Surgical strategies for treatment of malignant pancreatic tumors: extended, standard or local surgery?

Tumor related pancreatic surgery has progressed significantly during recent years. Pancreatoduodenectomy (PD) with lymphadenectomy, including vascular resection, still presents the optimal surgical procedure for carcinomas in the head of pancreas. For patients with small or low-grade malignant neoplasms, as well as small pancreatic metastases located in the mid-portion of pancreas, central pancreatectomy (CP) is emerging as a safe and effective option with a low risk of developing de-novo exocrine and/or endocrine insufficiency. Total pancreatectomy (TP) is not as risky as it was years ago and can nowadays safely be performed, but its indication is limited to locally extended tumors that cannot be removed by PD or distal pancreatectomy (DP) with tumor free surgical margins. Consequently, TP has not been adopted as a routine procedure by most surgeons. On the other hand, an aggressive attitude is required in case of advanced distal pancreatic tumors, provided that safe and experienced surgery is available. Due to the development of modern instruments, laparoscopic operations became more and more successful, even in malignant pancreatic diseases. This review summarizes the recent literature on the abovementioned topics

International Consensus Statement on Rhinology and Allergy: Rhinosinusitis

Background: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR‐RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR‐RS‐2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence‐based findings of the document. Methods: ICAR‐RS presents over 180 topics in the forms of evidence‐based reviews with recommendations (EBRRs), evidence‐based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. Results: ICAR‐RS‐2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence‐based management algorithm is provided. Conclusion: This ICAR‐RS‐2021 executive summary provides a compilation of the evidence‐based recommendations for medical and surgical treatment of the most common forms of RS

Prediction of bone mass gain by bone turnover parameters after parathyroidectomy for primary hyperparathyroidism: neural network software statistical analysis.

Background: Primary hyperparathyroidism (pHPT) is the most frequent endocrine hypersecretion disease, and parathyroidectomy is the only curative option, since pharmacologic therapy reduces hypercalcemia but does not impede parathyroid hormone hypersecretion. According to guidelines from the National Institutes of Health, parathyroidectomy is associated with bone mass increase in some asymptomatic patients, while in others bone mass is not changed after surgery. Therefore, we performed the present study in an attempt to elucidate whether a preoperative biochemical bone parameter can be predictive of a significant vertebral bone mass increase in patients with pHPT. Methods: For each patient we analyzed the following preoperative parameters: parathyroid hormone, urinary calcium excretion, urinary type I collagen cross-linked N-telopeptide (NTX), osteocalcin, and vertebral computerized bone mineralography. All patients underwent vertebral computerized bone mineralography 12 months after the operation. Statistical analysis was carried out by a neural network program, an event-predicting software modeled on human brain neuronal connections, which is able to examine independent statistical parameters. Results: The patients presenting with high preoperative bone turnover (especially high NTX levels) will have a 5% vertebral bone mass gain in 83.33% of cases after surgery, independently of the National Institutes of Health guidelines. Conclusions: A high preoperative NTX level seems to be the best predictor parameter for postoperative vertebral bone mass gain in patients with pHPT. Our study also illustrates that neural network software may be a valuable method to help elucidate which pHPT patients should undergo surgical treatmen

A randomized, controlled, clinical study of laparoscopic vs open tension-free inguinal hernia repair.

BACKGROUND: The aim of this prospective, randomized, controlled clinical study was to compare laparoscopic transabdominal preperitoneal (TAPP) hernia repair with a standard tension-free open mesh repair (open). METHODS: A total of 108 low-risk patients with unilateral (primary or recurrent) or bilateral hernias were randomized to TAPP (group 1 = 52 cases) or open (group 2 = 56 cases). The outcome measures included operating time, complications, postoperative pain, return to normal activity, operating theater costs, and recurrences. RESULTS: The mean operative time was longer for the TAPP than for the open group only in unilateral primary hernias. At rest, the median Visual Analog Scale (VAS) score was higher for group 1 than group 2 at 48 h postoperatively. Mild to discomforting pain in the inguinal region after 7 days, night pain after 30 days, and inguinal hardening after 3 months were more frequent in group 2 than group 1. No significant differences were observed in return to normal activities between the groups. One hernia recurrence was observed after 1 month in group 1. TAPP was significantly more expensive than open. CONCLUSIONS: TAPP was associated with less postoperative pain than open. The increase in operating theater costs, however, was dramatic and was not compensated by shorter time away from work. TAPP should not be adopted routinely unless its costs can be drastically reduced

Plastias de estenoses de intestino delgado na doença de Crohn: resultados imediatos e tardios Crohn’s disease small bowel strictureplasties: early and late results

RACIONAL: As enteroplastias constituem alternativa cirúrgica no tratamento da estenose da doença de Crohn. OBJETIVO: Analisar, retrospectivamente, a evolução precoce e tardia do tratamento cirúrgico das estenoses do intestino delgado, segmento ileocecal ou anastomose ileocólica secundária à doença de Crohn, com emprego de plastias intestinais. MÉTODOS: Foram estudados 28 doentes, operados entre setembro de 1991 e maio de 2004, com seguimento médio pós-operatório de 58,1 meses. Dezesseis (57,1%) eram do sexo masculino, com média etária de 33,3 anos, e 13 doentes (46,4%) apresentavam ressecções intestinais prévias. Foram realizadas 116 plastias, sendo 94 (81%) à Heineke-Mikulicz, 15 (13%) do tipo Finney e 7 (6%) ileocoloplastias látero-laterais. Em 18 doentes (64,3%) realizaram-se ressecções intestinais concomitantes. RESULTADOS: Verificaram-se 14 complicações em 7 doentes (25%) e um óbito (3,6%), secundário a complicações pulmonares após reoperações por sangramento intestinal da anastomose êntero-entérica. Ocorreram duas complicações gerais (14,3%), em dois doentes (7,1%) e oito complicações locais precoces (57,1%), em sete doentes (25%), sendo a mais freqüente deiscência de plastia, em três casos (10,7%). Complicações locais tardias ocorreram em dois doentes (7,1%), ambos com hérnia incisional e fístula êntero-cutânea. Recidiva sintomática da estenose ocorreu em 17 doentes (63%) e 2 deles (7,4%), apresentaram fístulas êntero-cutâneas, sendo o índice de reoperação de 40,7%. Observaram-se quatro recidivas (3,5%), em três doentes (11,1%) em local de plastia prévia, sendo mais comum no tipo Finney (20%). CONCLUSÃO: As plastias apresentaram baixos índices de complicações e propiciam alívio dos sintomas. Uma vez que muitos doentes com doença de Crohn necessitarão de várias cirurgias ao longo da vida, as plastias intestinais constituem alternativas eficazes, com resolução dos sintomas obstrutivos, evitando-se ressecções intestinais extensas e suas conseqüências.<br>BACKGROUND: Strictureplasty is an alternative surgical procedure for Crohn’s disease, particulary in patients with previous resections or many intestinal stenosis. AIM: To analyze surgical complications and clinical follow-up in patients submitted to strictureplasty secondary to Crohn’s disease. METHODS: Twenty-eight patients (57.1% male, mean age 33.3 years, range 16-54 years) with Crohn’s disease and intestinal stenosis (small bowel, ileocecal region and ileocolic anastomosis) were submitted to strictureplasty, at one institution, between September 1991 and May 2004. Thirteen patients had previous intestinal resections. The mean follow-up was 58.1 months. A total of 116 strictureplasties were done (94 Heineke-Mikulicz - 81%, 15 Finney - 13%, seven side-to-side ileocolic strictureplasty - 6%). Three patients were submitted to strictureplasty at two different surgical procedures and two in three procedures. RESULTS: Regarding to strictureplasty, postoperative complication rate was 25% and mortality was 3.6%. Early local complication rate was 57.1%, with three suture leaks (10.7%) and late complication was present in two patients, both with incisional hernial and enterocutaneous fistulas (28.6%). Patients remained hospitalized during a medium time of 12.4 days. Clinical and surgical recurrence rates were 63% and 41%, respectively. Among the patients submitted to another surgery, two patients had two more operations and one had three. Recurrence rate at strictureplasty site was observed in 3.5%, being Finney technique the commonest one. Presently, 19 patients had been asymptomatic with the majority of them under medical therapy. CONCLUSION: Strictureplasties have low complication rates, in spite of having been done at compromised site, with long term pain relief. Considering the clinical course of Crohn’s disease, with many patients being submitted to intestinal resections, strictureplasties should be considered as an effective surgical treatment to spare long intestinal resections