The impact of the multidisciplinary tumor board (MDTB) on the management of pancreatic diseases in a tertiary referral center

BACKGROUND

The implementation of multidisciplinary tumor board (MDTB) meetings significantly ameliorated the management of oncological diseases. However, few evidences are currently present on their impact on pancreatic cancer (PC) management. The aim of this study was to evaluate the impact of the MDTB on PC diagnosis, resectability and tumor response to oncological treatment compared with indications before discussion.

PATIENTS AND METHODS

All patients with a suspected or proven diagnosis of PC presented at the MDTB from 2017 to 2019 were included in the study. Changes of diagnosis, resectability and tumor response to oncological/radiation treatment between pre- and post-MDTB discussion were analyzed.

RESULTS

A total of 438 cases were included in the study: 249 (56.8%) were presented as new diagnoses, 148 (33.8%) for resectability assessment and 41 (9.4%) for tumor response evaluation to oncological treatment. MDTB discussion led to a change in diagnosis in 54/249 cases (21.7%), with a consequent treatment strategy variation in 36 cases (14.5%). Change in resectability was documented in 44/148 cases (29.7%), with the highest discrepancy for borderline lesions. The treatment strategy was thus modified in 27 patients (18.2%). The MDTB brought a modification in the tumor response assessment in 6/41 cases (14.6%), with a consequent protocol modification in four (9.8%) cases.

CONCLUSIONS

MDTB discussion significantly impacts on PC management, especially in high-volume centers, with consistent variations in terms of diagnosis, resectability and tumor response assessment compared with indications before discussion.

Atypical presentation of acute pancreatitis: a single center case-match analysis of clinical outcomes

OBJECTIVE

Acute pancreatitis (AP) may present an aspecific clinical picture without abdominal symptoms (atypical AP). We compared clinical outcomes between typical and atypical AP.

PATIENTS AND METHODS

Thirty out of 1163 patients (2.6%) presented an atypical AP. Demographic, clinical data, laboratory and radiological findings, management type, length of hospital stay (LOS) and mortality rate were retrospectively reviewed. A case match analysis 2:1 was performed. The final groups comprised 50 typical APs (TAP group) and 25 atypical APs (AAP group).

RESULTS

The AAP patients presented fever (36%), syncope (32%) and dyspnea (16%) as the most frequent symptoms. Laboratory values showed similarity between the two groups. We noted a comparable edematous AP rate in both groups (p=0.36). Ten (20%) TAP and 3 (12%) AAP patients needed ERCP, respectively (p=0.38). Cholecystectomy was similarly performed in both cohorts (p=0.81). One TAP patient underwent a percutaneous drainage and subsequent surgical necrosectomy compared to none in the AAP cohort (p=0.47). LOS and mortality rate were comparable (p=0.76 and 0.3, respectively).

CONCLUSIONS

Similar outcomes have been reached in the two groups. Routine evaluation of the serum amylase values fundamentally contributed to early diagnosis and appropriate treatment.

Colonoscopy quality assessment and accuracy: analysis of the influencing factors and surgical sequelae on 216 colonoscopies

OBJECTIVE

Colonoscopy is recognized as the primary screening test for colorectal cancer. However, its inaccuracy in identifying the exact tumor localization is still high. As a consequence, repeated colonoscopies and changes in the surgical management have been reported. This study aims to evaluate the quality of 216 colonoscopies, to define colonoscopy accuracy and to investigate the surgical sequelae of an incorrect localization.

PATIENTS AND METHODS

A retrospective analysis of 216 colonoscopies has been conducted. Colonoscopy quality was assessed on: quality of bowel preparation, completeness of the examination, video and/or photographic documentation, and reported the distance of the lesion from the anal verge. Colonoscopy accuracy was evaluated in terms of correspondence between the endoscopic and intra-operative tumor localization.

RESULTS

Bowel preparation adequateness was reported in 121 out of 216 (56%) colonoscopies, with an adequate grade in 68.6% of cases. A complete colonoscopy was accomplished in 86.9% of cases with photo documentation in only 59 colonoscopies (27.3%). The lesion distance from the anal verge was documented only in 93 out of 216 colonoscopies. Of the 157 lesions described at the colonoscopy, 117 matched with the intra-operative localization (accuracy 74.5%). Fifteen of the 40 incorrectly localized lesions (37.5%) required changes in the surgical management. At multivariate analysis, the colonoscopy completeness was the only influencing factor on the concordance between endoscopic and intra-operative localization.

CONCLUSIONS

Colonoscopy demonstrated adequate accuracy in localizing lesions. However, the incorrect tumor localization leads to a high rate of changes in surgical management. Increase in.

The hyperthermic intraoperative intraperitoneal chemotherapy in the treatment of advanced abdominopelvic cancer. Personal experience on 103 procedures during a seventeen year period in a single Italian center

OBJECTIVE

Integration of different therapeutic strategies in cancer surgery in the last years has led from treating primary lesions to the surgical treatment of metastases. The purpose of this paper is to report a single Italian center experience of treatment of peritoneal carcinosis of the abdominopelvic malignancies.

PATIENTS AND METHODS

103 HIPEC procedures were performed in 17 years on 94 selected patients affected by abdominopelvic cancer. The PCI score was calculated at laparotomy. The CC score was calculated before doing HIPEC. HIPEC was carried out according to the Coliseum technique.

RESULTS

The surgical cytoreduction allowed 89 patients to be subjected to HIPEC treatment with a CC score 0; 9 patients with a CC 1; 3 patients with a CC 2 and 2 patients with a CC 3. In 22 patients postoperative complications were recorded. No operative mortality occurred. The median follow-up of 53 months shows a rate of survival equivalent to 49 %, with a relapse in 46 patients, 29 of them reached exitus.

CONCLUSIONS

The surgical resection alone for patients affected by advanced cancer with peritoneal carcinomatosis cannot be considered a sufficient treatment any longer and HIPEC would help to prolong survival in these patients.

Complications related to hyperthermia during hypertermic intraoperative intraperitoneal chemiotherapy (HIPEC) treatment. Do they exist?

BACKGROUND AND OBJECTIVES

Hyperthermia, either alone or in combination with anticancer drugs, is becoming more and more a clinical reality for the treatment of far advanced gastrointestinal cancers, acting as a cytotoxic agent at a temperature between 40-42.5 degrees C. Although hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) is demonstrated to have some benefit in selected patients with peritoneal seeding, there are not enough data on the risk of damage of normal tissue that increases as the temperature rises, with possible serious and, sometimes, lethal complications.

MATERIALS AND METHODS

We searched on medline words like "intraoperative intraperitoneal chemohyperthermia and morbidity", focusing our attention on studies (published since 1990) which reported morbidity as bowel obstruction, bowel perforation or anastomic leak, during intraoperative intraoperitoneal chemotherapy in hyperthermia (HIPEC).

RESULTS

Heat acts increasing cancer cell killing after exposure to ionizing radiation, inhibiting repairing processes of radiation-induced DNA lesions (radiosensitization), and also sensitizing cancer cells to chemotherapeutic drugs, particularly to alkylating agents (chemosensitization). The peritoneal carcinomatosis (a frequent evolution of advanced digestive cancer) represents one of the main indication to hypertermic treatment. In the last fifteen years, in fact, different methods were developed for the surgery treatment (peritonectomy) and for loco-regional chemotherapic treatment of the carcinomatosis (intraperitoneal intra/post-operative iper/normothermic chemotherapy) to act directly on neoplastic seeding. We found, as result of different studies, 9 articles, written about perforation after HIPEC.

CONCLUSION

The aim of the present study is to present the review of the literature in terms of peri-operative complications related to the hyperthermia during intraoperative chemohyperthermia procedure.

Role of oxidized regenerated cellulose in preventing infections at the surgical site: prospective, randomized study in 98 patients affected by a dirty wound

AIM

The aim of this study was to evaluate whether oxidized regenerated cellulose (ORC), applied to "dirty" surgical wounds, is able to reduce the microbial load and, consequently, the infection rate as compared to conventional local wound treatment.

METHODS

The study included 98 patients who underwent intestinal recanalization procedures between December 2003 and December 2008, with the stoma as the surgical site. Authors considered several risk factors for SSI. The patients were divided into two groups. In group A (50 patients), the surgical wound, previous site of the stoma, was packed with ORC, whereas in group B (48 patients) gauze soaked in iodine was used. Microbial contamination was evaluated with three swabs (in subcutaneous tissue and the dermis), in the operating room before wound packing and on the 2nd and 3rd postoperative day (before suturing the skin).

RESULTS

There were no cases of wound dehiscence and no clinically evident superficial or deep surgical site infections in either group. Analysis of all data revealed that there was no or reduced bacterial contamination in the second and third swab in 33 patients (66%) of Group A versus 12 patients (25%) of Group B.

CONCLUSION

Although it is necessary to consider all factors which can have an influence on SSI and use all the means shown to be effective to reduce the risk of SSI, there is a rationale for using ORC to prevent this kind of infection, especially in patients who undergo "dirty" surgery.

Diffuse distribution of sulforhodamine-labeled neurons during serotonin-evoked locomotion in the neonatal rat thoracolumbar spinal cord

The fluorescent dye sulforhodamine-101 undergoes synaptic activity-dependent endocytotic uptake and consequent retrograde transport in presynaptic neurons. We used sulforhodamine to identify thoracolumbar spinal premotor neurons (T11-L6) activated during serotonin (5-HT) -induced hindlimb locomotor-like activity in the in vitro neonatal rat spinal cord preparation. Sulforhodamine labeling required locomotor-like activity because few neurons were labeled unless bath applied 5-HT recruited the locomotor rhythm. In contrast, N-methyl-D-aspartate (NMDA; 5 microM) profoundly increased spinal neuronal labeling irrespective of locomotor activity. The contribution of false-positive activity labeling during locomotion induced by application of NMDA with 5-HT (Kjaerulff et al. [1994] J Physiol (Lond). 478:265-273) necessitated the present re-mapping of sulforhodamine-labeled neurons. During 5-HT-evoked locomotion, the sulforhodamine-labeled neurons were diffusely scattered within the spinal cord with predominant labeling in lamina VII. Motor nuclei (lamina IX) and superficial laminae (I-II) were typically devoid of labeled cells in the isolated spinal cord. However, unilateral labeling of motoneurons was achieved when the ipsilateral hindlimb remained attached, suggesting that uptake in motoneurons requires an intact neuromuscular junction. The rostrocaudal incidence and distribution of labeled neurons was uniform in spinal segments L1-L5, with reduced numbers observed in thoracic and L6 spinal segments. Mean total cell labeling was less than 400 per spinal segment, suggesting recruitment from a very small fraction of the neurons contained within the spinal cord (calculated at < 0.1%). These results are consistent with the limited transfer of locomotor-related synaptic activity (Raastad et al. [1996] Neuron 17:729-738) and severe synaptic fatigue (Lev-Tov and Pinco [1992] J Physiol. 447:149-169; Pinco and Lev-Tov [1993] J Neurophysiol. 70:1151-1158; Fleoter and Lev-Tov [1993] J Neurophysiol. 70:2241-2250) observed in the neonatal rat spinal cord.

Traumatic rupture of the thoracic aorta: should one always operate immediately?

Although the traditional therapy for blunt traumatic rupture of the thoracic aorta (TRA) is immediate operative repair, there may be a selective role for delayed repair, particularly in patients with head trauma, respiratory failure, or cardiac dysfunction. The present study examines the hypothesis that TRA can be managed by selective delayed operative repair. Clinical data were collected from 59 consecutive patients with TRA at a regional trauma unit. All TRAs were at the aortic isthmus. Patients were retrospectively classified into three groups: group I (n = 12) included patients who either arrived in extremis or rapidly became unstable during triage; group II (n = 3) included patients who had no contraindications to early repair and underwent repair at the time of diagnosis; and group III (n = 44) consisted of patients who because of concomitant injuries or sepsis required initial admission and management in the intensive care unit until their clinical status had improved sufficiently to allow for deliberate delayed operative repair of the TRA. The delay ranged from 1 day to 7 months. Eight patients have yet to undergo repair and remain well at follow-up from 1 to 4 years. Overall survival rates in groups I, II, and III were 17%, 100%, and 82%, respectively. The surgery-related mortality rate in group III was 10% (three patients). Only two (4.5%) patients in group III died as a result of a ruptured aorta within 72 hours of admission. In conclusion, contrary to surgical doctrine, TRA may not require immediate operative repair in all cases, but may instead be managed selectively depending on the patient's clinical status.

Indications and role of axillofemoral bypass in high-risk patients

The purpose of this study was to determine whether axillofemoral bypass was justified as an alternative revascularization procedure to direct reconstruction and to specifically define the indications for this extraanatomical bypass. Forty-one patients operated on between 1978 and 1985 were evaluated. The average age was 69 years. Indications were based upon limb salvage for aortoiliac occlusive disease in the following situations: infected aortobifemoral bypass graft (8 patients) and high risk with co-existing medical problems (33 patients). Patients were classified according to Goldman's Multifactorial Index of Cardiac Risk and Cooperman's Cardiovascular Risk Index. Twenty-four patients had axillobifemoral bypass and 17 had unilateral axillofemoral procedures. In 66 femoral anastomoses there were 13 extended profundaplasties, 25 profunda arterioplasties, 11 profunda patch angioplasties and 16 anastomoses to the common femoral artery. Postoperative mortality was 4.8% (2 patients). Cumulative survival at 60 months was 43% +/- 11% and primary patency rate of the axillofemoral bypass was 69 +/- 9.8%. We conclude that axillo-femoral bypass is indicated in the presence of infection, in patients who fall into Goldman's Class III-IV or in patients with risk greater than 10% as calculated by Cooperman's equation.

Fibromuscular dysplasia of the posterior auricular artery: an unusual aneurysmal lesion

A 67-year-old patient was admitted to hospital with a pulsatile mass behind his left ear. The clinical diagnosis was a posterior auricular artery aneurysm, and this was confirmed on Digital Subtraction Angiography. The aneurysm was excised and sent for pathology. The findings were felt to be consistent with fibromuscular dysplasia. This appears to be only the second reported case in the literature of a posterior auricular artery aneurysm.

Current indications for axillounifemoral and axillobifemoral bypass grafts

Revascularization of the lower extremities may require an axillofemoral bypass when an aortobifemoral bypass is contraindicated. Thirty-one patients underwent axillounifemoral and 59 had an axillobifemoral bypass, with a mortality rate of 9%. The indication for operation was limb salvage in 67%, intra-abdominal sepsis in 21%, and disabling claudication in 12%. Cumulative survival, patency, and limb salvage rates were determined by life-table analysis. The cumulative patency and limb salvage rates (with standard errors) at 3 years were 68% +/- 8% and 78% +/- 9%, respectively. When stratified for type of operation, axillobifemoral bypass had a superior patency rate compared with axillounifemoral bypass (log rank = 3.882, p less than 0.05). There was no significant difference when patients were stratified for diabetes (log rank = 2.213, p = no significance [NS]), operative indication (disabling claudication vs. limb salvage) (log rank = 0.0005, p = NS), or outflow (no profundaplasty vs. profundaplasty) (log rank = 2.011, p = NS). We conclude that axillofemoral bypass is a reasonable alternative for revascularization in high-risk patients or in those patients in whom a transabdominal approach is contraindicated. We recommend aggressive use of the profunda femoris artery when the superficial femoral artery is occluded to achieve optimal results.

Transcutaneous oxygen tension in selection of amputation level

The utility of transcutaneous oxygen tension measurements in selection of a reliable amputation level was evaluated. Measurements were made at the proposed level of amputation in 37 patients, 22 of whom underwent major limb amputation and in 15 amputation was confined to the forefoot or toes. In patients with successful amputation healing, mean transcutaneous oxygen tension on the anterior skin surface was 50 +/- 8 mm Hg (index 0.79 +/- 0.1 mm Hg). In contrast, patients with failure of healing had a mean transcutaneous oxygen tension of 22 +/- 16 mm Hg (index 0.32 +/- 0.19 mm Hg) (p less than 0.001). Measurements on the posterior or plantar skin surface and posteroanterior differences provided even greater separation between success and failure groups, with no overlap of transcutaneous oxygen tension values or index. Transcutaneous oxygen tension measurement is easily obtained and noninvasive, and can be applied to all patients irrespective of Doppler signals, noncompressible vessels, or painful lesions. Transcutaneous oxygen tension appears to predict successful healing with accuracy, and should be a useful addition to clinical judgment in selection of optimal amputation level.

Utility of transcutaneous oxygen tension measurements in peripheral arterial occlusive disease

The use of transcutaneous oxygen tension (TCpO2) measurements to objectively and noninvasively diagnose peripheral arterial occlusive disease (PAOD) and to aid in the planning of vascular surgery was investigated. Thirty-two normal subjects and 100 patients with PAOD were studied. TCpO2 values decreased with age; when normalized by measurements on the chest, they did not. Absolute and normalized values of TCpO2 were equally effective in identifying the presence of PAOD and accurately characterized different degrees of severity (claudication vs. rest pain vs. impending gangrene; p less than 0.001). This was true even in diabetic patients, in whom tests based on hemodynamic function were less reliable. Healing of amputations was observed when TCpO2 greater than or equal to 38 mm Hg either preoperatively or after reconstruction; failure to heal in the absence of infection was associated with TCpO2 less than or equal to 38 mm Hg. The need for revascularization was associated with TCpO2 less than 30 mm Hg. A similar distribution of TCpO2 values was associated with success vs. failure of ulcer healing. TCpO2 is a useful complement to standard hemodynamic tests in the diagnosis and management of PAOD and, in addition, provides some distinct advantages.

[Ventricle rupture in myocardial infarction]

22 patients with rupture of the heart after myocardial infarction in the years 1974-1978 were compared with a matched sample of other patients with infarction. No increase in rupture rate was observed under present-day intensive care methods over the time period, nor did early heparin administration in one of the institutions involve increased risk of subsequent rupture.