2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy.

Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI

EUS-guided endoscopic internal drainage with lumen-apposing metal stent for symptomatic hepatic cysts: a case series (with video)

: Background and study aims  Simple hepatic cysts (SHCs) are usually asymptomatic and detected incidentally. However, larger cysts may present with clinical signs and require treatment such as percutaneous aspiration or surgery with non negligeable rate of recurrence. We report a series of 13 consecutive patients who underwent EUS-guided lumen-apposing metal stent (LAMS) drainage of SHCs of the right and left liver. Patients and methods  Nine men and four women, average age 71.9 years, underwent EUS-guided LAMS cyst drainage because of significant symptoms. At 1 month, LAMS was exchanged for a double pigtail stent (DPS), which was left in place for 3 months. Nine of the SHCs were located in the right liver and four in the left. The average diameter was 22.2 cm. Results  Thirteen LAMS were successful delivered in all patients. However only 12 of 13 (92.3 %) remained in place. In one case, the LAMS slipped out immediately and was promptly removed and the cyst treated percutaneously. One of 12 patients experienced bleeding, which was treated conservatively. In seven patients, the LAMS was exchanged for a DPS; in the other five, it was successfully left in place until the patients died, given their comorbidities. At 10.5 months of follow-up, none of the SHCs had recurred. Conclusions  EUS-guided LAMS drainage permits treatment of symptomatic SHCs without recurrence and with few adverse events. Comparative studies are needed to consider this approach as first intention

Needle Tract Seeding after Endoscopic Ultrasound Tissue Acquisition of Pancreatic Lesions: A Systematic Review and Meta-Analysis

There is limited evidence on the incidence of needle tract seeding (NTS) in patients undergoing endoscopic ultrasound (EUS) tissue acquisition (TA) of pancreatic lesions. This meta-analysis aimed to assess the incidence of NTS after EUS-TA. With a search of the literature up until April 2022, we identified 10 studies (13,238 patients) assessing NTS incidences in patients undergoing EUS-TA. The primary outcome was NTS incidence. The secondary outcome was a comparison in terms of peritoneal carcinomatosis incidence between patients who underwent EUS-TA and non-sampled patients. Results were expressed as pooled rates or odds ratio (OR) and 95% confidence intervals (CI). The pooled rate of NTS was 0.3% (95% CI 0.2–0.4%), with no evidence of heterogeneity (I2 = 0%). Subgroup analysis based on the type of sampled lesion confirmed this finding both in patients with pancreatic adenocarcinoma (0.4%, 0.2–0.6%) and in patients with cystic pancreatic lesions (0.3%, 0.1–0.5%). No difference in terms of metachronous peritoneal dissemination was observed between patients who underwent EUS-TA and non-sampled patients (OR 1.02, 0.72–1.46; p = 0.31), with evidence of low heterogeneity (I2 = 16%). Rates of NTS after EUS-TA are very low; therefore, EUS-TA could be safely performed in a pre-operative setting

The role of laparoscopic surgery in localized pancreatic neuroendocrine tumours

Pancreatic neuroendocrine tumours (PNETs) are a rare and heterogeneous group of tumours with various clinical manifestations and biological behaviours. They represent approximately 2–4% of all pancreatic tumours, with an incidence of 2–3 cases per million people. PNETs are classified clinically as non-functional or functional, and pancreatic resection is recommended for lesions greater than 2 cm. The surgical approach can involve “typical” and “atypical” resections depending on the number, size and location of the tumour. Typical resections include pancreaticoduodenectomy, distal pancreatectomy enucleation and, rarely, total pancreatectomy. Atypical resections comprise central pancreatectomies or enucleations. Minimally invasive pancreatic resection has been proven to be technically feasible and safe in high-volume and specialized centres with highly skilled laparoscopic surgeons, with consolidated benefits for patients in the postoperative course. However, open and minimally invasive pancreatic surgery remains to have a high rate of complications; there is no specific technical contraindication to minimally invasive pancreatic surgery, but an appropriate patient selection is crucial to obtain satisfactory clinical and oncological outcomes

Invasive mucormycosis in children with cancer: A retrospective study from the Infection Working Group of Italian Pediatric Hematology Oncology Association

Invasive mucormycosis is a rare but frequently fatal fungal disease. The acute and rapidly progressive evolution causes unfavourable outcome in 22%-59% of patients and its treatment represents a clinical challenge, especially in immunocompromised patients. Current data in paediatric oncological patients are limited

Oral Lactoferrin Supplementation during Induction Chemotherapy Promotes Gut Microbiome Eubiosis in Pediatric Patients with Hematologic Malignancies

Induction chemotherapy is the first-line treatment for pediatric patients with hematologic malignancies. However, several complications may arise, mainly infections and febrile neutropenia, with a strong impact on patient morbidity and mortality. Such complications have been shown to be closely related to alterations of the gut microbiome (GM), making the design of strategies to foster its eubiosis of utmost clinical importance. Here, we evaluated the impact of oral supplementation of lactoferrin (LF), a glycoprotein endowed with anti-inflammatory, immunomodulatory and antimicrobial activities, on GM dynamics in pediatric oncohematologic patients during induction chemotherapy. Specifically, we conducted a double blind, placebo-controlled trial in which GM was profiled through 16S rRNA gene sequencing before and after two weeks of oral supplementation with LF or placebo. LF was safely administered with no adverse effects and promoted GM homeostasis by favoring the maintenance of diversity and preventing the bloom of pathobionts (e.g., Enterococcus). LF could, therefore, be a promising adjunct to current therapeutic strategies in these fragile individuals to reduce the risk of GM-related complications

Eus-guided gallbladder drainage as a first approach for jaundice palliation in unresectable malignant distal biliary obstruction: A prospective study

Background and study aim: Endoscopic retrograde cholangiopancreatography (ERCP) represents the gold standard for jaundice palliation in patients with distal malignant biliary obstruction (DMBO) . Biliary drainage using electrocautery lumen apposing metal stent (EC-LAMS) is currently a well-established procedure when ERCP fails. In a palliative setting the endoscopic ultrasound gallbladder drainage (EUS-GBD) should represent an easiest and valid option. We performed a prospective study with a new EC-LAMS with the primary aim to assess the clinical success rate of EUS-GBD as first-line approach to the palliation of DMBO. Patients and methods: 37 consecutive patients undergoing EUS-GBD with a new EC-LAMS were prospectively enrolled. Clinical success was defined as bilirubin level decrease >15% within 24 hours and >50% within 14 days after EC-LAMS placement. Results: Mean age was 73.5±10.8 years; male patients were 17 (45.9%). EC-LAMS placement was technically feasible in all of the patients (100%) and clinical success rate was 100%. 4 patient (10.8%) experienced adverse events (AEs), one bleeding, one food impaction and two cystic duct obstructions because of the disease progression. No stent-related deaths were observed. The mean of hospital stay was 7.7± 3.4 days. Median overall survival was 4 months (95% CI 1-8). Conclusions: EUS-GBD with the new EC-LAMS is a valid option in palliative endoscopic biliary drainage as first-step approach in low survival patients with malignant jaundice unfit for surgery. A smaller diameter EC-LAMS should be preferred, particularly if the drainage is performed through the stomach, to avoid potentially food impaction, which could result in stent dysfunction

Candidaemia in haematological malignancy patients from a SEIFEM study: epidemiological patterns according to antifungal prophylaxis

Candidaemia is an important infectious complication for haematological malignancy patients. Antifungal prophylaxis reduces the incidence of candidaemia but may be associated with breakthrough candidaemia