C-Reactive Protein and Procalcitonin as Predictors of Postoperative Inflammatory Complications After Pancreatic Surgery

BACKGROUND

The association between postoperative inflammatory markers and risk of complications after pancreaticoduodenectomy (PD) is controversial. We sought to assess the diagnostic value of perioperative C-reactive protein (CRP) and procalcitonin (PCT) levels in the early identification of patients at risk for complications after PD.

METHODS

In 2014, 84 patients undergoing elective PD were enrolled in a prospective database. Clinicopathological characteristics, CRP and PCT, as well as short-term outcomes, such as complications and pancreatic fistula, were analyzed. Complications and pancreatic fistula were defined based on the Clavien-Dindo classification and the International Study Group on Pancreatic Fistula (ISGPF) classification, respectively. High CRP and PCT were classified using cut-off values based on ROC curve analysis.

RESULTS

The majority (73.8 %) of patients had pancreatic adenocarcinoma. CRP and PCT levels over the first 5 postoperative days (POD) were higher among patients who experienced a complication versus those who did not (p < 0.001). Postoperative CRP and PCT levels were also higher among patients who developed a grade B or C pancreatic fistula (p < 0.05). A CRP concentration >84 mg/l on POD 1 (AUC 0.77) and >127 mg/l on POD 3 (AUC 0.79) was associated with the highest risk of overall complications (OR 6.86 and 9.0, respectively; both p < 0.001). Similarly patients with PCT >0.7 mg/dl on POD 1 (AUC 0.67) were at higher risk of developing a postoperative complication (OR 3.33; p = 0.024). On POD 1, a CRP >92 mg/l (AUC 0.72) and a PCT >0.4 mg/dl (AUC 0.70) were associated with the highest risk of pancreatic fistula (OR 5.63 and 5.62, respectively; both p < 0.05).

CONCLUSIONS

CRP and PCT concentration were associated with an increased risk of developing complications and clinical relevant pancreatic fistula after PD. Use of these biomarkers may help identify those patients at highest risk for perioperative morbidity and help guide postoperative management of patients undergoing PD.

Serous cystic neoplasm of the pancreas: a multinational study of 2622 patients under the auspices of the International Association of Pancreatology and European Pancreatic Club (European Study Group on Cystic Tumors of the Pancreas)

OBJECTIVES

Serous cystic neoplasm (SCN) is a cystic neoplasm of the pancreas whose natural history is poorly known. The purpose of the study was to attempt to describe the natural history of SCN, including the specific mortality.

DESIGN

Retrospective multinational study including SCN diagnosed between 1990 and 2014.

RESULTS

2622 patients were included. Seventy-four per cent were women, and median age at diagnosis was 58 years (16-99). Patients presented with non-specific abdominal pain (27%), pancreaticobiliary symptoms (9%), diabetes mellitus (5%), other symptoms (4%) and/or were asymptomatic (61%). Fifty-two per cent of patients were operated on during the first year after diagnosis (median size: 40 mm (2-200)), 9% had resection beyond 1 year of follow-up (3 years (1-20), size at diagnosis: 25 mm (4-140)) and 39% had no surgery (3.6 years (1-23), 25.5 mm (1-200)). Surgical indications were (not exclusive) uncertain diagnosis (60%), symptoms (23%), size increase (12%), large size (6%) and adjacent organ compression (5%). In patients followed beyond 1 year (n=1271), size increased in 37% (growth rate: 4 mm/year), was stable in 57% and decreased in 6%. Three serous cystadenocarcinomas were recorded. Postoperative mortality was 0.6% (n=10), and SCN's related mortality was 0.1% (n=1).

CONCLUSIONS

After a 3-year follow-up, clinical relevant symptoms occurred in a very small proportion of patients and size slowly increased in less than half. Surgical treatment should be proposed only for diagnosis remaining uncertain after complete workup, significant and related symptoms or exceptionally when exists concern with malignancy. This study supports an initial conservative management in the majority of patients with SCN.

TRIAL REGISTRATION NUMBER

IRB 00006477.

Cystic "feminine" pancreatic neoplasms in men. Do any clinical alterations correlate with these uncommon entities?

INTRODUCTION

Mucinous cystic neoplasm (MCN) and solid pseudopapillary neoplasm (SPN) of the pancreas are uncommon hormone-related pancreatic tumors (HRPTs) with a clear predominance in young women. This trial aims to investigate the possible association between HRPTs development in males and phenotypic and sex hormone alterations.

METHODS

We performed a retrospective analysis of our database between February 1990 and February 2012. Risk factors for sexual dysfunction were considered exclusion criteria. We investigated secondary sexual characteristics development, sex hormone level and overall sexual dysfunction degree according with the International Index of Erectile Function Questionnaire (IIEF).

RESULTS

We initially identified 25 patients [(MCN: n = 16 (64%); SPN: n = 9 (36%)]. At follow-up, 5 patients were lost, 8 resulted dead and 3 were excluded according to exclusion criteria. We finally enrolled 9 patients (MCN: n = 5; SPN: n = 4). Puberty occurred within physiological age for 7 patients, whereas it was delayed in 2 cases. Three patients revealed mild to moderate sexual dysfunction, along with low testosterone level in two cases. One patient presented hormonal alteration with a normal IIEF score.

DISCUSSION

In this study, the first in literature with similar aim, hormonal and/or sexual dysfunction was present in 4 out of 9 patients affected by HRPT. The rarity of these lesions makes further trials to be needed for reliable conclusions.

Combined modality treatment for patients with locally advanced pancreatic adenocarcinoma

BACKGROUND

Radiofrequency ablation (RFA) is an emerging treatment for patients with locally advanced pancreatic carcinoma, and can be combined with radiochemotherapy and intra-arterial plus systemic chemotherapy.

METHODS

This observational study compared two groups of patients with locally advanced pancreatic carcinoma treated with either primary RFA (group 1) or RFA following any other primary treatment (group 2).

RESULTS

Between February 2007 and May 2010, 107 consecutive patients were treated with RFA. There were 47 patients in group 1 and 60 in group 2. Median overall survival was 25·6 months. Median overall survival was significantly shorter in group 1 than in group 2 (14·7 versus 25·6 months; P = 0·004) Patients treated with RFA, radiochemotherapy and intra-arterial plus systemic chemotherapy (triple-approach strategy) had a median overall survival of 34·0 months.

CONCLUSION

RFA after alternative primary treatment was associated with prolonged survival. This was further extended by use of a triple-approach strategy in selected patients. Further evaluation of this approach seems warranted.

Feasibility and safety of radiofrequency ablation for locally advanced pancreatic cancer

BACKGROUND

: Radiofrequency ablation (RFA) may be a valuable treatment option for locally advanced pancreatic cancer. The present study examined its feasibility and safety.

METHODS

: Fifty patients with locally advanced pancreatic cancer were studied prospectively. Ultrasound-guided RFA was performed during laparotomy. The main outcome measures were short-term morbidity and mortality.

RESULTS

: The tumour was located in the pancreatic head or uncinate process in 34 patients and in the body or tail in 16; median diameter was 40 (interquartile range 30-50) mm. RFA was the only treatment in 19 patients. RFA was combined with biliary and gastric bypass in 19 patients, gastric bypass alone in eight, biliary bypass alone in three and pancreaticojejunostomy in one. The 30-day mortality rate was 2 per cent. Abdominal complications occurred in 24 per cent of patients; in half they were directly associated with RFA and treated conservatively. Three patients with surgery-related complications needed reoperation. Reduction of RFA temperature from 105 degrees C to 90 degrees C resulted in a significant reduction in complications (ten versus two of 25 patients; P = 0.028). Median postoperative hospital stay was 10 (range 7-31) days.

CONCLUSION

: RFA of locally advanced pancreatic cancer is feasible and relatively well tolerated, with a 24 per cent complication rate.

[Asbestos fibre lung burden and exposure indices in asbestos-cement workers]

BACKGROUND

In many previous studies, the asbestos fibres retained in the lung were regarded as a good index of cumulative occupational asbestos exposure. Twelve workers suffering from asbestos-related diseases and had been employed in an asbestos-cement factory operating from 1961 to 1994 underwent post mortem investigations in the course of a criminal law suit.

OBJECTIVES

Samples of lung tissues were collected for electron microscopy analysis to measure the asbestos fibre burden of the lungs in workers with high exposure, and assess the possible correlation between asbestos fibre lung burden and the estimated levels of cumulative exposure.

METHODS

Samples of lung parenchyma obtained from a consecutive series of 12 post-mortem examinations that were performed between 1994 and 2007and included 5 cases of malignant pleural mesothelioma, 4 lung cancers, 1 case of asbestosis and2 ofpleuralplagues, were collected, stored and analysed by SEM electron microscopy, according to the methods suggested by the current scientific literature. For each worker, all males, a detailed occupational history was reconstructed by means ofpersonal interviews; both the measurements of airborne asbestos fibresperformed by the factory in the 1970's and the duration of each single job in the plant were taken into account to estimate an individual cumulative exposure index.

RESULTS

A wide variation of total asbestos fibre concentrations in the lung (1,320-118 million) was observed; in all 12 workers, the lung amphibole fibre burden exceeded 1,000,000 fibres per g/dry tissue, The highest values were detected in the mesothelioma cases, in which the mean fibre concentrations differed statistically (t=2.29, p=0.045) from the mean calculated for the other asbestos-related diseases; in 9 subjects only amphibole fibres were detected. There was a good correlation between total asbestos fibre concentration and cumulative exposure index (r=0.91, p<0.0001).

CONCLUSION

This study, which was numerically the biggest ever performed in Italy for this category of workers, confirms a wide range of total asbestos fibre burden in heavily occupationally exposed workers and showed that of the asbestos-related diseases, the highest lung concentrations of asbestos fibres were reached in cases of mesothelioma. It was also observed that almost the entire lung burden consists of only amphibole fibres, all exceeding 1 million per gramme of dry tissue. This study tested a synthetic cumulative occupational exposure index, which appears to be well correlated to the level of exposure established by biological analysis.

[Recycle of jute bags; asbestos in agriculture, exposure and pathology ]

During the last four years, a deeper examination of malignant mesothelioma (MM) cases occurred within non asbestos textile industry highlighted asbestos past exposure in several textile industrial divisions. In spite of that, poor information about recycled textile bags previously containing asbestos fibres is available to the National Mesothelioma Registry, although holding a remarkable data bank on more than 3500 work histories and sources of asbestos exposures. Besides the analysis of the exposure circumstances and the registered health effects of the past exposure within the recycling activity, the aim of this research was to relate the possible involvement of the agricultural sector, where the use of recycled jute bags was very diffused. The MM cases were collected from the Mesothelioma Registry of Brescia, asbestosis, pleural plaques and lung cancer cases were collected from the Occupational Diseases Archive of the Local Public Occupational Health Service of the Province of Brescia. During the 1977-2006 period, 8 cases of MM, 4 cases of pulmonary asbestosis, 4 of isolated bilateral pleural plaques and I of lung cancer in pulmonary asbestosis, were observed among workers employed in bags recycling activity in 4 small companies, one of them still operating, employing about 50 workers. Even more, among the 65 MM cases classified by the Registry with "unknown asbestos exposure" (UAE), the most relevant frequency of working histories concerned the agriculture sector. Confirming a past signalling, the investigations underlined the cross linkage between this working activity and the diffusion of recycled bags in the agriculture sector. In the Province of Brescia, the activities of these small jute bags recycling plants were linked, even geographically, to the asbestos cement manufacture plant using a huge number of bags, roughly until mid seventies. Therefore, a large number of these recycled bags, previously containing asbestos, were generally used for harvesting and trading agricultural typical products of northern Italy. According to the 2003 National Mesothelioma Registry Guide Lines, MM in agricultural workers are still classified as UAE due to poor information available. In the light of these new findings, it looks reasonable to review the UAE within agriculturalists attributing a new classification of "possible" occupational asbestos exposure, although other exposure circumstances might have occurred in the past.

[Malignant mesothelioma in garment sewing-machine workers]

BACKGROUND

Due to poor information collected through patient interviews, a considerable number of malignant mesothelioma (MM) cases still remain classified as "unknown" asbestos exposure in the Italian Mesotelioma Registry (Re.Na.M). At the same time, some occupational asbestos exposures, which were previously unknown, have been demonstrated in certain types of work, i.e., in agriculture and in the textile industry.

OBJECTIVES

The aim of this research was to investigate the possible past occupational exposure to asbestos in clothing workers using sewing-machines.

METHODS

The MM cases were collected from the Mesothelioma Registry of Brescia. Work histories were obtained via a standardized questionnaire. Investigations were conducted in sewing-machine maintenance workshop in order to collect information regarding the possible use of asbestos parts. In addition, the use of asbestos friction materials and the use of insulated asbestos materials was checked in the clothing divisions by interviewing the management and maintenance workers of two companies where cases of MM were observed.

RESULTS

The Mesothelioma Registry of Brescia identified and collected 10 MM cases with past work in the clothing industry: 6 used sewing-machines and 4 were self-employed tailors. The search for asbestos materials gave positive results as the use of friction materials had been widespread since the 1950's in all types of sewing-machines; in addition, asbestos materials were used to insulate some parts of the ironing equipment and the steam pipelines.

CONCLUSION

The results of this investigation suggest assigning at least "possible occupational asbestos exposure" to those cases employed in clothing manufacture since the 1950's, who used sewing-machines or pressing machines, according to the Re.Na.M guidelines. Other possible occupational exposures to asbestos in this working sector cannot be excluded; when the simple interview of patients does not reveal such exposures further investigations are needed in order to demonstrate all the possible circumstances of exposure.

[Two cases of pleural mesothelioma following unusual and unrecognized exposure to asbestos. The role of Occupational Health and Safety Service in identifying past occupational exposure]

BACKGROUND

In Italy there was a wide use of asbestos in various manufacturing sectors and for many different uses, some of which are still partly or completely unknown. A detailed reconstruction of the work histories of mesothelioma patients made it possible, in some cases, to identify ignored circumstances of asbestos exposure. Moreover, the identification of cluster of cases takes on special significance in suggesting a possible previous asbestos exposure, where the information collected on single cases do not imply as much.

OBJECTIVES

This report concerns two cases of malignant mesothelioma that occurred in two workers employed in the same processes in a small factory that manufactured and repaired electric motors for hand tools.

METHODS AND RESULTS

In the Province of Brescia (one million inhabitants) a Mesothelioma Register is in operation. The first case was classified, according to Re.Na.M.1996 criteria (National Mesothelioma Register) as "unknown" occupational exposure. The identification of a second case, that was discovered thanks to the surveillance system of the Mesothelioma Register, encouraged the local Occupational Health and Safety Service to perform a more detailed investigation that revealed, for both subjects, previously unknown occupational exposure. This consisted of grinding, in a damp setting, electric motor parts bushed with phenolic thermosetting resins reinforced with chrysotile asbestos. Moreover, weekly cleaning of the plants could have been an occasion for dust dispersion. It is likely that this exposure did not last long and was limited in extent. Other similar reports of such circumstances of occupational exposure were not available in the literature.

CONCLUSIONS

The results confirm the high information value of systematic collection of incidental cases in the population, which is feasible thanks to the disease register, and the significant role of the local Occupational Health Services in demonstrating past asbestos exposure.

Pancreatic cystic manifestations in von Hippel-Lindau disease

CONCLUSION

In view of the frequent absence of symptoms related to pancreatic lesions, screening tests for VHL should always include assessment of the pancreas and, considering the frequency of polycystic manifestations, VHL should always be borne in mind in the differential diagnosis of multiple pancreatic cysts, especially when occurring in young patients and in the absence of a positive history of pancreatic disease.

BACKGROUND

Von Hippel-Lindau disease (VHL) is a hereditary disease transmitted with an autosomal dominant character and characterized by hemangioblastomas of the central nervous system and retina, renal tumors and cysts, and pheochromocytoma. Pancreatic manifestations of VHL are reported in the literature with incidences ranging from 16 to 29% of cases and consist mainly in cystadenomas of the serous type and in multiple cystic lesions, often with complete replacement of the gland.

METHODS AND RESULTS

We report five cases of VHL with a polycystic pancreas as the main or only manifestation, all devoid of symptoms related to involvement of the pancreas, who were referred to our Pancreatic Surgery center with diagnoses of multiple pancreatic pseudocysts of undefined origin.

[Neurobehavioral effects of inhalation anesthetics used occupationally: a critical analysis]

Unlike other apparatuses, the potential effects on the nervous system of occupational exposure to anaesthetic gases have not been exhaustively reviewed. Because of the relevance of these effects, their significance of the quality of life of the exposed subjects and of the increased risk inherent in their delicate work tasks, these themes deserve the greatest attention. This paper briefly examines the data from the international literature as well as the neurobehavioral methods employed, underlines the existing gaps of knowledge and eventually proposes strategies aimed at filling these gaps of knowledge.

Early graft injuries after pancreatic transplantation in syngeneic rats. Cytoprotective effects of gabexate-mesilate

Failures in experimental and human pancreatic transplantation are mainly attributable to rejection, graft thrombosis, and technical problems. There are, however, problems related to other causes, such as preservation injuries, which we found to exhibit, at least within the first 6 h, the same histological patterns seen in experimental acute pancreatitis. We performed pancreatic transplantation in 110 syngeneic rats under different preservation techniques and administration of gabexate mesilate, a synthetic protease inhibitor. The results showed that antiprotease treatment reduces graft preservation injuries significantly.

Necrosectomy by lavage in the surgical treatment of severe necrotizing pancreatitis. Results in 263 patients

A conservative surgical technique for treatment of necrotizing pancreatitis is described. Standardized since 1976, the technique is based on washout mechanical necrosectomy accomplished by lavages via intraoperatively placed wide-bore drainage tubes. The overall mortality rate from necrotizing pancreatitis was thereby reduced from 61% (with resective technique) to 18%, and in 106 cases observed from the onset of the disease the mortality fell to only 6.6%. The series included also patients with fulminant acute pancreatitis and multiorgan failure.

Pancreatic abscess and other pus-harboring collections related to pancreatitis: a review of 108 cases

This is a report on 108 cases collected from 1970 to 1987, in the same department, of surgically-detected pancreatic abscesses or pus-harboring collections. The purulent areas were either of a spreading pattern or represented a clearly localized mass. To the spreading pattern belong 47 cases of necrotizing pancreatitis, without discontinuity in the clinical course from the early toxic to the late septic phase, 4 cases of acute pancreatitis, initially in remission and later complicated by septic collections, and 4 cases which developed after an acute attack of chronic pancreatitis. The abscess pattern was made up of 19 each of pseudocysts and predisposing pancreatitis, 10 cases of chronic pancreatitis, and only 5 necrotizing "nonstop" pancreatitis. The surgical treatment in all cases consisted of multiple drainages and postoperative irrigation. We exclude 3 cases of associated open packing. The etiological, clinical, and biochemical features of each group of patients are reported and discussed. Computed tomography availability seems to be the most important improvement reported as regards diagnosis and surgical tactics. The overall mortality rate was 15.7% with a significant difference between the 2 patterns (23.6% for the spreading pattern versus 7.5% for the abscess pattern). On the basis of this experience, it is possible to establish a relationship between the gross appearance of the collection and the underlying pancreatic disease with differences in terms of prognosis, morbidity, and mortality. Finally, a simple nomenclature can be chosen which is capable of distinguishing between the diverse pancreatic purulent collections. While the presence of pus may characterize the course of severe acute pancreatitis in many cases, the low incidence of "true" pancreatic abscess is emphasized.

Retroperitoneal and peritoneal drainage and lavage in the treatment of severe necrotizing pancreatitis

In severe necrotizing pancreatitis, the retroperitoneum is the main site both of autodigestion and of the production of toxins. With the aim of removing necrotic tissues and active enzymes from the retroperitoneum, we developed a surgical approach based on a wide exposure of the pancreas and on the insertion of multiple drainages with postoperative irrigations with hypertonic solutions and antiproteases. We treated 191 patients, and our results correlated with the timing of the operation. The operative mortality rate ranges from 8.1 in patients undergoing our procedure within 48 hours from the onset of the disease to 28.4 per cent when the operation was delayed for more than 96 hours. Our technique is detailed and the indications as to the timing of surgical treatment in instances of pancreatitis are discussed.

Pancreaticoduodenal graft in the rat: an original microsurgical technique

The authors describe an original surgical technique for pancreatic transplantation carried out on an experimental rat model which duplicates as closely as possible the anatomic-functional situation of a pancreatic graft in man (one arterovenous vascular peduncle with one functioning kidney only). The technique entails a microanastomosis between the mesenteric artery and the portal vein of the donor organ with the left renal artery and vein of the recipient. This method appears to be technically encouraging and particularly useful in studying the early phases of ischemic graft injuries, a field in which the authors are particularly interested.

[Epithelial splenic cysts]

The authors describe a case of an epithelial cyst of the spleen treated successfully by splenectomy. Diagnostic techniques and the principles adopted in treatment this rare disease are discussed.

[Pancreas transplant today: review of the literature]

The authors, after analysing the world literature concerning the pancreatic transplantation, dwell in considering the problems involved in the indications and techniques of the transplantation itself. Among the several problems expecting an ultimate solution, the improvement of prophylaxis, diagnosis and treatment of rejection seems to heavily affect the future of this surgery.

[Retroperitoneal neurilemmoma (considerations on 4 cases)]

The authors show 4 cases of retroperitoneal neurilemmoma, surgically treated by simple excision of the tumour. From the general observations, as well as from the analysis of the literature, they can remark the rareness of the location in such anatomical region. The clinical symptoms are common to those of the region retroperitoneal tumours, and are due to the compressive effect developed by the tumour on the contiguous structures. As regards the diagnostic procedures, they emphasize the primary value of axial computed tomography in the evaluation of the retroperitoneal pathology. The diagnosis cannot be but histologic, and is based upon the presence of the typical histologic pictures according to Antoni A and B types.

[A case of duodenal duplication in the adult]

The authors describe a rare case of duodenal duplication presenting in adult life; the complete preoperative investigations did not substantiate. The diagnosis which can be accomplished in most cases only intraoperatively. The diagnosis is mainly based upon knowledge of the condition and upon pathologic examination.

[2 cases of enterorrhagia caused by Meckel's diverticulum. Problems of diagnosis and therapy]

The authors study two cases of enterorrhage due to Meckel's diverticulum. They particularly emphasize the importance of two instrumental inspections: enema and abdominal scintigraphy with 99mTcO4, in the diagnostics of this malformative pathology, and the treatment with H2-blocking substances with the purpose to stop hemorrhage, circumstantiate the diagnostic suspicion, and operate electively.