Venous resection and reconstruction within pancreatoduodenectomy

Catedra Chirurgie Generală, Universitatea de Stat de Medicină și Farmacie „Nicolae Testemiţanu”; Spitalul Clinic Municipal Nr.1, Chişinău, Republica Moldova, Al XIII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” și al III-lea Congres al Societății de Endoscopie, Chirurgie miniminvazivă și Ultrasonografie ”V.M.Guțu” din Republica MoldovaIntroducere: Pancreatoduodenectomia (PDE) este singura metodă potențial curativă pentru cancerul periampular. Totodată, la momentul stabilirii diagnosticului adenocarcinomul pancreasului în circa 50% de observaţii concreşte în confluenţa venei mezenterice superioare (VMS) şi venei porte (VP). Rezecţia venoasă (RV) este indicată în cazul, când capul şi/sau procesul uncinat nu pot fi disecate de la confluenţa VMS-VP fără rămânerea ţesutului tumoral. Material si metode: În perioada 2010-2018 au fost efectuate 68 PDE consecutive. Bărbați – 35, femei – 33, vârsta medie – 60,3 ani. RV a fost efectuată la 16 (23,5%) pacienţi. Conform clasificării Tseng, RV1 (rezecţie tangenţială cu patch) s-a practicat în 2 (12,5%) cazuri; RV2 (rezecţie segmentară cu ligaturarea venei lienale (VL) și anastomoză primară – în 6 (37,5%); RV3 (rezecţie segmentară cu ligaturarea VL și interpoziţia grefei) – în 3 (18,7%); RV4 (rezecţie segmentară cu păstrarea VL și anastomoză primară) – în 4 (25%); RV5 (rezecţie segmentară cu păstrarea VL și interpoziţia grefei) – în 1 (6,3%) caz. Rezultate: Durata operației a constituit 302±6 min (în lotul fără RV) vs 364±12 min (cu RV), p<0,0001. Pierderea sangvină intraoperatorie: 570±39 ml (fără RV) vs 1093±73 ml (cu RV), p<0,0001. Decesul în perioada postoperatorie precoce a survenit la 2 (3%) bolnavi. Pacienții după PDE cu RV au avut o supraviețuire similară cu cea după PDE fără RV. Concluzii: Invazia izolată a tumorii în VMS-VP nu trebuie să fie o contraindicație pentru PDE în cazul cancerului pancreatic localizat. RV pot fi efectuate pe parcursul PDE cu rezultate bune, inclusiv supraviețuirea medie similară în comparație cu pacienții fără rezecție venoasă.Introduction: Pancreatoduodenectomy (PDE) is the only potentially curative method for periampular carcinoma. However, at the time of diagnosis, pancreatic adenocarcinoma in about 50% of cases invades into the confluence of the superior mesenteric vein (SMV) and portal vein (PV). Venous resection (VR) is indicated when the head and/or uncinate process can not be dissected from the SMVPV confluence without leaving the tumor tissue. Material and methods: Sixty eight consecutive PDEs were performed during 2010-2018. Men – 35, women – 33, average age – 60.3 years. VR was performed in 16 (23.5%) patients. According to the Tseng classification, VR1 (tangential resection with) was performed in 2 (12.5%) cases; VR2 (segmental resection with splenic vein (SV) ligation with primary anastomosis – in 6 (37.5%), VR3 (segmental resection with SV ligation, with interposition of graft) – in 3 (18.7%); VR4 (segmental resection with SV preservation, with primary anastomosis) – in 4 (25%); VR5 (segmental resection with SV preservation, with graft interposition) – in 1 (6.3%). Results: The length of surgery was 302±6 min (in the group without VR) vs 364±12 min (with VR), p<0.0001. Intraoperative blood loss: 570±39 ml (without VR) vs 1093±73 ml (with VR), p<0.0001. Death in the early postoperative period occurred in 2 (3%) patients. Patients after PDE with VR had similar survival as after PDE without VR. Conclusions: The isolated tumor invasion in SMV-PV should not be a contraindication for PDE in localized pancreatic cancer. VR can be performed durng PDE with good results, including similar mean survival compared to patients without venous resection

Twenty five consecutive pancreaticoduodenectomies without postoperative mortality

Catedra chirurgie generală, USMF „Nicolae Testemițanu”, Spitalul Clinic Municipal nr.1, Chișinău, Republica Moldova, Al XII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova cu participare internațională 23-25 septembrie 2015Introducere: Pancreatoduodenectomia (PDE) este singura metodă potențial curativă în tratamentul cancerului capului pancreatic și a altor adenocarcinoame periampulare. Totodată, decizia în favoarea procedeului radical este încă limitată din cauza părerii comune eronate referitoare la mortalitatea postoperatorie înaltă. Material și metode: În perioada mai 2011 – aprilie 2015, 25 PDE consecutive au fost efectuate în Clinica Chirurgie. Au fost 13 bărbați și 12 – femei. Vârsta medie era 60,3 (41-80) ani. La internare pacienții au avut icter mecanic (88%), pierdere ponderală (96%), dureri epigastrale (68%) și alte manifestări ale tumorii capului pancreatic. Diagnosticul a fost confirmat prin ecografie abdominală și tomografie computerizată cu contrast sau rezonanță magnetică în regim de colangiopancreatografie. Rezultate: Toți pacienții au suportat PDE clasică tip Whipple cu pancreaticojejunostomie. Durata medie a intervenției a constituit 5 ore 21 minute (de la 4 ore pînă la 8,25 ore), iar pierderea sangvină intraoperatorie – 674 (250-1500) ml. Rezecția și reconstrucția axului venos mezentericoportal a fost efectuată în 5 (20%) cazuri. Examinarea histologică a relevat adenocarcinom periampular la 21 pacienți (pancreatic – 15, ampular – 5, duodenal – 1). Patru pacienți au avut pancreatită cronică. Perioada postoperatorie necomplicată s-a constatat la 7 (28%) pacienți. Cele mai frecvente complicații postoperatorii au fost: lipsa evacuării din stomac, fistule pancreatice și biliare. Tratamentul conservativ pentru complicațiile specifice și sistemice a fost aplicat la 11 bolnavi, drenaj chirurgical sau ecoghidat au necesitat 7 pacienți. Nu a fost notată mortalitate postoperatorie. Durata medie de spitalizare a constituit 26 zile. Concluzii: PDE a devenit o intervenție obișnuită, efectuată în multe spitale. Durata operației, pierderea sangvină și durata spitalizării au devenit acceptabile. Actualmente, PDE este un procedeu sigur, cu o mortalitate postoperatorie redusă.Introduction: Pancreaticoduodenectomy (PDE) is the only potential curative method for treatment of pancreatic head cancer and other periampullary adenocarcinoma. However, decisions in favor of radical procedure are still limited, because of common misconseption about high postoperative mortality. Material and methods: Between May 2011 and April 2015, 25 consecutive PDE were performed in Surgical Department. A total of 13 were male, and 12 were female. Mean age was 60.3 (range 41-80) years. On presentation patients had mechanical jaundice (88%), weight loss (96%), epigastric pain (68%), and other symptoms of pancreatic head tumor. Diagnosis was confirmed by abdominal ultrasonography and contrast computed tomography or magnetic resonance cholangiopancreatography. Results: All patients underwent classic Whipple PDE with pancreaticojejunostomy. Mean operative time was 5 hours 21 minutes (range 4-8.25 hours), and intraoperative blood loss – 674 (250-1500) ml. Mesentericoportal vein resection and reconstruction was performed in 5 (20%) cases. Histological examination revealed a periampullary adenocarcinoma in 21 patients (pancreatic – 15, ampullary – 5, duodenal – 1). Four patients had chronic pancreatitis. Postoperative course was uneventful in 7 (28%) patients. The most common postoperative complication were delayed gastric emptying, pancreatic and biliary fistulas. Treatment for specific and systemic complications was conservative in 11 patients, surgical or ultrasound guided drainage required 7 patients. No postoperative mortality was noted. Mean length of hospital stay was 26 days. Conclusions: PDE has become a commonly performed operation in many hospitals. Operative time, blood loss, and length of stay have become acceptable. Nowadays, PDE is the safe procedure, with low hospital mortality

Management of pancreatic pseudoaneurysm

Catedra chirurgie generală, USMF „N.Testemițanu”, Chișinău, Moldova, Spitalul Clinic Municipal nr.1, Chișinău, Moldova, Al XI-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova și cea de-a XXXIII-a Reuniune a Chirurgilor din Moldova „Iacomi-Răzeșu” 27-30 septembrie 2011Introducere: Pseudoanevrismul pancreatic (PP) reprezintă o complicație rară, însă deseori fatală a pancreatitei. Apariția PP este cauzată de lezarea peretelui arterial, ce duce la instituirea formațiunii pulsatile în cavitatea pseudochistului pancreatic cu sau fara erupție în tractul gastrointestinal. Letalitatea în PP constituie 12-33%. Material și metode: În Clinica chirurgie generală au fost tratați 6 bolnavi cu PP, vârsta medie - 39 ani. Etiologia etilică a pancreatitei a fost stabilită la toți pacienții. În 5 cazuri fistula arterială a fost originară din artera lienală și într-un caz - din artera pancreatoduodenală inferioară. Patru bolnavi s-au prezentat cu hemoragie în cavitatea pseudochistului pancreatic per se, 2 - cu erupție ulterioară în stomac și hemoragie digestivă superioară masivă. Prezența și localizarea fistulei arteriale s-a stabilit la ultrasonografia Doppler-duplex, CT cu contrastare intravenoasa și angiografia transcateteriană. Rezultate: Cinci bolnavi au fost operați: în 2 cazuri s-a efectuat pancreatectomie distală, în 3 - suturarea transchistică a arterei lezate. Într-un caz la o pacientă HIV-pozitivă tromboza PP a fost obținută prin injectarea transcutanată ecoghidată a trombinei umane. Într-un caz s-a practicat tentativa nereușită de embolizare angiografică. Un pacient a decedat. Concluzii: Diagnosticul definitiv de PP se stabilește în baza angiografiei computerizate sau transcateteriene. În lipsa eficacității embolizarii arterei sângerânde prin cateter sau a trombozării PP este necesar tratamentul chirurgical. Rezecția pancreatică este mai indicată bolnavilor cu localizarea periferică a PP, iar ligaturarea arterei - în situarea centrală.Background: Pancreatic pseudoaneurysm (PP) is rare, but often life-threatening complication of pancreatitis. Development of PP is caused by a lesion of arterial wall and formation of pulsatile cavity into pancreatic pseudocyst, with or without subsequent eruption in the gastrointestinal lumen. Mortality in PP is nearly 12-33%. Material and methods: Six patients with PP were treated in the department of general surgery, median age - 39 years. In all cases was established an alcoholic etiology of pancreatitis. In 5 cases the origin of vascular fistula was splenic artery, and inferior pancreatoduodenal artery - in one. Four patients were admitted with acute bleeding into pancreatic cyst per se, but 2 - with consequent rupture in the stomach and massive upper gastrointestinal bleeding. The presence and location of arterial fistula were determined by duplex ultrasound, contrasted enhanced CT and conventional angiography. Results: Five patients underwent surgery: distal pancreatectomy was performed in 2 cases and transcystic ligature of affected vessel - in 3. In one case of a HIV-positive women thrombosis of PP was achived by ultrasonography-guided percutaneous needle injection of human thrombin. An unsuccessful attempt of angiographic embolization was done in one case. One patient dies. Conclusions: Definitive diagnosis of PP should be done basing on CT or conventional angiography. Failure to embolize bleeding artery or to thrombose the PP serves as an indication for surgery. Pancreatic resection is preferable in patients with distal localization of PP, whereas arterial ligation - in central one

Methods for Assessing Mitochondrial Function in Diabetes

A growing body of research is investigating the potential contribution of mitochondrial function to the etiology of type 2 diabetes. Numerous in vitro, in situ, and in vivo methodologies are available to examine various aspects of mitochondrial function, each requiring an understanding of their principles, advantages, and limitations. This review provides investigators with a critical overview of the strengths, limitations and critical experimental parameters to consider when selecting and conducting studies on mitochondrial function. In vitro (isolated mitochondria) and in situ (permeabilized cells/tissue) approaches provide direct access to the mitochondria, allowing for study of mitochondrial bioenergetics and redox function under defined substrate conditions. Several experimental parameters must be tightly controlled, including assay media, temperature, oxygen concentration, and in the case of permeabilized skeletal muscle, the contractile state of the fibers. Recently developed technology now offers the opportunity to measure oxygen consumption in intact cultured cells. Magnetic resonance spectroscopy provides the most direct way of assessing mitochondrial function in vivo with interpretations based on specific modeling approaches. The continuing rapid evolution of these technologies offers new and exciting opportunities for deciphering the potential role of mitochondrial function in the etiology and treatment of diabetes

Effect of resonant tunneling on exciton dynamics in coupled dot-well nanostructures

Excitonic dynamics in a hybrid dot-well system composed of InAs quantum dots (QDs) and an InGaAs quantum well (QW) is studied by means of femtosecond pump-probe reflection and continuous wave (cw) photoluminescence (PL) spectroscopy. The system is engineered to bring the QW ground exciton state into resonance with the third QD excited state. The resonant tunneling rate is varied by changing the effective barrier thickness between the QD and QW layers. This strongly affects the exciton dynamics in these hybrid structures as compared to isolated QW or QD systems. Optically measured decay times of the coupled system demonstrate dramatically different response to temperature change depending on the strength of the resonant tunneling or coupling strength. This reflects a competition between purely quantum mechanical and thermodynamical processes.NSF (DMR-1008107)DFG (580/8-1

Effect of tunneling transfer on thermal redistribution of carriers in hybrid dot-well nanostructures

The thermally induced redistribution of carriers between quantum well (QW) and quantum dot (QD) layers in a hybrid dot-well system composed of InAs QDs and an InGaAs QW is studied by means of photoluminescence (PL) spectroscopy. This redistribution significantly affects the QD and QW PL intensities depending both on the dot-well barrier thickness and height. For comparatively thin barriers, the interplay between tunnel and thermal carrier fluxes becomes crucial, governing the exciton dynamics in a tunnel injection dot-well structure at elevated temperatures. For a sufficiently thick spacer, it is shown that exciton localization within the QW, apparently induced by QD strain fields, has a profound influence on the transfer dynamics at low temperatures.NSF (DMR-1008107)DFG (580/8-1

Matters of the heart in bioenergetics: mitochondrial fusion into continuous reticulum is not needed for maximal respiratory activity

International audienceMitochondria are dynamic structures for which fusion and fission are well characterized for rapidly dividing cells in culture. Based on these data, it has recently been proposed that high respiratory activity is the result of fusion and formation of mitochondrial reticulum, while fission results in fragmented mitochondria with low respiratory activity. In this work we test the validity of this new hypothesis by analyzing our own experimental data obtained in studies of isolated heart mitochondria, permeabilized cells of cardiac phenotype with different mitochondrial arrangement and dynamics. Additionally, we reviewed published data including electron tomographic investigation of mitochondrial membrane-associated structures in heart cells. Oxygraphic studies show that maximal ADP-dependent respiration rates are equally high both in isolated heart mitochondria and in permeabilized cardiomyocytes. On the contrary, these rates are three times lower in NB HL-1 cells with fused mitochondrial reticulum. Confocal and electron tomographic studies show that there is no mitochondrial reticulum in cardiac cells, known to contain 5,000-10,000 individual, single mitochondria, which are regularly arranged at the level of sarcomeres and are at Z-lines separated from each other by membrane structures, including the T-tubular system in close connection to the sarcoplasmic reticulum. The new structural data in the literature show a principal role for the elaborated T-tubular system in organization of cell metabolism by supplying calcium, oxygen and substrates from the extracellular medium into local domains of the cardiac cells for calcium cycling within Calcium Release Units, associated with respiration and its regulation in Intracellular Energetic Units