Pancreatic resection in very elderly patients: A critical analysis of existing evidence

The aging of the population results in a rise of number of elderly patients (aged 80 years and older) with pancreatic or periampullary cancer, and more pancreatectomies could eventually be performed in such complex patients. However, early and long-term results after pancreatic resection in octogenarians are still controversial, and may trouble the surgeon when approaching this type of population. Evaluation of reported experiences shows that for almost all Authors, pancreatectomy can be performed safely in elderly population, although overall morbidity and mortality rates were 34.9% and 13.2% respectively, with a mean length of hospital stay of 18 d. These features appear higher in older patients compared to the younger counterpart. Less than 50% of patients underwent adjuvant therapy after operation. Long-term survival is reported not significantly different in aged 80 years and older patients, with a median overall survival time of 17.6 mo. The quality of life after pancreatic resection is only sporadically evaluated but, when considered, it highlights the need of health facility service after operation for these "frail" patients. Prospective studies on the quality of life of pancreatectomized octogenarians are welcome. Proper selection of patients, geriatric assessment with multidisciplinary approach, centralization of pancreatic surgery in high-volume centres and rehabilitation programs after surgery appear to be crucial points in order to improve surgical treatments of pancreatic tumors in very elderly patients

Thymoma metastatic to liver and pancreas: case report and review of the literature

A 71-year-old man presented with a thymic mass involving the superior vena cava. A mediastinoscopical biopsy initially suggested a diagnosis of type A thymoma. After neoadjuvant chemotherapy, the patient underwent en-bloc thymectomy and vascular resection for a pathology-confirmed type B3 thymoma involving the superior vena cava, the left brachiocephalic vein and the distal part of the right brachiocephalic vein. Adjuvant radiotherapy was administered. Two years after the primary surgery, abdominal computed tomography (CT) and whole body fluorodeoxyglucose (18-FDG) positron emission tomography (PET) scans showed a single hepatic lesion that was treated with wedge liver resection. Pathological examination confirmed metastatic type B3 thymoma. Almost 4 years later, abdominal CT and 18-FDG PET revealed a 2.9-cm solid mass involving the body of the pancreas. Distal pancreatectomy with lymph node dissection was performed. Pathological examination showed a pancreatic metastasis from a type B3 thymoma, without lymph node involvement. The patient is alive and free of disease 6 months after the pancreatectomy (68 months after the initial thymectomy surgery). Intra-abdominal recurrence and pancreatic metastases are very uncommon manifestations of thymoma, but this event should be kept in mind when an abdominal mass is seen during follow-up

Solid-pseudopapillary tumor of the pancreas: A single center experience

open6noAim of this study was to review the institutional experience of solid-pseudopapillary tumors of the pancreas with particular attention to the problems of preoperative diagnosis and treatment. From 1997 to 2013, SPT was diagnosed in 18 patients among 451 pancreatic cystic neoplasms (3.7%). All patients underwent preoperative abdominal ultrasound, computed assisted tomography, and tumor markers (CEA and CA 19-9) determinations. In some instances, magnetic resonance, positron emission tomography, and endoscopic ultrasound with aspiration cytology were performed. There were two males and 16 females. Serum CA 19-9 was slightly elevated in one case. Preoperative diagnosis was neuroendocrine tumor (n = 2), mucinous tumor (n = 2), and SPT (n = 14). Two patients underwent previous operation before referral to our department: one explorative laparotomy and one enucleation of SPT resulting in surgical margins involvement. All patients underwent pancreatic resection associated with portal vein resection (n = 1) or liver metastases (n = 1). One patient died of metastatic disease, 77 months after operation, and 17 are alive and free with a median survival time of 81.5 months (range 36-228 months). Most of SPT can be diagnosed by CT or MRI, and the role of other diagnostic tools is very limited. We lack sufficient information regarding clinicopathologic features predicting prognosis. Caution is needed when performing limited resection, and long and careful follow-up is required for all patients after surgery.openBeltrame, Valentina; Pozza, Gioia; Dalla Bona, Enrico; Fantin, Alberto; Valmasoni, Michele; Sperti, CosimoBeltrame, Valentina; Pozza, Gioia; DALLA BONA, Enrico; Fantin, Alberto; Valmasoni, Michele; Sperti, Cosim

Collision of ductal adenocarcinoma and neuroendocrine tumor of the pancreas: a case report and review of the literature

Background: Simultaneous occurrence of exocrine and neuroendocrine tumors of the pancreas is very infrequent. We report a patient with an endocrine tumor in the pancreatic-duodenal area and extensive exocrine carcinoma involving the whole pancreas. Case presentation: A 69-year-old woman was hospitalized in May 2016 for epigastric pain and weight loss. Her past medical history revealed an undefined main pancreatic duct dilation that was subsequently confirmed at CT scan (23 mm) and endoscopic ultrasound. There was no evidence of pancreatic masses, but the cephalic portion of the main pancreatic duct presented hypoechoic nodules. A diagnosis of the main-duct intraductal papillary mucinous neoplasm was made, and the patient underwent total pancreatectomy. Pathological examination showed a collision tumor constituted by a ductal adenocarcinoma involving the whole pancreas and a neuroendocrine tumor located in the duodenal peripancreatic wall and the head of the pancreas. There was one peripancreatic lymph node metastasis from the ductal adenocarcinoma and eight node metastases from the neuroendocrine tumor. These findings suggested a diagnosis of collision of neuroendocrine and ductal adenocarcinomas of the pancreas. The postoperative course was uneventful. Conclusions: The coexistence of pancreatic endocrine and exocrine tumors is very uncommon. When present, problems in differential diagnosis may arise between mixed exocrine-endocrine carcinoma or the collision of separate tumors

Solid-Pseudopapillary Tumor of the Pancreas: A Single Center Experience

Aim of this study was to review the institutional experience of solid-pseudopapillary tumors of the pancreas with particular attention to the problems of preoperative diagnosis and treatment. From 1997 to 2013, SPT was diagnosed in 18 patients among 451 pancreatic cystic neoplasms (3.7%). All patients underwent preoperative abdominal ultrasound, computed assisted tomography, and tumor markers determinations. In some instances, magnetic resonance, positron emission tomography, and endoscopic ultrasound with aspiration cytology were performed. There were two males and 16 females. Serum CA 19-9 was slightly elevated in one case. Preoperative diagnosis was neuroendocrine tumor ( = 2), mucinous tumor ( = 2), and SPT ( = 14). Two patients underwent previous operation before referral to our department: one explorative laparotomy and one enucleation of SPT resulting in surgical margins involvement. All patients underwent pancreatic resection associated with portal vein resection ( = 1) or liver metastases ( = 1). One patient died of metastatic disease, 77 months after operation, and 17 are alive and free with a median survival time of 81.5 months (range 36-228 months). Most of SPT can be diagnosed by CT or MRI, and the role of other diagnostic tools is very limited. We lack sufficient information regarding clinicopathologic features predicting prognosis. Caution is needed when performing limited resection, and long and careful follow-up is required for all patients after surgery

Mobile opportunity against stress: Open study protocol on the effectiveness of a mobile platform for stress self-management in the post-pandemic era

Mobile health platforms have shown promise in the management of various mental health conditions (including stress, anxiety, and depression) and cognitive behavioral strategies emerged as a popular and effective option offered by the platforms. This paper presents the protocol of a study aimed to test the effectiveness of a mobile platform that uses cognitive-behavioral strategies for stress self-management in the Tuscany region (Italy). The mobile app is adapted to the specific needs of each vulnerable population for which it is designed: young and older people, healthcare professionals, entrepreneurs. The app will be evaluated on the following outcomes: (i) perceived susceptibility and severity of the pandemic situation, perceived benefits, and costs of preventive health behaviors, (ii) knowledge about Covid-19 preventive behaviors and negative consequences of social distancing, (iii) stress and psychopathological symptoms (i.e., anxiety, depression, and post-traumatic stress symptoms) and cognitive distortions. If successful, we expect that the platform could give various groups clinical benefits by providing symptom self-monitoring and early intervention, consolidating the number of mental health programs available, and decreasing barriers to treatment-seeking. This population-level approach has the potential to improve mental health outcomes in pandemic periods for many people

Surgical Outcomes, Long-Term Recurrence Rate, and Resource Utilization in a Prospective Cohort of 165 Patients Treated by Transanal Total Mesorectal Excision for Distal Rectal Cancer.

A transanal total mesorectal excision (taTME) is a smart alternative to a conventional TME. However, worrisome reports of a high recurrence and complications triggered a moratorium in a few countries. This study assessed the outcomes and resource utilization of a taTME. Consecutive patients with distal rectal cancer treated by a taTME were prospectively included. Outcomes were reported as the median and interquartile range (IQR). One hundred sixty-five patients (67% male and 33% female) with a tumor 7 cm (IQR 5-10) from the anal verge were followed for 50 months (IQR 32-79). The resection margins were threatened in 25% of the patients, while 75% of the patients received neoadjuvant radiochemotherapy. A good mesorectal dissection and clear margins were achieved in 96% of the specimens, and 27 lymph nodes (IQR 20-38) were harvested. Ninety-day major morbidity affected 36 patients (21.8%), including 12 with anastomotic leakages (7.2%). A recurrence occurred locally in 9 patients (5.4%), and 44 patients had a distant metastasis (26.7%). The five-year disease-free survival and overall survival were 67% and 90%, respectively. A multivariate analysis found a long operation and frailty predicted an anastomotic leak, while a positive distal margin and lymph nodes predicted a local recurrence and distant metastasis. A two-team taTME saved 102 min of operative time and EUR 1385 when compared to a one-team approach. Transanal total mesorectal excision produced sound surgical quality and excellent oncologic outcomes

Simultaneous laparoscopic resection of distal pancreas and liver nodule for pancreatic neuroendocrine tumor

Laparoscopic distal pancreatectomy (LDP) with or without splenic preservation is increasingly performed for benign or border-line neoplasms of the body and tail of the pancreas. Pancreatic neuroendocrine tumors appear as an excellent indication for laparoscopic resection and this procedure is becoming the gold standard for the surgical treatment of such neoplasms. The safety and advantage of laparoscopic resection over open distal pancreatectomy (ODP) have been proven. In this video, we present a LDP with splenectomy for a neuroendocrine tumor of distal pancreas, with associated wedge resection of a liver nodule. Technical considerations were also discussed