Duodenocefalopancreatectomia con exeresi totale del mesopancreas (Total Mesopancreas Excision) vs tecnica standard nel trattamento del carcinoma cefalopancreatico

Introduzione La prognosi del tumore della testa del pancreas è strettamente legata all’infiltrazione tumorale del margine posteriore retropancreatico che, se non radicalmente asportato, determina un’alta frequenza di resezioni incomplete e alti tassi di recidiva locale. Il mesopancreas è una struttura anatomica linfo-neuro-vascolare localizzata in sede retropancreatica retroportale in continuità con la testa del pancreas recentemente descritta come sede preferenziale di infiltrazione tumorale da parte del carcinoma pancreatico, la cui exeresi completa consentirebbe un maggior numero di resezioni R0 e un minor tasso di recidiva locale. Scopo di questo studio è quello di confrontare la tecnica standard (DCP-S) rispetto alla tecnica di exeresi totale del mesopancreas (DCP-TMpE) in corso di duodenocefalopancreatectomia per tumore della testa del pancreas. Pazienti e metodi Complessivamente sono stati inclusi 132 pazienti sottoposti a DCP per tumore cefalopancreatico dal 2010 al 2018, suddivisi in due gruppi omogenei di studio in base alla tecnica resettiva utilizzata: standard (DCP-S) vs exeresi totale del mesopancreas (DCP-TMpE). La maggior parte delle DCP-S sono state eseguite nel primo periodo (2010-2013) mentre la DCP-TMpE è stata eseguita preferenzialmente nel secondo periodo di studio (2014-2018). I risultati intra- e post-operatori dei due gruppi sono poi stati confrontati e analizzati con particolare riferimento al margine chirurgico, al tasso di recidiva e alle sopravvivenze globale e libera da malattia. Risultati 46 pazienti sono stati sottoposti a DCP-S contro 86 pazienti sottoposti a DCP-TMpE. A parità di morbilità postoperatoria in cui non vi è stata differenza tra i due gruppi, i tassi di resezione R1 (35% vs 9%) e il numero di linfonodi asportati (10 vs 18) sono stati significativamente a favore della TMpE, mentre la tecnica standard è stata associata a tassi di recidiva maggiore (66% vs 41%), indipendentemente dalla sede della recidiva. L’analisi univariata dei fattori di rischio associati al margine R1 ha dimostrato che la DCP-S rappresenta un importante fattore di rischio rispetto alla DCP-TMpE (OR 5.29; 95%CI 2.24-12.50; p=0.001), assieme alla presenza di infiltrazione vascolare preoperatoria e a perdite ematiche >350 mL. Tali risultati sono stati confermati all’analisi multivariata che ha dimostrato la DCP-S come fattore prognostico indipendente per margine R1 (OR 6.28; 95%CI 1.96-20.1; p=0.002), assieme all’infiltrazione vascolare preoperatoria e al BMI >25. Per quanto riguarda l’analisi della sopravvivenza tra i due gruppi, è stato riscontrato per la TMpE un guadagno complessivo di sopravvivenza libera da malattia, particolarmente evidente nei primi 12 mesi (72.7% vs 44.8%), con una significatività statistica accettabile, anche a lungo termine (p=0.09), mentre la sopravvivenza globale non è statisticamente differente tra i due gruppi nonostante la sopravvivenza mediana sia maggiore nel gruppo TMpE (27 mesi vs 23 mesi). Conclusione Questo studio dimostra che rispetto alla tecnica standard, l’exeresi totale del mesopancreas (DCP-TMpE) permette di ottenere risultati oncologici migliori rispetto alla DCP-S, in termini di numero di linfonodi asportati e resezioni R0, con tassi di recidiva inferiori ed una sopravvivenza libera da malattia significativamente superiore

Severe chest allodynia as an unusual first presentation of hydatid disease. A case report

Background: Cystic echinococcosis (CE) is a worldwide zoonosis and the liver is the most commonly affected organ. Clinical manifestations range from completely asymptomatic cysts to a potential lethal cyst rupture and anaphylaxis. Case presentation: Severe chest allodynia was an unusual clinical presentation of hepatic cyst rupture in the retroperitoneal space, without any other specific symptoms. CE diagnosis was confirmed by computed tomography scan and magnetic resonance. The patient underwent hepatectomy with complete resolution of the neuropathic pain. Conclusions: Retroperitoneal hydatid cyst rupture is a rare event and its clinical manifestation may mimic other chest neuropathies

Challenging Scenarios and Debated Indications for Laparoscopic Liver Resections for Hepatocellular Carcinoma

Simple Summary Minimally invasive liver resections are nowadays performed worldwide for both benign and malignant lesions. Good short-term and safe long-term outcomes have been reported. Despite this growing implementation of the technique, challenging scenarios and debated indications still exist. There is currently a lack of high-quality evidence regarding minimally invasive liver resections in portal hypertension, advanced cirrhosis, lesions in the posterosuperior segments and large and recurrent tumors. Laparoscopic liver resections (LLRs) have been increasingly adopted for the treatment of hepatocellular carcinoma (HCC), with safe short- and long-term outcomes reported worldwide. Despite this, lesions in the posterosuperior segments, large and recurrent tumors, portal hypertension, and advanced cirrhosis currently represent challenging scenarios in which the safety and efficacy of the laparoscopic approach are still controversial. In this systematic review, we pooled the available evidence on the short-term outcomes of LLRs for HCC in challenging clinical scenarios. All randomized and non-randomized studies reporting LLRs for HCC in the above-mentioned settings were included. The literature search was run in the Scopus, WoS, and Pubmed databases. Case reports, reviews, meta-analyses, studies including fewer than 10 patients, non-English language studies, and studies analyzing histology other than HCC were excluded. From 566 articles, 36 studies dated between 2006 and 2022 fulfilled the selection criteria and were included in the analysis. A total of 1859 patients were included, of whom 156 had advanced cirrhosis, 194 had portal hypertension, 436 had large HCCs, 477 had lesions located in the posterosuperior segments, and 596 had recurrent HCCs. Overall, the conversion rate ranged between 4.6% and 15.5%. Mortality and morbidity ranged between 0.0% and 5.1%, and 18.6% and 34.6%, respectively. Full results according to subgroups are described in the study. Advanced cirrhosis and portal hypertension, large and recurrent tumors, and lesions located in the posterosuperior segments are challenging clinical scenarios that should be carefully approached by laparoscopy. Safe short-term outcomes can be achieved provided experienced surgeons and high-volume centers

How future surgery will benefit from SARS-COV-2-related measures: a SPIGC survey conveying the perspective of Italian surgeons

COVID-19 negatively affected surgical activity, but the potential benefits resulting from adopted measures remain unclear. The aim of this study was to evaluate the change in surgical activity and potential benefit from COVID-19 measures in perspective of Italian surgeons on behalf of SPIGC. A nationwide online survey on surgical practice before, during, and after COVID-19 pandemic was conducted in March-April 2022 (NCT:05323851). Effects of COVID-19 hospital-related measures on surgical patients' management and personal professional development across surgical specialties were explored. Data on demographics, pre-operative/peri-operative/post-operative management, and professional development were collected. Outcomes were matched with the corresponding volume. Four hundred and seventy-three respondents were included in final analysis across 14 surgical specialties. Since SARS-CoV-2 pandemic, application of telematic consultations (4.1% vs. 21.6%; p < 0.0001) and diagnostic evaluations (16.4% vs. 42.2%; p < 0.0001) increased. Elective surgical activities significantly reduced and surgeons opted more frequently for conservative management with a possible indication for elective (26.3% vs. 35.7%; p < 0.0001) or urgent (20.4% vs. 38.5%; p < 0.0001) surgery. All new COVID-related measures are perceived to be maintained in the future. Surgeons' personal education online increased from 12.6% (pre-COVID) to 86.6% (post-COVID; p < 0.0001). Online educational activities are considered a beneficial effect from COVID pandemic (56.4%). COVID-19 had a great impact on surgical specialties, with significant reduction of operation volume. However, some forced changes turned out to be benefits. Isolation measures pushed the use of telemedicine and telemetric devices for outpatient practice and favored communication for educational purposes and surgeon-patient/family communication. From the Italian surgeons' perspective, COVID-related measures will continue to influence future surgical clinical practice

Association of kidney disease measures with risk of renal function worsening in patients with type 1 diabetes

Background: Albuminuria has been classically considered a marker of kidney damage progression in diabetic patients and it is routinely assessed to monitor kidney function. However, the role of a mild GFR reduction on the development of stage 653 CKD has been less explored in type 1 diabetes mellitus (T1DM) patients. Aim of the present study was to evaluate the prognostic role of kidney disease measures, namely albuminuria and reduced GFR, on the development of stage 653 CKD in a large cohort of patients affected by T1DM. Methods: A total of 4284 patients affected by T1DM followed-up at 76 diabetes centers participating to the Italian Association of Clinical Diabetologists (Associazione Medici Diabetologi, AMD) initiative constitutes the study population. Urinary albumin excretion (ACR) and estimated GFR (eGFR) were retrieved and analyzed. The incidence of stage 653 CKD (eGFR < 60 mL/min/1.73 m2) or eGFR reduction > 30% from baseline was evaluated. Results: The mean estimated GFR was 98 \ub1 17 mL/min/1.73m2 and the proportion of patients with albuminuria was 15.3% (n = 654) at baseline. About 8% (n = 337) of patients developed one of the two renal endpoints during the 4-year follow-up period. Age, albuminuria (micro or macro) and baseline eGFR < 90 ml/min/m2 were independent risk factors for stage 653 CKD and renal function worsening. When compared to patients with eGFR > 90 ml/min/1.73m2 and normoalbuminuria, those with albuminuria at baseline had a 1.69 greater risk of reaching stage 3 CKD, while patients with mild eGFR reduction (i.e. eGFR between 90 and 60 mL/min/1.73 m2) show a 3.81 greater risk that rose to 8.24 for those patients with albuminuria and mild eGFR reduction at baseline. Conclusions: Albuminuria and eGFR reduction represent independent risk factors for incident stage 653 CKD in T1DM patients. The simultaneous occurrence of reduced eGFR and albuminuria have a synergistic effect on renal function worsening

Semeiotica e patologia del pancreas e della milza

Il capitolo descrive la semeiotica clinica e strumentale delle patologie del pancreas e della milza

Semeiotica e patologia del fegato e della vie biliari

Semeiotica e Clinica del Fegato e delle Vie Biliar