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Duodenocefalopancreatectomia con exeresi totale del mesopancreas (Total Mesopancreas Excision) vs tecnica standard nel trattamento del carcinoma cefalopancreatico
Full text linkIntroduzione
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
The left-to-right approach during difficult total hepatectomy for liver transplantation: A safe strategy for challenging cases
No full textLaparoscopic left hepatectomy with hanging maneuver for hepatocellular carcinoma with thrombectomy of the left portal vein (with video)
No full textDouble inferior vena cava does not complicate para-aortic nodal dissection for the treatment of pancreatic carcinoma
No full textDuplication of the inferior vena cava (IVC) involves large veins on both sides of the aorta that join anteriorly at the level of the renal arteries to become the suprarenal IVC. We report CT scan and intraoperative images of a patient with duplication of the IVC who underwent pancreaticoduodenectomy with para-aortic lymphadenectomy for carcinoma of the pancreatic head: nodal dissection along the left caval vein was not carried out. The anatomical background of the lymphatic flow to the para-aortic lymph nodes and the theoretic basis for lymph node dissection of the para-aortic area in cases of double IVC are highlighted. Lymphadenectomy along the left caval vein is not necessary in patients with double IVC who undergo pancreaticoduodenectomy with extended lymphadenectomy for carcinoma of the pancreatic head in the absence of preoperative appearance of para-aortic disease
Portal vein aneurysm: What to know
No full textAbstractPortal vein aneurysm is an unusual vascular dilatation of the portal vein, which was first described by Barzilai and Kleckner in 1956 and since then less than 200 cases have been reported.The aim of this article is to provide an overview of the international literature to better clarify various aspects of this rare nosological entity and provide clear evidence-based summary, when available, of the clinical and surgical management.A systematic literature search of the Pubmed database was performed for all articles related to portal vein aneurysm. All articles published from 1956 to 2014 were examined for a total of 96 reports, including 190 patients.Portal vein aneurysm is defined as a portal vein diameter exceeding 1.9cm in cirrhotic patients and 1.5cm in normal livers. It can be congenital or acquired and portal hypertension represents the main cause of the acquired version. Surgical indication is considered in case of rupture, thrombosis or symptomatic aneurysms. Aneurysmectomy and aneurysmorrhaphy are considered in patients with normal liver, while shunt procedures or liver transplantation are the treatment of choice in case of portal hypertension. Being such a rare vascular entity its management should be reserved to high-volume tertiary hepato-biliary centres
Semeiotica e patologia del pancreas e della milza
No full textIl capitolo descrive la semeiotica clinica e strumentale delle patologie del pancreas e della milza
Semeiotica e patologia del fegato e della vie biliari
No full textSemeiotica e Clinica del Fegato e delle Vie Biliar
Recurrent hepatocellular carcinoma: A Western strategy that emphasizes the impact of pathologic profile of the first resection
No full textHepatocellular carcinoma (HCC) often recurs after curative resection,
and thus the optimal treatment strategy to treat recurrences remains uncertain.
We analyzed the results of different options to treat recurrent HCC and
emphasized the impact of pathologic patterns of the tumor at initial resection.
METHODS: Between 2000 and 2014, 293 patients underwent potentially curative
hepatic resection for HCC. Among them, 150 experienced a recurrence and have been
treated by repeat resection (RR), radiofrequency ablation (RFA), salvage liver
transplantation (SLT), transarterial chemoembolization (TACE), or conservative
treatment, including systemic or targeted chemotherapy. Clinical outcomes were
analyzed and compared between the treatment groups, focusing on clinical and
pathologic characteristics of the tumor at initial resection.
RESULTS: After a median follow-up of 26 months, the overall survival (OS) at 1,
3, and 5 years after recurrence was 62%, 48%, and 40%, respectively. Survival
rates were greater in patients treated by a curative approach (RR, RFA, SLT) than
those treated by TACE, with 5-year OS of >70% and 37%, respectively. Univariate
analysis showed satellitosis and microvascular invasion (MVI) at initial
resection as negative prognostic factors of survival after recurrence (P < .05).
On multivariate analysis, type of treatment was the only independent factor
associated with survival. A subgroup analysis showed that RR/RFA led to better
survival outcomes than TACE for early stage intrahepatic recurrences in the
absence of satellitosis or MVI on the primary resected tumor.
CONCLUSION: Curative treatments of recurrent HCC improve patient survival.
Satellitosis and MVI on the primary resected specimen may be used as selection
criteria for the best treatment strategy for intrahepatic recurrences
Acute pancreatitis complicated by infected pseudocyst in a child with pancreas divisum.
No full textINTRODUCTION:
Acute pancreatitis occurs less frequently in children than in adults, although it seems to be more common than has been considered in the past. There are several causes of pancreatitis in childhood: trauma, infections or structural gland anomalies as pancreas divisum.
CASE PRESENTATION:
We report a case of non-traumatic severe acute pancreatitis in a 8-year-old girl with pancreas divisum, complicated by a rapid formation of a large infected pseudocyst which required a surgical internal drainage by a Roux-en-Y cystojejunostomy.
DISCUSSION:
Pancreas divisum is the most common congenital anomaly of the pancreas with an incidence of 3-10% of population, and its role in causing acute or recurrent pancreatitis is still controversial. There are only sporadic observations of acute pancreatitis complicated by pseudocyst in children with pancreatic anomalies and its treatment is not standardized. Three different approaches have been described to treat a pancreatic pseudocyst: percutaneous, endoscopic or surgical drainage. We decided to perform a pseudocyst-jejunostomy because of the disease severity.
CONLUSION:
Even in the non-invasive era, the surgical approach to treat a large complicated pseudoysts in children still represents a safe and feasible approach in emergencies as acute abdomen, bleeding or sepsis. Complications of percutaneous and endoscopic drainages are avoided and long term results are excellent
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