Hind Right Approach Pancreaticoduodenectomy: From Skill to Indications

Background. Pancreaticoduodenectomy is the potentially curative treatment for malignant and several benign conditions of the pancreatic head and periampullary region. While performing pancreaticoduodenectomy, early neck division may be impossible or inadequate in case of hepatic artery anatomic variants, suspected involvement of the superior mesenteric vessels, intraductal papillary mucinous neoplasm, and pancreatic head bleeding pseudoaneurysm. Our work aims to highlight a particular hind right approach pancreaticoduodenectomy in selected indications and assess the preliminary results. Methods. We describe our early hind right approach to the retropancreatic vasculature during pancreaticoduodenectomy by mesopancreas dissection before any pancreatic or digestive transection. Results. We used this approach in 52 patients. Thirty-two had hepatic artery anatomic variant and 2 had bleeding pancreatic head pseudoaneurysm. The hepatic artery variant was preserved in all cases out of 2 in which arterial reconstruction was performed. In nine patients with intraductal papillary mucinous neoplasms the pancreaticoduodenectomy was extended to the body in 6 and totalized in 3 patients. Seven patients with adenocarcinoma involving the portomesenteric axis required venous resection and reconstruction. Conclusions. Early hind right approach is advocated in selected cases of pancreaticoduodenectomy to improve locoregional vascular control and determine, safely and early, whether there is mesopancreas involvement

Removal of an Intraperitoneal Foreign Body Using a Single Port Laparoscopic Procedure

A single-port laparoscopic approach may be feasible and safe for the removal of a foreign body in the peritoneal cavity

Our initial experience with ventriculo-epiplooic shunt in treatment of hydrocephalus in two centers

Introduction Hydrocephalus represents impairment in cerebrospinal fluid (CSF) dynamics. If the treatment of hydrocephalus is considered difficult, the repeated revisions of ventriculo-peritoneal (VP) shunts are even more challenging. Objective The aim of this article is to evaluate the efficiency of ventriculo-epiplooic (VEp) shunt as a feasible alternative in hydrocephalic patients. Material and methods A technical modification regarding the insertion of peritoneal catheter was imagined: midline laparotomy 8–10cm long was performed in order to open the peritoneal cavity; the great omentum was dissected between its two layers; we placed the distal end of the catheter between the two epiplooic layers; a fenestration of 4cm in diameter into the visceral layer was also performed. A retrospective study of medical records of 15 consecutive patients with hydrocephalus treated with VEp shunt is also presented. Results Between 2008 and 2014 we performed VEp shunt in 15 patients: 5 with congenital hydrocephalus, 8 with secondary hydrocephalus and 2 with normal pressure hydrocephalus. There were 7 men and 8 women. VEp shunt was performed in 13 patients with multiple distal shunt failures and in 2 patients, with history of abdominal surgery, as de novo extracranial drainage procedure. The outcome was favorable in all cases, with no significant postoperative complications. Conclusions VEp shunt is a new, safe and efficient surgical technique for the treatment of hydrocephalus. VEp shunt is indicated in patients with history of recurrent distal shunt failures, and in patients with history of open abdominal surgery and high risk for developing abdominal complications

Statistical Analysis and Machine Learning Used in the Case of Two Behavioral Tests Applied in Zebrafish Exposed to Mycotoxins

Machine learning is a branch of artificial intelligence that allows computer systems to learn directly from examples, data, and experience. Statistical modeling is more about finding connections between variables and consequently the impact of these relationships, while also catering for prediction. It should be clear that these two methodologies are different in terms of their purpose, despite the fact that they use similar means to get there. The evaluation of the machine learning algorithm uses a set of tests to validate its accuracy. Although, for a statistical model, the analysis of regression parameters by confidence intervals, significance tests and other tests can be used to assess the legitimacy of the model. To demonstrate the applications and usefulness of this theory, an experimental study was conducted on zebrafish exposed to mycotoxin. Methods: Patulin (70 µg/L) and kojic acid (100 mg/L, 204 mg/L, and 284 mg/L) were administered by immersion to zebrafish once daily for a period of 7 days before the behavior testing. The following behavioral tests were performed: a novel tank test (NTT) (to assess the explorative behavior and anxiety); and a Y-maze test (which measures the spontaneous explorative behavior). Behavioral tests were performed on separate days. For the behavior tests, the statistical analysis was performed using ANOVA variation analysis (two-way ANOVA). All results are expressed as the mean ± standard error of the mean. The values of the general index F for which p < 0.05 were considered statistically significant. Results: Y-maze—patulin exposure led to an intensification of the locomotor activity and an increased traveled distance and number of arm entries. By increasing the spontaneous alternation between the aquarium’s arms, patulin has shown a stimulating effect on spatial memory. In the case of zebrafish exposed to 100 mg/L kojic acid, the traveled distance was shorter by 27% than the distance attained by those in the control group. The higher doses of kojic acid (204 mg/L and 284 mg/L) led to an increased locomotor activity, distance traveled, number of arm entries, and the spontaneous alternation. The increase in spontaneous alternation demonstrates that 204 mg/L and 284 mg/L kojic acid doses had a stimulating effect on spatial memory. Novel tank test—compared to the control group, the traveled distance of the patulin-exposed fish is slightly reduced. Compared to the control group, the traveled distance of the kojic acid-exposed fish is reduced, due to a shorter mobile time (by 25–27% in the case of fish exposed to 204 mg/L and 284 mg/L kojic acid). Patulin and kojic acid exhibit toxic effects on zebrafish liver, kidney, and myocardium and leads to severe alteration. We continued the analysis by trying some machine learning algorithms on the classification problems in the case of the two behavioral tests MAZE and NTT, after which we concluded that the results were better in the case of the NTT test relative to the MAZE test and that the use of decision tree algorithms leads to amazing results, knowing that their hierarchical structure allows them to learn signals from both classes. Conclusions: The groups exposed to patulin and kojic acid show histological changes in the liver, kidneys, and myocardial muscle tissue. The novel tank test, which assesses exploratory behavior, has been shown to be conclusive in the behavioral analysis of fish that have been given toxins, demonstrating that the intoxicated fish had a decreased explorative behavior and increased anxiety. We were able to detect a machine learning algorithm in the category of decision trees, which can be trained to classify the behavior of fish that were given a toxin in the category of those used in the experiment, only by analyzing the characteristic features of the NTT Behavior Test

Abdominopelvic Actinomycosis&mdash;The Diagnostic and Therapeutic Challenge of the Most Misdiagnosed Disease

Abdominopelvic actinomycosis is a rare chronic or subacute bacterial infection caused by Actinomyces israelii, a Gram-positive anaerobic bacterium that normally colonizes the digestive and genital tracts, clinically presented as an inflammatory mass or abscess formation. Methods: We reviewed the medical records of the patients from our clinic with abdominopelvic actinomycosis who underwent surgery between 2002 and 2022. In this period, 28 cases (9 men and 19 women) were treated. The mean age was 43.36 years and they were hospitalized for abdominopelvic tumors or inflammatory tumors in 15 cases and inflammatory disease in 13 cases. Results: Causes of actinomycosis in the studied group were an intra-uterine contraceptive device in 17 cases, foreign bodies in 2 cases, diabetes in 4 cases, stenting of the bile duct in 1 case, and immunodepression. For 6 patients, we performed surgery by open approach and for 21 patients by a laparoscopic approach. For nine patients, abdominopelvic actinomycosis had been mimicking a colon malignancy (cecum and ascending colon, four cases; transverse colon, two cases; and on the greater omentum, three cases) and for six patients, a pelvic tumor (advanced ovarian cancer). After surgery the patients underwent specific treatment with antibiotics, with good results. In two cases we discovered and treated hepatic actinomycosis, one case by a laparoscopic approach and one case by a percutaneous approach. In our lot we noticed three recurrences that required reintervention in patients who had had short-term antibiotics due to non-compliance with treatment out of four such cases. Conclusions: For abdominopelvic malignancies, actinomycosis should be included in the differential diagnosis, as well as for inflammatory bowel diseases and bowel obstructions. We have a wide range of patients considering the rarity of this condition. Long-term antibiotics are necessary to prevent recurrence

Emergency Backwards Whipple for Bleeding: Formidable and Definitive Surgery

Introduction. During the past decades, the safety of pancreatoduodenectomy has improved, with low mortality and reduced morbidity, particularly in centers with extensive experience. Emergency pancreatoduodenectomy is an uncommon event, for treatment of pancreaticoduodenal trauma, bleeding, or perforation. We herein present a single center experience concerning nontrauma emergency pancreatoduodenectomy for pancreaticoduodenal bleeding. Methods. From January 2007 to December 2015, from a population of 134 PD (70 males and 64 females, mean age 62.2, range 34–82), 5 patients (3.7%; 2 males and 3 females, mean age 64, range 57–70) underwent one-stage emergency pancreatoduodenectomy for uncontrollable nontrauma pancreaticoduodenal bleeding in our tertiary center. Results. All the 5 patients underwent a backwards Whipple with a morbidity of 60% and a mortality of 20% (1/5). The other 4 patients were recovered and discharged with a median postoperative length of stay of 17 days (range 14–23). Conclusion. Emergency pancreatoduodenectomy is a definitive life-saving procedure allowing for a rapid control of bleeding when other less invasive approaches (transcatheter arterial embolization or interventional endoscopy) are exhausted, unavailable, or unsafe. It should be particularly considered in neoplastic disease and tailored by surgeons with a high level of experience in pancreatic surgery

Protective or Risk Factors for Postoperative Pancreatic Fistulas in Malignant Pathology

Introduction: Malignant tumors are associated with a low incidence of postoperative pancreatic fistulas. The presence of peritumoral fibrosis is considered the protective factor for the development of postoperative pancreatic fistulas after pancreatic resections for pancreatic ductal adenocarcinomas. Methods: We analyzed a series of 109 consecutive patients with pancreatic resections for malignant pathology: pancreatic ductal adenocarcinomas and periampullary adenocarcinomas. The incidence of postoperative pancreatic fistulas has been reported in tumor histological type, in the presence of peritumoral fibrosis, and in the association between adenocarcinomas and areas of acute pancreatitis. The data obtained were processed with the statistical analysis program SPSS, and statistically significant p were considered at a value &lt;0.05. Results: For the entire study group, the incidence of postoperative pancreatic fistulas was 11.01%. The lowest incidence was observed in the group of patients with pancreatic ductal adenocarcinomas (4.06% vs. 25.72% in the group with periampullary adenocarcinoma), with a p = 0.002. The presence of peritumoral fibrous tissue was observed in 49.31% of cases without pancreatic fistulas, and in 54.54% of cases that developed this postoperative complication (p = 0.5). Also, the peritumoral fibrous tissue had a uniform distribution depending on the main diagnosis (56.14% in pancreatic ductal adenocarcinoma group vs. 37.04% in periampullary adenocarcinoma group, with a p = 0.08). In the group of patients who associated areas of acute pancreatitis on the resections, the incidence of postoperative pancreatic fistulas was 7.8 times higher (30% vs. 3.8%, p = 0.026). Conclusions: Peritumoral fibrous tissue was not a factor involved in the developing of postoperative pancreatic fistulas. The association of adenocarciomas with areas of acute pancreatitis has led to a significant increase in postoperative pancreatic fistulas, which is a significant and independent risk factor

Statistical Analysis and Machine Learning Used in the Case of Two Behavioral Tests Applied in Zebrafish Exposed to Mycotoxins

Machine learning is a branch of artificial intelligence that allows computer systems to learn directly from examples, data, and experience. Statistical modeling is more about finding connections between variables and consequently the impact of these relationships, while also catering for prediction. It should be clear that these two methodologies are different in terms of their purpose, despite the fact that they use similar means to get there. The evaluation of the machine learning algorithm uses a set of tests to validate its accuracy. Although, for a statistical model, the analysis of regression parameters by confidence intervals, significance tests and other tests can be used to assess the legitimacy of the model. To demonstrate the applications and usefulness of this theory, an experimental study was conducted on zebrafish exposed to mycotoxin. Methods: Patulin (70 &micro;g/L) and kojic acid (100 mg/L, 204 mg/L, and 284 mg/L) were administered by immersion to zebrafish once daily for a period of 7 days before the behavior testing. The following behavioral tests were performed: a novel tank test (NTT) (to assess the explorative behavior and anxiety); and a Y-maze test (which measures the spontaneous explorative behavior). Behavioral tests were performed on separate days. For the behavior tests, the statistical analysis was performed using ANOVA variation analysis (two-way ANOVA). All results are expressed as the mean &plusmn; standard error of the mean. The values of the general index F for which p &lt; 0.05 were considered statistically significant. Results: Y-maze&mdash;patulin exposure led to an intensification of the locomotor activity and an increased traveled distance and number of arm entries. By increasing the spontaneous alternation between the aquarium&rsquo;s arms, patulin has shown a stimulating effect on spatial memory. In the case of zebrafish exposed to 100 mg/L kojic acid, the traveled distance was shorter by 27% than the distance attained by those in the control group. The higher doses of kojic acid (204 mg/L and 284 mg/L) led to an increased locomotor activity, distance traveled, number of arm entries, and the spontaneous alternation. The increase in spontaneous alternation demonstrates that 204 mg/L and 284 mg/L kojic acid doses had a stimulating effect on spatial memory. Novel tank test&mdash;compared to the control group, the traveled distance of the patulin-exposed fish is slightly reduced. Compared to the control group, the traveled distance of the kojic acid-exposed fish is reduced, due to a shorter mobile time (by 25&ndash;27% in the case of fish exposed to 204 mg/L and 284 mg/L kojic acid). Patulin and kojic acid exhibit toxic effects on zebrafish liver, kidney, and myocardium and leads to severe alteration. We continued the analysis by trying some machine learning algorithms on the classification problems in the case of the two behavioral tests MAZE and NTT, after which we concluded that the results were better in the case of the NTT test relative to the MAZE test and that the use of decision tree algorithms leads to amazing results, knowing that their hierarchical structure allows them to learn signals from both classes. Conclusions: The groups exposed to patulin and kojic acid show histological changes in the liver, kidneys, and myocardial muscle tissue. The novel tank test, which assesses exploratory behavior, has been shown to be conclusive in the behavioral analysis of fish that have been given toxins, demonstrating that the intoxicated fish had a decreased explorative behavior and increased anxiety. We were able to detect a machine learning algorithm in the category of decision trees, which can be trained to classify the behavior of fish that were given a toxin in the category of those used in the experiment, only by analyzing the characteristic features of the NTT Behavior Test

Proposal of a Preoperative CT-Based Score to Predict the Risk of Clinically Relevant Pancreatic Fistula after Cephalic Pancreatoduodenectomy

Background and Objectives: Postoperative pancreatic fistula after cephalic pancreatoduodenectomy (CPD) is still the leading cause of postoperative morbidity, entailing long hospital stay and costs or even death. The aim of this study was to propose the use of morphologic parameters based on a preoperative multisequence computer tomography (CT) scan in predicting the clinically relevant postoperative pancreatic fistula (CRPF) and a risk score based on a multiple regression analysis. Materials and Methods: For 78 consecutive patients with CPD, we measured the following parameters on the preoperative CT scans: the density of the pancreas on the unenhanced, arterial, portal and delayed phases; the unenhanced density of the liver; the caliber of the main pancreatic duct (MPD); the preoperatively estimated pancreatic remnant volume (ERPV) and the total pancreatic volume. We assessed the correlation of the parameters with the clinically relevant pancreatic fistula using a univariate analysis and formulated a score using the strongest correlated parameters; the validity of the score was appreciated using logistic regression models and an ROC analysis. Results: When comparing the CRPF group (28.2%) to the non-CRPF group, we found significant differences of the values of unenhanced pancreatic density (UPD) (44.09 ± 6.8 HU vs. 50.4 ± 6.31 HU, p = 0.008), delayed density of the pancreas (48.67 ± 18.05 HU vs. 61.28 ± 16.55, p = 0.045), unenhanced density of the liver (UDL) (44.09 ± 6.8 HU vs. 50.54 ± 6.31 HU, p = 0.008), MPD (0.93 ± 0.35 mm vs. 3.14 ± 2.95 mm, p = 0.02) and ERPV (46.37 ± 10.39 cm3 vs. 34.87 ± 12.35 cm3, p = 0.01). Based on the odds ratio from the multiple regression analysis and after calculating the optimum cut-off values of the variables, we proposed two scores that both used the MPD and the ERPV and differing in the third variable, either including the UPD or the UDL, producing values for the area under the receiver operating characteristic curve (AUC) of 0.846 (95% CI 0.694–0.941) and 0.774 (95% CI 0.599–0.850), respectively. Conclusions: A preoperative CT scan can be a useful tool in predicting the risk of clinically relevant pancreatic fistula

Predicting the Feasibility of Curative Resection in Low Rectal Cancer: Insights from a Prospective Observational Study on Preoperative Magnetic Resonance Imaging Accuracy

Background and Objectives: A positive pathological circumferential resection margin is a key prognostic factor in rectal cancer surgery. The point of this prospective study was to see how well different MRI parameters could predict a positive pathological circumferential resection margin (pCRM) in people who had been diagnosed with rectal adenocarcinoma, either on their own or when used together. Materials and Methods: Between November 2019 and February 2023, a total of 112 patients were enrolled in this prospective study and followed up for a 36-month period. MRI predictors such as circumferential resection margin (mCRM), presence of extramural venous invasion (mrEMVI), tumor location, and the distance between the tumor and anal verge, taken individually or combined, were evaluated with univariate and sensitivity analyses. Survival estimates in relation to a pCRM status were also determined using Kaplan–Meier analysis. Results: When individually evaluated, the best MRI predictor for the detection of a pCRM in the postsurgical histopathological examination is mrEMVI, which achieved a sensitivity (Se) of 77.78%, a specificity (Sp) of 87.38%, a negative predictive value (NPV) of 97.83%, and an accuracy of 86.61%. Also, the best predictive performance was achieved by a model that comprised all MRI predictors (mCRM+ mrEMVI+ anterior location+ p Conclusions: The use of selective individual imaging predictors or combined models could be useful for the prediction of positive pCRM and risk stratification for local recurrence or distant metastasis