Incidental intraoperative discovery of a pancreatic neuroendocrine tumor associated with chronic pancreatitis

<p>Abstract</p> <p>Pancreatic neuroendocrine tumors are a rare entity with an incidence between 2 per million to 5 per 100 000. Association with pancreatitis (acute or chronic) is rare and is considered to be determined by the tumoral obstruction of pancreatic ducts, but sometimes occurs without any apparent relationship between them. Non-functional neuroendocrine pancreatic tumors are usually diagnosed when either very large or metastatic. Small ones are occasionally diagnosed when imagery is performed for other diagnostic reasons. Intraoperative discovery is even rarer and poses problems of differential diagnosis with other pancreatic tumors. Association with chronic pancreatitis is rare and usually due to pancreatic duct obstruction by the tumor. We describe the case of a patient with a small non-functioning neuroendocrine tumor in the pancreatic tail accidentally discovered during surgery for delayed traumatic splenic rupture associated with chronic alcoholic pancreatitis. The tumor of 1.5cm size was well differentiated and confined to the pancreas, and was resected by a distal splenopancreatectomy.</p> <p>Conclusions</p> <p>Surgeons should be well aware of the rare possibility of a non-functional neuroendocrine tumor in the pancreas, associated with chronic pancreatitis, surgical resection being the optimal treatment for cure. Histopathology is of utmost importance to establish the correct diagnosis, grade of differentiation, malignancy and prognosis.</p> <p>Virtual slides</p> <p>The virtual slide(s) for this article can be found here: <url>http://www.diagnosticpathology.diagnomx.eu/vs/2114470176676003</url>.</p

Schwannoma: A Rare Case of Submucosal Gastric Tumor

Schwannoma is a tumor that originates from the Schwann cells that surround a neuron’s axon. This tumor is very rare in the gastrointestinal tract and develops submucosally from intestinal nerve plexuses. The most common location for gastrointestinal schwannomas is the stomach, where they account for only 0.2% of gastric tumors. We present the case of a 56-year-old asymptomatic patient who was diagnosed, following a routine ultrasound examination, with an abdominal tumor. An abdominal MRI confirmed the gastric origin of the tumor. Although a subsequent upper-digestive endoscopic ultrasound was performed, a definitive diagnosis could not be established. Thus, a laparoscopic wedge resection of the stomach was performed. The immunohistochemical examination of the tumor established the diagnosis of benign schwannoma. Despite the availability of advanced endoscopy and imaging techniques, the diagnosis of gastric schwannoma is very rarely preoperative. The immunohistochemical identification of S-100 on the surgical specimen confirmed the diagnosis

Therapeutic Options in Postoperative Enterocutaneous Fistula&mdash;A Retrospective Case Series

Objectives: The aim of the study was to present the results obtained in our experiment regarding the management of postoperative enterocutaneous fistulas (PECF). Materials and Methods: We conducted a retrospective study on 64 PECF registered after 2030 abdominal surgeries (1525 digestive tract surgeries and 505 extra-digestive ones) over a period of 7 years (1st of January 2014&ndash;31th of December 2020) in the 1st and 2nd Surgery Clinics, Clinical County Emergency Hospital of Craiova, Romania. The group included 41 men (64.06%) and 23 women (35.34%), aged between 21&ndash;94 years. Of the cases, 71.85% occurred in elderly patients over 65 years old. Spontaneous fistulas in Crohn&rsquo;s disease, intestinal diverticulosis, or specific inflammatory bowel disease were excluded. Results: The overall incidence of 3.15% varied according to the surgery type: 6.22% after gastroduodenal surgery, 1.78% after enterectomies, 4.30% after colorectal surgery, 4.28% after bilio-digestive anastomoses, and 0.39% after extra-digestive surgery. We recorded a 70.31% fistula closure rate, 78.94% after exclusive conservative treatment and 57.61% after surgery; morbidity was 79.68%, mortality was 29.68%. Conclusion: PECF management requires a multidisciplinary approach and is carried out according to an algorithm underlying well-established objectives and priorities. Conservative treatment including resuscitation, sepsis control, output control, skin protection, and nutritional support is the first line treatment; surgery is reserved for complications or permanent repair of fistulas that do not close under conservative treatment. The therapeutic strategy is adapted to topography, morphological characteristics and fistula output, age, general condition, and response to therapy

Intraoperative cardiovascular response of natural orifice transluminal endoscopic surgery versus laparoscopy: A comparative animal study

Background: Natural orifice transluminal endoscopic surgery (NOTES) emerged as a new alternative method in minimally invasive techniques. Although a very small number of studies have compared the physiologic response in NOTES to laparoscopy, the results remain controversial. Aim: This experimental animal study aims to evaluate the intraoperative cardiovascular and respiratory effects of pure transluminal natural orifice surgery and conventional laparoscopy. Materials and Methods: Twenty female pigs (Sus scrofa domesticus) equally divided into two study groups were assigned to either pure natural orifice transluminal endoscopic techniques (Group 1) or conventional laparoscopic surgery (Group 2) and monitored intraoperatively in terms of heart rate (HR), systolic blood pressure (SBP) and O2saturation (SpO2) for 1 h. Both groups underwent simple surgical procedures such as gastrojejunostomy, oophorectomy and adnexectomy. Results: All procedures were successfully completed. The findings indicated statistically significant differences between SBP (P = 0.0065) and SpO2(P = 0.027) in the two groups at the beginning of the interventions. HR showed significant differences during the last 20 min of the interventions (min 40 and 45; P < 0.001). For the whole procedure (from the beginning of the intervention to 60 min interval), HR, SBP and SpO2values showed no statistical difference. Conclusions: Although significant differences in terms of HR, mean blood pressure and SpO2were noted at specific intervals during surgery, no real variance of the cardiovascular parameters was observed when considering the entire procedure. Therefore, NOTES seems to be a safe approach with minimally intraoperative cardiovascular and respiratory implications

Stoma-free survival after anastomotic leak following rectal cancer resection: worldwide cohort of 2470 patients

Background: The optimal treatment of anastomotic leak after rectal cancer resection is unclear. This worldwide cohort study aimed to provide an overview of four treatment strategies applied. Methods: Patients from 216 centres and 45 countries with anastomotic leak after rectal cancer resection between 2014 and 2018 were included. Treatment was categorized as salvage surgery, faecal diversion with passive or active (vacuum) drainage, and no primary/secondary faecal diversion. The primary outcome was 1-year stoma-free survival. In addition, passive and active drainage were compared using propensity score matching (2: 1). Results: Of 2470 evaluable patients, 388 (16.0 per cent) underwent salvage surgery, 1524 (62.0 per cent) passive drainage, 278 (11.0 per cent) active drainage, and 280 (11.0 per cent) had no faecal diversion. One-year stoma-free survival rates were 13.7, 48.3, 48.2, and 65.4 per cent respectively. Propensity score matching resulted in 556 patients with passive and 278 with active drainage. There was no statistically significant difference between these groups in 1-year stoma-free survival (OR 0.95, 95 per cent c.i. 0.66 to 1.33), with a risk difference of -1.1 (95 per cent c.i. -9.0 to 7.0) per cent. After active drainage, more patients required secondary salvage surgery (OR 2.32, 1.49 to 3.59), prolonged hospital admission (an additional 6 (95 per cent c.i. 2 to 10) days), and ICU admission (OR 1.41, 1.02 to 1.94). Mean duration of leak healing did not differ significantly (an additional 12 (-28 to 52) days). Conclusion: Primary salvage surgery or omission of faecal diversion likely correspond to the most severe and least severe leaks respectively. In patients with diverted leaks, stoma-free survival did not differ statistically between passive and active drainage, although the increased risk of secondary salvage surgery and ICU admission suggests residual confounding

Stoma-free Survival After Rectal Cancer Resection With Anastomotic Leakage: Development and Validation of a Prediction Model in a Large International Cohort.

Objective:To develop and validate a prediction model (STOMA score) for 1-year stoma-free survival in patients with rectal cancer (RC) with anastomotic leakage (AL).Background:AL after RC resection often results in a permanent stoma.Methods:This international retrospective cohort study (TENTACLE-Rectum) encompassed 216 participating centres and included patients who developed AL after RC surgery between 2014 and 2018. Clinically relevant predictors for 1-year stoma-free survival were included in uni and multivariable logistic regression models. The STOMA score was developed and internally validated in a cohort of patients operated between 2014 and 2017, with subsequent temporal validation in a 2018 cohort. The discriminative power and calibration of the models' performance were evaluated.Results:This study included 2499 patients with AL, 1954 in the development cohort and 545 in the validation cohort. Baseline characteristics were comparable. One-year stoma-free survival was 45.0% in the development cohort and 43.7% in the validation cohort. The following predictors were included in the STOMA score: sex, age, American Society of Anestesiologist classification, body mass index, clinical M-disease, neoadjuvant therapy, abdominal and transanal approach, primary defunctioning stoma, multivisceral resection, clinical setting in which AL was diagnosed, postoperative day of AL diagnosis, abdominal contamination, anastomotic defect circumference, bowel wall ischemia, anastomotic fistula, retraction, and reactivation leakage. The STOMA score showed good discrimination and calibration (c-index: 0.71, 95% CI: 0.66-0.76).Conclusions:The STOMA score consists of 18 clinically relevant factors and estimates the individual risk for 1-year stoma-free survival in patients with AL after RC surgery, which may improve patient counseling and give guidance when analyzing the efficacy of different treatment strategies in future studies