"Shades of Gray" in pancreatic ductal adenocarcinoma: Reappraisals on resectability criteria: Debated indications for surgery in pancreatic cancer.

Pancreatic ductal adenocarcinoma is one of the leading causes of cancer-related deaths and, currently, surgery is the only curative treatment. Patients with borderline resectable pancreatic cancer (BRPC) can benefit from a multidisciplinary approach and R0 resection, and can achieve the same outcome as resectable patients treated with upfront surgery. However, the definition of BRPC changes according to different classifications with a heterogeneous distribution of patients, and it is thus difficult to compare clinical evidence. We performed a literature review to assess the most suitable classification of BRPC. Our review was conducted using the PubMed database. Only articles containing more than ten patients classified according to NCCN, MDACC or AHPBA/SSAT/SSO classifications were selected. A total of 16 studies were included in our analysis, and were grouped according to one of these three classifications. The total resection rate was 61.4%, with considerable differences between the groups (68.4% for NCCN, 54.9% for MDACC and 53.2% for AHPBA/SSO/SSAT). The total R0 resection rate was 90.1% (89.1% for NCCN, 92.5% for MDACC and 84% for AHPBA/SSO/SSAT). Of the three classifications, NCCN limits the use of confusing terms and uses restrictive criteria to define the most appropriate treatment for each subgroup. However, several reports have suggested that, even in the case of a limited disease, biological and clinical factors should be considered in order to classify patients as resectable. NCCN classification appears to be the classification that allows the highest percentage of patients with BRPC to achieve resection without reducing the R0 resection rate. The choice of therapy should not only be based on imaging results, but also on a wider clinical multidisciplinary evaluation.

Preoperative oral immunonutrition versus standard preoperative oral diet in well nourished patients undergoing pancreaticoduodenectomy.

BACKGROUND: Pancreaticoduodenectomy is still associated to high morbility, especially due to pancreatic surgery related and infectious complications: many risk factors have already been advocated. Aim of this study is to evaluate the role of preoperative oral immunonutrition in well nourished patients scheduled for pancreaticoduodenectomy. METHODS: From February 2014 to June 2015, 54 well nourished patients undergoing pancreaticoduodenectomy were enrolled for 5 days preoperative oral immunonutrition. A series of consecutive patients submitted to the same intervention in the same department, with preoperative standard oral diet, was matched 1:1. For analysis demographic, pathological and surgical variables were considered. Mortality rate, overall postoperative morbility, pancreatic fistula, post pancreatectomy haemorrhage, delayed gastric emptying, infectious complications and length of hospital stay were described for each groups. Chi squared test, Fisher's Exact test and Student's T test were used for comparison. Differences were considered statistically significant at p < 0.05. Statistics was performed using a freeware Microsoft Excel (®) based program and SPSS v 10.00. RESULTS: No statistical differences in term of mortality (2.1% in each groups) and overall morbility rate (41.6% vs 47.9%) occurred between the groups as well as for pancreatic surgery related complications. Conversely, statistical differences were found for infectious complications (22.9% vs 43.7%, p = 0.034) and length of hospital stay (18.3 ± 6.8 days vs 21.7 ± 8.3, p = 0.035) in immunonutrition group. CONCLUSION: Preoperative oral immunonutrition is effective for well nourished patients scheduled for pancreaticoduodenectomy; it helps to reduce the risk of postoperative infectious complications and length of hospital stays.

Role of TachoSil® in distal pancreatectomy: a single center experience.

AIM: Distal pancreatectomies (DP) are associated with high risk of postoperative complications, and in many series higher morbidity rate than duodenopancreatectomies has been reported. To evaluate the role of a collagen sponge with human fibrinogen and thrombin film (TachoSil®) in limiting the incidence of complications after DP. METHODS: From 1996 to 2013, 221 patients have been submitted to distal pancreatectomy (± splenectomy) in our Division. A retrospective analysis has been conducted in a group of 36 consecutive and prospectively collected DP treated with intraoperative placement of TachoSil® on pancreatic stump from 2010 to 2013 (group 1). A control series of 36 consecutive patients (group 2) was matched 1:1 from hystorical database. The variables considered in the analysis were: age, gender, ASA score, pancreatic texture (hard vs. soft), histology, operative time, postoperative mortality, morbility (postoperative pancreatic fistula - POPF, postoperative hemorrage - PPH, delayed gastric emptying - DGE) and hospital stay. Differences between POPF, PPH, DGE and hospital stays between grops were investigated with χ² and t-Student test. Univariate analysis was conducted to determine factors related to POPF development. Statistical analysis was performed using freeware Microsoft Excel based program. RESULTS: Post operative mortality was 0% in both groups. POPF were registered in 36.1% (13/36) and 41.6 % (15/36) in groups 1 and 2, respectively (P=n.s.); in group 1 we didn't observe grade C POPF, while 4 patients in control group developed grade C POPF (P<0,05). No differences were found between two groups in terms of incidence of PPH and DGE. The median duration of postoperative hospital stay in group 1 was 21.8 (7-189) days compared with 31.13 (9-249) days in group 2 (P<0.001). CONCLUSION: The use of TachoSil® seems to be associated with lower incidence of grade C POPF but larger controlled trials are needed to surely assess the usefulness of TachoSil® in pancreatic surgery in order to reduce pancreatic specific complications and their severity.

[Congenital Milroy Oedema: a case report of a family]. / Edema congenito di Milroy. descrizione di una famiglia.

The authors describe the case of a newborn and their family with Nonne-Milroy disease (hereditary lymphedema type I), a genetic disease that is usually characterized by lymphedema, that most often affects the lower extremities or less frequently the back of the hands. We discuss etiology, inheritance pattern, differential diagnosis and follow-up.

[Role of EUS in a diagnostic and staging algorithm of pancreatic carcinoma: the surgeon point of view]. / Il ruolo dell'EUS in un algoritmo diagnostico-stadiativo del carcinoma pancreatico: il punto di vista del chirurgo.

Survival of pancreatic cancer is improved by surgery and is related to R0 resection. An accurate diagnosis and a careful staging are mandatory. Differential diagnosis must be estabilished between the different pancreatic lesions as carcinoma, chronic pancreatitis, cystic or endocrine neoplasms. Endoscopic ultrasound (EUS) is the best technique for diagnosis and allows cytological examination by fine needle aspiration (FNA). Preoperative resectability is defined by EUS in borderline tumors. EUS is a useful procedure for the surgical strategy of pancreatic cancer.

[Sleeping in the supine position in the ASL 11 region of Piemonte. Assessment of the efficacy of a promotional campaign]. / Dormire sulla schiena nell'asl 11--regione Piemonte Valutazione dell'efficacia di una campagna promozionale.

OBJECTIVES: To record the prevalence of the sleeping position of sucklings living in the ASL 11-Regione Piemonte; to make an information campaign about the utility of sleeping in the supine position (most important protection factor against the SIDS); to find out its efficacy for a short or long time. METHODS: During the first two months of 2002 all the parents coming to the consulting rooms for the compulsory vaccinations of their 3 and 5 months old babies have been interviewed about the position of their babies during sleep. The same recording has been made in the first two months of 2003 and 2004. During 2002 various consciousness campaigns have been made, above all for medical operators of hospital nurseries and of Mother-and-Child Departments and Prevention Departments in ASL 11 area. RESULTS: Before the consciousness campaign the percentage of 3 months old sucklings sleeping in the supine position was 62,3% and 55% for the 5 months old suckings; after the campaign the percentage has grown to 77,4% for 3 months old sucklings and 74,5% for 5 months old sucklings during 2003 and during 2004 the percentage has grown to 80,3% and 74,2%, respectively. CONCLUSIONS: A simple and not expensive but capillary consciousness and information campaign addressed to medical operators has obtained valid and statistically relevant results in a short time.

Ectopic secretion of LH by an endocrine pancreatic tumor.

Ectopic production of biologically active glycoprotein hormones other than hCG has been reported in exceptional cases. A 61-yr-old man came to our Unit complaining of weakness, fatigue and reduced libido with erectile dysfunction. There was also a history of polycythemia, known for about 10 yr and never further investigated. The physical examination showed acne and redness of facial skin and upper chest; no other significant abnormalities were detected. Serum levels of LH were very high, whereas alpha-subunit and hCG were only slightly increased. Testosterone and 17beta-estradiol levels were increased too. Abdominal computed tomography (CT) scan revealed a large hypervascularized mass within the pancreatic tail, which was surgically removed by distal splenopancreatectomy. Diffuse immunoreactivity for LH was detected in more than 70% of the tumor cells. The alpha-subunit was also positive, while chorionic gonadotropin had only a focal reactivity. Reverse transcriptase-polymerase chain reaction (RT-PCR) and Southern Blot analysis confirmed the synthesis of LH by the tumor. Four weeks after surgery, serum levels of LH, alpha-subunit, testosterone, hCG and 17beta-estradiol were all undetectable. The redness of facial skin and upper chest had disappeared, but libido was still reduced. At a further control, 3 months after surgery, serum levels of LH, FSH, hCG, alpha-subunit and 17beta-estradiol were all within the normal range, as well as hemoglobin concentration and the red blood cells count. Testosterone was slightly below normal, but the patient reported an increase of libido. This is an unusual case of ectopic secretion of LH from an endocrine tumor of the pancreas.

[Postoperative pain management: epidural analgesia]. / Controllo del dolore postoperatorio: la via peridurale.

BACKGROUND: Epidural analgesia is one of the most effective regimens for postoperative pain relief after abdominal surgery. The use of epidural analgesia in high risk patients has been associated with significant decrease in surgical stress response, in cardiac and pulmonary morbidity, in recovery of gastrointestinal function and in thromboembolic events. The aim of this paper is to describe pain relief, side effects and recovery of gastrointestinal function during epidural analgesia. METHODS: During the period January 1999 to September 2001, 590 patients undergoing elective major abdominal surgery received epidural analgesia. Epidural catheters were inserted at T8-T9 (upper abdominal surgery) or T9-T11 (lower abdominal surgery) and ropivacaine 0.5% ml 7-12 combined with sufentanil 30 microg or with morphine 2 mg was injected. General anesthesia was induced and a continuous epidural infusion of ropivacaine 0.5% 5-10 ml/h was begun. Postoperatively, continuous epidural administration of ropivacaine 0.2% plus sufentanil 0.5 microg/ml or ropivacaine 0.2% plus morphine 0.02 mg/ml was continued. Data on the quality of analgesia, recovery of gastrointestinal function and all side effects were recorded for 4 days. RESULTS: Resting and incident pain scores were <4 and <5; 20% of patients received a rescue dose; the incidence of nausea was 6%, pruritus 5%; all patients also recovered from postoperative ileus. CONCLUSIONS: Continuous epidural analgesia resulted in good pain relief, provided the best balance of analgesia and side effects and improved postoperative outcome.

[What shall I eat today? Survey about dietary habits of infants and toddlers in Valsesia]. / Cosa mangio oggi? Indagine sulle abitudini alimentari dei bambini fino a tre anni in Valsesia.

In April 2002 a survey was conducted about dietary habits of infants and toddlers attending kindergartens in Valsesia, through dietary journal compilation. From 149 answers (response rate = 70%) the results are: a limited vegetables consumption, with a potatoes excess and a legumes scarcity; only one half of children eats fruits daily; consumption of ham and cheese is higher than other proteinic foods; foods variety is weak and the menu is often repetitive in lunch and dinner.

[Opinions and attitudes of youngsters about sexually transmitted diseases]. / Cosa pensano i giovani delle malattie sessualmente trasmesse (Indagine conoscitiva su 1.085 studenti valsesiani).

A group of 1.085 students (582 M, 503 F) attending high school (742) and nursing school (343) filled in an anonymous questionnaire on their sexual habits and their knowledge of contraception and sexually transmitted diseases. Overall, 57% of the study population had already a complete sexual intercourse at a mean age of 16,4 (SD +/- 1,8). 74% had 1-3 sexual partners, whereas 28% had more than 3. All students affirmed that it was possible to prevent sexually transmitted diseases and 92,6% indicated correct methods. However 10% of students did not know that AIDS is transmitted sexually as 47% hepatitis B. The responses made by nursing students were more correct that those of high school students.

[Groove pancreatitis. A case report of chronic focal pancreatitis]. / La "groove pancreatitis". Descrizione di un caso di pancreatite cronica focale.

The "groove pancreatitis" is a special form of segmental chronic pancreatitis affecting the "groove" between pancreatic head, duodenum and common bile duct. This type of chronic pancreatitis was first described in 1973 and only few cases have been reported in literature. Unlike other forms of chronic pancreatitis, this is often preceded by peptic ulcers, gastric resections or biliary tract diseases; it could be associated with cysts of the duodenal wall and pancreatic cysts. Abdominal pain, vomiting due to duodenal stenosis, obstructive jaundice and weight loss are the most common presenting symptoms. The radiological features show a pancreatic mass similar to a pancreatic head carcinoma and the discrimination of groove pancreatitis from pancreatic carcinoma is often difficult or even impossible in some patients. We describe a case of groove pancreatitis treated with pancreatoduodenectomy, reviewing the clinical and radiological features. We remark that the groove pancreatitis is a disease that must be known and should be considered in the differential diagnosis of pancreatic carcinoma.

Minute and small early gastric cancers in a Western population: a clinicopathologic study.

Early endoscopic diagnosis improves the prognosis of patients with gastric cancer, as shown by the finding that 5-year survival rates exceeding 90% are observed in Japanese patients with early gastric cancer. It has been hypothesized that tumor size may have prognostic significance; therefore, a distinction between minute, small, and large early gastric cancers has been proposed. The aim of this study was to determine the prevalence of minute and small early gastric cancers in Western countries and to compare their clinicopathologic features with those of large early gastric cancers. Of 465 Italian patients with gastric cancer who were studied, 20.5% had an early gastric cancer, and 34.7% of these were minute or small. Tumor size is correlated with intramural spreading and metastasis to perigastric lymph nodes. Nodal involvement occurs more frequently in the diffuse than in the intestinal type of early gastric cancer. Long-term survival rate is not correlated with tumor size, intramural spreading, or nodal metastasis. The minute and small early gastric cancers of Italian patients are indistinguishable from those occurring in Japanese patients. These lesions are more common than previously thought and should be carefully searched for by endoscopists. The correlation of tumor size with intramural invasion and perigastric lymph node metastasis suggests that minute and small early gastric cancers are precursors of large early gastric cancers. Although the distinction between minute, small, and large early gastric cancers is of low prognostic value, the distinction might be useful for selecting different therapeutic approaches.