17 research outputs found
Solid Pseudopapillary Neoplasms of the Pancreas: A Surgical and Genetic Enigma
Solid pseudopapillary neoplasms of the pancreas are rare tumors
accounting for 1-2% of pancreatic exocrine neoplasms. This entity was
first described by Dr. Frantz in 1959 and was defined by the World
Health Organization in 1996 as “solid pseudopapillary tumor.” It is
most often a benign neoplasm, but 10-15% of the cases are malignant.
Over the past decades, the incidence of this tumor is increasing.
However, many surgeons are still unfamiliar with this neoplasm and its
unique characteristics, which can lead to pitfalls in the diagnosis and
treatment. The correct diagnosis of SPNP is of utmost importance since
it has a low malignant potential and with the appropriate treatment,
patients have a long life expectancy. There are many genetic
alterations, involving various signaling pathways that have been
associated with SPNP and are very important in diagnosing the tumor. The
cornerstone of SPNP treatment includes surgical excision of the tumor,
preserving as much pancreatic tissue as possible. We review the
information in the literature regarding more organ-preserving techniques
and possible clinical features that might indicate a malignant
potential, thus demanding a more radical intraoperative excision
Comment on “Muscle wasting and survival following pre-operative chemoradiotherapy for locally advanced rectal carcinoma”
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Increased risk of malignancy for patients older than 40 years with appendicitis and an appendix wider than 10 mm on computed tomography scan: A post hoc analysis of an EAST multicenter study
Background: The incidence of underlying malignancy in appendicitis ranges between 0.5% and 1.7%. We sought to identify the subset of patients with appendicitis who are at increased risk of appendiceal malignancy
Recurrent aggressive mesenteric desmoid tumor successfully treated with sorafenib: A case report and literature review
BACKGROUND
Desmoid tumors (DT) are locally advanced but histologically benign
monoclonal neoplasms that can occur from any musculoaponeurotic
structure. The aim of this report is to analyze a rare clinical case of
an aggressive intra-abdominal DT successfully treated with sorafenib.
CASE SUMMARY
A 36-year-old man presented with increasing colicky abdominal pain and a
self-palpable mass in his left abdomen. Fourteen years earlier he was
diagnosed with a large intra-abdominal tumor, which adhered to the left
colonic flexure, part of the major gastric curvature and the spleen.
Subsequent exploratory laparotomy revealed a voluminous mass in the
epigastrium, arising from the posterior surface of the stomach and
invading the superior mesenteric vessels, transverse mesocolon and the
small bowel mesentery. As the tumor was unresectable, a jejunojejunal
bypass was performed. Traditional therapeutic interventions proved
insufficient, and the patient was started on sorafenib with a subsequent
full-disease response.
CONCLUSION
DT's pathogenesis has been associated with mutations in the adenomatous
polyposis coli (APC) gene or beta-catenin gene CINNB1, sex steroids or
previous surgical trauma. Local treatment modalities, such as surgery or
radiotherapy, are implemented in aggressively progressing or symptomatic
patients. Sorafenib is a hopeful therapeutic option against DTs, while
several pharmacological agents have been successfully used
Antiplatelet Therapy in Acute Coronary Syndromes. Evidence Based Medicine
Background: Acute coronary syndromes (ACS) represent the final step in
the chronic process of atherothrombotic coronary disease which begins
early in life as thickening of intima layer and progresses to
fibroatheroma and fibrocalcific lesions with vulnerable characteristics.
Methods: As abrupt occlusion in the settings of ACS happens due to
platelet aggregation and mobilization antiplatelet treatment has gained
significant interest especially in the settings of primary percutaneous
intervention and the aim of this review article is to understand the
current evidence justifying the use and combination of different
antiplatelet agents. Results: Beyond aspirin, several antiplatelet
agents (ADP receptor inhibitors, Glycoprotein IIb/IIIa inhibitors and
varopaxar) are used in combination to effectively inhibit platelet
activity. However the best choice, initiation, combination and duration
of anti-thrombotic treatment, in order to maximize the effectiveness of
therapy and reduce the hazard of bleeding, depends on the clinical
setting and patient specific characteristics and is an issue of intense
scientific interest. Conclusion: Early and potent platelet inhibition
with safety reassurance can be achieved by a combination of antiplatelet
agents and is essential for the management of ACS. Therefore in this
review article we focus on the current evidence regarding rational,
safety and effectiveness of current antiplatelet approaches in acute
coronary syndromes
Treatment and outcomes of anticoagulated geriatric trauma patients with traumatic intracranial hemorrhage after falls
Introduction: Emergency physicians and trauma surgeons are increasingly confronted with pre-injury direct oral anticoagulants (DOACs). The objective of this study was to assess if pre-injury DOACs, compared to vitamin K antagonists (VKA), or no oral anticoagulants is independently associated with differences in treatment, mortality and inpatient rehabilitation requirement. Methods: We performed a review of the prospectively maintained institutional trauma registry at an urban academic level 1 trauma center. We included all geriatric patients (aged ≥ 65 years) with tICH after a fall, admitted between January 2011 and December 2018. Multivariable logistic regression analysis controlling for demographics, comorbidities, vital signs, and tICH types were performed to identify the association between pre-injury anticoagulants and reversal agent use, neurosurgical interventions, inhospital mortality, 3-day mortality, and discharge to inpatient rehabilitation. Results: A total of 1453 tICH patients were included (52 DOAC, 376 VKA, 1025 control). DOAC use was independently associated with lower odds of receiving specific reversal agents [odds ratio (OR) 0.28, 95% confidence interval (CI) 0.15–0.54] than VKA patients. DOAC use was independently associated with requiring neurosurgical intervention (OR 3.14, 95% CI 1.36–7.28). VKA use, but not DOAC use, was independently associated with inhospital mortality, or discharge to hospice care (OR 1.62, 95% CI 1.15–2.27) compared to controls. VKA use was independently associated with higher odds of discharge to inpatient rehabilitation (OR 1.41, 95% CI 1.06–1.87) compared to controls. Conclusion: Despite the higher neurosurgical intervention rates, patients with pre-injury DOAC use were associated with comparable rates of mortality and discharge to inpatient rehabilitation as patients without anticoagulation exposure. Future research should focus on risk assessment and stratification of DOAC-exposed trauma patients
Evaluation of oral factor Xa inhibitor‐associated extracranial bleeding reversal with andexanet alfa
Circulating cellular clusters are associated with thrombotic complications and clinical outcomes in COVID-19
Summary: We sought to study the role of circulating cellular clusters (CCC) –such as circulating leukocyte clusters (CLCs), platelet-leukocyte aggregates (PLA), and platelet-erythrocyte aggregates (PEA)– in the immunothrombotic state induced by COVID-19. Forty-six blood samples from 37 COVID-19 patients and 12 samples from healthy controls were analyzed with imaging flow cytometry. Patients with COVID-19 had significantly higher levels of PEAs (p value<0.001) and PLAs (p value = 0.015) compared to healthy controls. Among COVID-19 patients, CLCs were correlated with thrombotic complications (p value = 0.016), vasopressor need (p value = 0.033), acute kidney injury (p value = 0.027), and pneumonia (p value = 0.036), whereas PEAs were associated with positive bacterial cultures (p value = 0.033). In predictive in silico simulations, CLCs were more likely to result in microcirculatory obstruction at low flow velocities (≤1 mm/s) and at higher branching angles. Further studies on the cellular component of hyperinflammatory prothrombotic states may lead to the identification of novel biomarkers and drug targets for inflammation-related thrombosis
Trauma and nontrauma damage-control laparotomy: The difference is delirium (data from the Eastern Association for the Surgery of Trauma SLEEP-TIME multicenter trial)
BackgroundDamage-control laparotomy (DCL) has been used for traumatic and nontraumatic indications. We studied factors associated with delirium and outcome in this population.MethodsWe reviewed DCL patients at 15 centers for 2 years, including demographics, Charlson Comorbidity Index (CCI), diagnosis, operations, and outcomes. We compared 30-day mortality; renal failure requiring dialysis; number of takebacks; hospital, ventilator, and intensive care unit (ICU) days; and delirium-free and coma-free proportion of the first 30 ICU days (DF/CF-ICU-30) between trauma (T) and nontrauma (NT) patients. We performed linear regression for DF/CF-ICU-30, including age, sex, CCI, achievement of primary fascial closure (PFC), small and large bowel resection, bowel discontinuity, abdominal vascular procedures, and trauma as covariates. We performed one-way analysis of variance for DF/CF-ICU-30 against traumatic brain injury severity as measured by Abbreviated Injury Scale for the head.ResultsAmong 554 DCL patients (25.8% NT), NT patients were older (58.9 ± 15.8 vs. 39.7 ± 17.0 years, p < 0.001), more female (45.5% vs. 22.1%, p < 0.001), and had higher CCI (4.7 ± 3.3 vs. 1.1 ± 2.2, p < 0.001). The number of takebacks (1.7 ± 2.6 vs. 1.5 ± 1.2), time to first takeback (32.0 hours), duration of bowel discontinuity (47.0 hours), and time to PFC were similar (63.2 hours, achieved in 73.5%). Nontrauma and T patients had similar ventilator, ICU, and hospital days and mortality (31.0% NT, 29.8% T). Nontrauma patients had higher rates of renal failure requiring dialysis (36.6% vs. 14.1%, p < 0.001) and postoperative abdominal sepsis (40.1% vs. 17.1%, p < 0.001). Trauma and NT patients had similar number of hours of sedative (89.9 vs. 65.5 hours, p = 0.064) and opioid infusions (106.9 vs. 96.7 hours, p = 0.514), but T had lower DF/CF-ICU-30 (51.1% vs. 73.7%, p = 0.029), indicating more delirium. Linear regression analysis indicated that T was associated with a 32.1% decrease (95% CI, 14.6%-49.5%; p < 0.001) in DF/CF-ICU-30, while achieving PFC was associated with a 25.1% increase (95% CI, 10.2%-40.1%; p = 0.001) in DF/CFICU-30. Increasing Abbreviated Injury Scale for the head was associated with decreased DF/CF-ICU-30 by analysis of variance (p < 0.001).ConclusionNontrauma patients had higher incidence of postoperative abdominal sepsis and need for dialysis, while T was independently associated with increased delirium, perhaps because of traumatic brain injury.Level of evidenceTherapeutic study, level IV
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The Emergency Surgery Score accurately predicts the need for postdischarge respiratory and renal support after emergent laparotomies: A prospective EAST multicenter study
The Emergency Surgery Score (ESS) was recently validated as an accurate mortality risk calculator for emergency general surgery. We sought to prospectively evaluate whether ESS can predict the need for respiratory and/or renal support (RRS) at discharge after emergent laparotomies (EL).This is a post hoc analysis of a 19-center prospective observational study. Between April 2018 and June 2019, all adult patients undergoing EL were enrolled. Preoperative, intraoperative, and postoperative variables were systematically collected. In this analysis, patients were excluded if they died during the index hospitalization, were discharged to hospice, or transferred to other hospitals. A composite variable, the need for RRS, was defined as the need for one or more of the following at hospital discharge: tracheostomy, ventilator dependence, or dialysis. Emergency Surgery Score was calculated for all patients, and the correlation between ESS and RRS was examined using the c-statistics method.From a total of 1,649 patients, 1,347 were included. Median age was 60 years, 49.4% were men, and 70.9% were White. The most common diagnoses were hollow viscus organ perforation (28.1%) and small bowel obstruction (24.5%); 87 patients (6.5%) had a need for RRS (4.7% tracheostomy, 2.7% dialysis, and 1.3% ventilator dependence). Emergency Surgery Score predicted the need for RRS in a stepwise fashion; for example, 0.7%, 26.2%, and 85.7% of patients required RRS at an ESS of 2, 12, and 16, respectively. The c-statistics for the need for RRS, the need for tracheostomy, ventilator dependence, or dialysis at discharge were 0.84, 0.82, 0.79, and 0.88, respectively.Emergency Surgery Score accurately predicts the need for RRS at discharge in EL patients and could be used for preoperative patient counseling and for quality of care benchmarking.Prognostic and epidemiological, level III