypertension, even severe, is commonly under-diagnosed and under-treated in the UAE. Preventive strategies, better diagnosis and proper treatment compliance should be emphasized to reduce incidence of CVD in this population