Home medical nutrition during SARS-CoV-2 pandemic - A position paper.

BACKGROUND: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a worldwide rapidly spreading illness, Coronavirus Disease 2019 (COVID-19). Patients fed enterally and parenterally at home are exposed to the same risk of infection as the general population, but more prone to complications than others. Therefore the guidance for care-givers and care-takers of these patients is needed. METHODS: The literature search identified no relevant systematic reviews or studies on the subject. Therefore a panel of 21 experts from 13 home medical nutrition (HMN) centres in Poland was formed. Twenty-three key issues relevant to the management of SARS-CoV-2 infection or COVID-19 in the HMN settings were identified and discussed. Some statements diverge from the available nutrition, surgical or ICU guidelines, some are based on the best available experience. Each topic was discussed and assessed during two Delphi rounds subsequently. Statements were graded strong or weak based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. RESULTS: the panel issued 23 statements, all of them were graded strong. Two scored 85.71% agreement, eleven 95.23%, and ten 100%. The topics were: infection control, enrolment to HMN, logistics and patient information. CONCLUSIONS: the position paper present pragmatic statements for HMN to be implemented in places without existing protocols for SARS-CoV-2 pandemic. They represent the state of knowledge available at the moment and may change should new evidence occurs.

Surgical Repair of Small Bowel Fistulas: Risk Factors of Complications or Fistula Recurrence.

BACKGROUND Definitive surgical repair of persistent fistulas of the small intestine remains a surgical challenge with a high rate of re-fistulation and mortality. The aim of this study was to evaluate the type and incidence of complications after definitive surgical repair, and to identify factors predictive of severe postoperative complications or fistula recurrence. MATERIAL AND METHODS This was a retrospective study of 42 patients who underwent elective surgical repair of a persistent fistula of the small intestine. The analysis included preoperative and intraoperative parameters. RESULTS The healing rate after definitive surgery was 71.4%. Postoperative complications developed in 88.1% of patients. The mortality rate was 7.2%. Fistula recurrence was recognized in 21.4% of cases. Overall, 93 complications occurred in 37 patients. The most common complications were septic (48.0%). Hemorrhagic and digestive tract-related complications accounted for 19.0% and 15.0% of all complications, respectively. Severe complications (Clavien-Dindo grade III-V) made up 28.0% of all complications. In univariate analysis, multiple fistulas (p=0.03), higher C-reactive protein level (p=0.01), and longer time interval from admission to definitive surgery (p=0.01) were associated with an increased risk of severe complications or fistula recurrence. In multivariate analysis, only multiple fistulas were an independent risk factor for severe complications or fistula recurrence (OR=8.2, p=0.04). CONCLUSIONS Fistula complexity determines the risk of severe postoperative complications or fistula recurrence after definitive surgical repair of the persistent small intestine fistulas. Inflammatory parameters should be normalized before definitive surgery.

Surgical management of the grade C pancreatic fistula after pancreatoduodenectomy.

BACKGROUND: Surgical management of severe pancreatic fistula after pancreatoduodenectomy remains challenging, and carries high mortality. The aim of this retrospective study was to compare different surgical techniques used at relaparotomy for pancreatic fistula after pancreatoduodenectomy, and to identify factors predictive of failure to rescue. METHODS: A total of 43 patients after pancreatoduodenectomy developed a pancreatic fistula requiring relaparotomy. The perioperative data and outcomes were reviewed retrospectively. RESULTS: Completion pancreatectomy, simple drainage of the pancreatic anastomosis and external wirsungostomy were performed in 17, 16, and 10 cases, respectively. The mortality rate for completion pancreatectomy was 47.1%, compared with 56.3% for simple drainage (p = 0.598) and 50.0% for external wirsungostomy (p = 0.883). Simple drainage was associated with a higher rate of further relaparotomies (56.3%) in comparison with completion pancreatectomy (23.5%, p = 0.055) and external wirsungostomy (0%, p = 0.003). A rescue resection of the pancreatic remnant after failed simple drainage resulted invariably in death. On multivariate analysis, the factors predictive of mortality after relaparotomy for pancreatic fistula were organ failure on the day of reoperation (p = 0.001) and need of further surgical reintervention (p = 0.007). CONCLUSION: Timely reintervention and appropriate surgical technique are essential for reducing mortality after reoperation for pancreatic fistula after pancreatoduodenectomy.

Surgical treatment of extra-appendiceal colorectal neuroendocrine tumors.

BACKGROUND: Extra-appendiceal colorectal neuroendocrine tumors are rare neoplasms with a variable biological behavior. MATERIALS AND METHODS: The study group consisted of 15 patients with an extra-appendiceal colorectal neuroendocrine tumor who underwent surgical resection (M/F=3:12, mean age=62.9 years). Lower-grade neuroendocrine tumors and neuroendocrine carcinomas were recognized in 5 and 10 patients, respectively. Data were evaluated retrospectively with regard to clinical and pathologic characteristics and outcomes. RESULTS: The median age of the patients with lower-grade NETs was significantly lower than that in patients with NECs (53 yr vs. 68 yr, p=0.03). NETs G1-G2 were significantly smaller than neuroendocrine carcinomas (4.0 cm vs. 6.4 cm, p=0.02). There were no differences between lower-grade NETs and NECs with regard to tumor location, rate of nodal involvement and distant metastases. All the patients underwent open segmental resection of the colon or rectum. Complete resection was achieved in 3 of 5 patients from the lower-grade NET group, and in 5 of 10 patients in the NEC group. Overall survival was significantly better for lower-grade NETs tumors (p=0.005). The median survival was 4.8 months in the NEC group. The median survival in the lower-grade NET group was not achieved after a median follow-up of 69 months. Three-year overall survival was 100% for lower-grade NETs, and only 27% for NECs. CONCLUSION: Lower-grade neuroendocrine tumors seem to exhibit comparable potential for dissemination as neuroendocrine carcinomas, but prognostic implications of metastases are distinct.

Comparison between minimally invasive and open surgical treatment in necrotizing pancreatitis.

BACKGROUND: Minimal access techniques have gained popularity for the management of necrotizing pancreatitis, but only a few studies compared open necrosectomy with a less invasive treatment. The aim of this study was to evaluate the outcomes of minimally invasive treatment for necrotizing pancreatitis in comparison with open necrosectomy. MATERIALS AND METHODS: This retrospective study included 70 patients who underwent minimally invasive intervention or open surgical debridement for necrotizing pancreatitis between January 2007 and December 2014. Data were analyzed for postoperative morbidity and outcome. RESULTS: Of 70 patients, 22 patients underwent primary open necrosectomy and 48 patients were treated with minimally invasive techniques. Percutaneous and endoscopic drainage were successful in 34.9% and 75.0% of patients, respectively. The rates of postoperative new-onset organ failure and intensive care unit stay were significantly lower in the minimally invasive group (25.0% versus 54.5%; P = 0.016, and 29.2% versus 54.5%; P = 0.041, respectively). Gastrointestinal fistulas occurred more frequently after primary open necrosectomy (36.4% versus 10.4%; P = 0.009). Mortality was comparable in both groups (18.6% versus 27.3%; P = 0.420). Mortality for salvage open necrosectomy was similar to that for primary open debridement (28.6% versus 27.3%; P = 0.924). The independent risk factors for major postoperative complications were primary open necrosectomy (P = 0.028) and shorter interval to first intervention (P = 0.020). Mortality was independently associated only with older age (P = 0.009). CONCLUSIONS: Minimally invasive treatment should be preferred over open necrosectomy for initial management of necrotizing pancreatitis.

Walled-off necrosis: safety of watchful waiting.

BACKGROUND: Asymptomatic pancreatic necrosis should be managed conservatively, regardless of its extent. However, late sequelae and safety of non-interventional management in patients with asymptomatic walled-off necrosis remain unclear. AIMS: The purpose of this study was to report the clinical outcome of outpatient expectant management in a cohort of patients with walled-off necrosis who were discharged asymptomatic after an episode of acute pancreatitis. METHODS: Sixteen patients with walled-off necrosis asymptomatic at discharge were identified retrospectively from a single institution. Data were analyzed for the type of complications, their incidence and treatment. RESULTS: Seven of 16 patients (44 %) did not experience any complications during a median follow-up of 17 months. Nine of 16 patients (56 %) became symptomatic or developed complications within a median follow-up of 49 days after discharge. The most common complication was infection of pancreatic necrosis which occurred in 7 of 9 patients. Six of these patients were successfully treated with minimally invasive techniques. In 5 of 7 patients, infection of necrosis was due to oral commensal bacteria. Acute intracavitary hemorrhage and intractable abdominal pain developed in one patient each. There was no mortality in this series. CONCLUSIONS: Outpatient watchful waiting can be used safely in patients with asymptomatic walled-off necrosis, although nearly half of them eventually develop complications which require interventional treatment. Most late infections of pancreatic necrosis are probably due to a blood-borne transmission of oral commensal bacteria.

Combined minimally invasive management of infected pancreatic necrosis: a case report.

Infected necrosis is a potentially fatal complication of necrotizing pancreatitis. Open surgical debridement is the mainstay management of infected pancreatic necrosis. Over the last decade minimally invasive techniques have been increasingly used for the treatment of infected pancreatic necrosis and their results are encouraging. However, the optimal technique of minimal access necrosectomy and the timing of intervention have not been established yet. Patients with septic complications of acute pancreatitis represent a challenging group which requires individualized management often involving numerous techniques. We report a case of a 52-year-old patient in whom 3 minimally invasive techniques were needed for complete recovery.

Minimally invasive treatment of infected pancreatic necrosis.

Infected pancreatic necrosis is a challenging complication that worsens prognosis in acute pancreatitis. For years, open necrosectomy has been the mainstay treatment option in infected pancreatic necrosis, although surgical debridement still results in high morbidity and mortality rates. Recently, many reports on minimally invasive treatment in infected pancreatic necrosis have been published. This paper presents a review of minimally invasive techniques and attempts to define their role in the management of infected pancreatic necrosis.

Parenchyma-Sparing Pancreatic Resections: With or Without a Pancreaticojejunostomy?

BACKGROUND/AIM: Parenchyma-sparing pancreatic resections are used in low-grade malignant tumors, but result in a high incidence of pancreatic fistula. Pancreaticojejunostomy to the site of resection might decrease the risk of pancreatic fistula. The purpose of this study was to evaluate the influence of pancreaticojejunostomy on the outcomes of parenchyma-sparing resections. METHODOLOGY: The study group consisted of 21 patients (M/F = 4:17, mean age = 47 years). Local tumor resection with a pancreaticojejunostomy was performed in 11 patients and enucleation in 10 patients. Both groups were compared retrospectively with regard to perioperative variables. RESULTS: The operative time was significantly shorter in the enucleation group (median 180 min vs. 222 min, P = 0.005). The overall surgical morbidity was similar in both groups (81% vs. 70%, P = 0.64). The rate of clinically significant pancreatic fistula (64% vs. 40%, P = 0.39), hemorrhagic complications (27% vs. 10%, P = 0.59) and wound infection (18% vs. 40%, P = 0.36) were comparable in both groups. One patient died after central pancreatectomy. There were no new-onset cases of diabetes mellitus postoperatively. CONCLUSIONS: Local resection combined with pancreaticojejunostomy is an option to avoid extensive resection of the pancreatic parenchyma, but is still associated with a high incidence of pancreatic fistula which is comparable to that after enucleation.

Ultrasound-guided percutaneous drainage of infected pancreatic necrosis.

BACKGROUND: The role of percutaneous drainage in the management of infected pancreatic necrosis remains controversial, and ultrasound-guided technique is rarely used for this indication. The purpose of this study was to evaluate the safety and efficacy of sonographically guided percutaneous catheter drainage for infected pancreatic necrosis. METHODS: The patient group consisted of 16 men and 2 women. The mean age of the patients was 47 years. The median computed tomography severity index of acute pancreatitis was 10 points. Percutaneous catheter drainage was performed under sonographic guidance using preferably retroperitoneal approach, and transperitoneal access in selected cases. The medical records and imaging scans were reviewed retrospectively for each patient. RESULTS: Percutaneous catheter drainage resulted in a complete resolution of infected pancreatic necrosis in 6 of 18 patients (33 %). Twelve of 18 patients who were initially managed with PCD required eventually necrosectomy (67 %). The most common reason for crossover to surgical intervention was persistent sepsis (n = 7). Open necrosectomy was performed in 4 of these patients, and 3 patients underwent successful minimally invasive retroperitoneal necrosectomy. Five patients required conversion to open surgery because of procedure-related complications. In 3 cases, there was leakage of the necrotic material into the peritoneal cavity. Two other patients experienced hemorrhagic complications. Overall mortality rate was 17 %. The size of the largest necrotic collection in patients who were successfully treated with percutaneous drainage decreased by a median of 76 % shortly after the procedure, whereas it decreased only by a median of 16 % in cases of failure of percutaneous drainage. CONCLUSIONS: Ultrasound-guided percutaneous catheter drainage used in infected pancreatic necrosis is a technique with acceptably low morbidity and mortality that may be the definitive treatment or a bridge management to necrosectomy. A negligible decrease in size of the necrotic collection predicts failure of percutaneous drainage.

Retroperitoneal minimally invasive pancreatic necrosectomy using single-port access.

Infected pancreatic necrosis is a life-threatening complication of acute pancreatitis that has been traditionally managed with open surgical debridement. Over the last decade, minimally invasive techniques have been increasingly used for the treatment of infected pancreatic necrosis and their results are encouraging. Percutaneous retroperitoneal pancreatic necrosectomy is one of the minimally invasive approaches used for debridement of pancreatic necrosis. We report our technique of retroperitoneoscopic necrosectomy using a single-port access.

Optimizing management of pancreaticopleural fistulas.

AIM: To evaluate the management of pancreaticopleural fistulas involving early endoscopic instrumentation of the pancreatic duct. METHODS: Eight patients with a spontaneous pancreaticopleural fistula underwent endoscopic retrograde cholangiopancreatography (ERCP) with an intention to stent the site of a ductal disruption as the primary treatment. Imaging features and management were evaluated retrospectively and compared with outcome. RESULTS: In one case, the stent bridged the site of a ductal disruption. The fistula in this patient closed within 3 wk. The main pancreatic duct in this case appeared normal, except for a leak located in the body of the pancreas. In another patient, the papilla of Vater could not be found and cannulation of the pancreatic duct failed. This patient underwent surgical treatment. In the remaining 6 cases, it was impossible to insert a stent into the main pancreatic duct properly so as to cover the site of leakage or traverse a stenosis situated downstream to the fistula. The placement of the stent failed because intraductal stones (n = 2) and ductal strictures (n = 2) precluded its passage or the stent was too short to reach the fistula located in the distal part of the pancreas (n = 2). In 3 out of these 6 patients, the pancreaticopleural fistula closed on further medical treatment. In these cases, the main pancreatic duct was normal or only mildly dilated, and there was a leakage at the body/tail of the pancreas. In one of these 3 patients, additional percutaneous drainage of the peripancreatic fluid collections allowed better control of the leakage and facilitated resolution of the fistula. The remaining 3 patients had a tight stenosis of the main pancreatic duct resistible to dilatation and the stent could not be inserted across the stenosis. Subsequent conservative treatment proved unsuccessful in these patients. After a failed therapeutic ERCP, 3 patients in our series developed superinfection of the pleural or peripancreatic fluid collections. Four out of 8 patients in our series required subsequent surgery due to a failed non-operative treatment. Distal pancreatectomy with splenectomy was performed in 3 cases. In one case, only external drainage of the pancreatic pseudocyst was done because of diffuse peripancreatic inflammatory infiltration precluding safe dissection. There were no perioperative mortalities. There was no recurrence of a pancreaticopleural fistula in any of the patients. CONCLUSION: Optimal management of pancreaticopleural fistulas requires appropriate patient selection that should be based on the underlying pancreatic duct abnormalities.

Necrotizing fasciitis: early sonographic diagnosis.

Necrotizing fasciitis is a rare, but potentially fatal bacterial infection of the soft tissues. Establishing the diagnosis at the early stages of the disease remains the greatest challenge. We report a case of necrotizing fasciitis involving the upper extremity. Sonography revealed subcutaneous emphysema spreading along the deep fascia, swelling, and increased echogenicity of the overlying fatty tissue with interlacing fluid collections. The patient responded well to early surgical debridement and parenteral antibiotics.

Sonographic findings in groove pancreatitis.

Groove pancreatitis is a rare form of chronic pancreatitis involving the anatomic plane between the pancreatic head and duodenum. The radiographic diagnosis remains challenging, and most patients undergo exploratory laparotomy on suspicion of a periampullary malignancy. The appearance of groove pancreatitis on transabdominal and intraoperative sonography has rarely been reported in the literature. The sonographic findings in our 2 patients included a hypoechoic thin area between the pancreatic head and duodenum, a hyperechoic and thickened wall of the adjacent duodenum, and a heterogeneous or hyperechoic dorsocranial part of the pancreatic head.

Mesenteric fibromatosis with intestinal involvement mimicking a gastrointestinal stromal tumour.

INTRODUCTION: Mesenteric fibromatosis or intra-abdominal desmoid tumour is a rare proliferative disease affecting the mesentery. It is a locally aggressive tumour that lacks metastatic potential, but the local recurrence is common. Mesenteric fibromatosis with the intestinal involvement can be easily confused with other primary gastrointestinal tumours, especially with that of the mesenchymal origin. CASE REPORT: We report a case of a 44-year-old female who presented with an abdominal mass that radiologically and pathologically mimicked a gastrointestinal stromal tumour. CONCLUSIONS: The diagnosis of mesenteric fibromatosis should always be considered in the case of mesenchymal tumours apparently originating from the bowel wall that diffusely infiltrate the mesentery.

Gastrointestinal stromal tumors: ultrasonographic spectrum of the disease.

OBJECTIVE: The purpose of this series was to determine the spectrum of findings on gray scale trans-abdominal ultrasonography (TAUS) in pathologically proven cases of primary gastrointestinal stromal tumors (GISTs) and correlate them with gross morphologic and pathologic findings. METHODS: The series included 18 patients with a primary GIST tumor detected on preoperative TAUS. The ultrasonographic findings were evaluated for features such as tumor size, shape, margin, echogenicity, and presence of fluid components, and the features were compared with morphologic and pathologic findings. RESULTS: All of the primary GISTs were hypoechoic extraluminal masses with well-delineated margins. Eight GISTs were homogeneously solid masses, and 8 were heterogeneously solid masses that contained a large central area of lower echogenicity (n = 4) or multiple internal hypoechoic irregular spaces (n = 4) corresponding to necrosis and hemorrhage. Other tumors had a cystic appearance (n = 1) or showed a dual hyperechoic-hypoechoic echo structure (n = 1). Three tumors showed intratumoral gas due to fistulization into the bowel lumen, which appeared as hyperechoic foci or a linear hyperechoic area with acoustic shadowing. The heterogeneous tumors were significantly larger (P = .03) and had higher mitotic counts (P = .05). Gastrointestinal stromal tumors with high malignant potential tended to be large and showed intratumoral heterogenicity with areas of lower echogenicity. CONCLUSIONS: Gastrointestinal stromal tumors showed varied patterns on TAUS. The ultrasonographic pattern depended on the tumor size and mitotic activity. Ultrasonographic features suggesting high malignant potential were size and internal heterogenicity with the presence of intratumoral hypoechoic areas.

Synchronous occurrence of gastrointestinal stromal tumors and other primary gastrointestinal neoplasms.

AIM: To review clinical and pathologic features of Gastrointestinal stromal tumors (GISTs) occurring synchronously with other primary gastrointestinal neoplasms. METHODS: Twenty-eight patients with primary GIST were treated at our institution between 1989 and 2005. Clinical and pathologic records were reviewed. RESULTS: The gastrointestinal stromal tumor occurred simultaneously with other primary GI malignancies in 14% of all patients with GIST. The synchronous stromal tumors were located in the stomach and were incidentally found during the operation. The coexistent neoplasms were colon adenocarcinoma, gastric cancer (2 cases) and gastric lymphoma. CONCLUSION: The synchronous occurrence of GISTs and other gastrointestinal malignancies is more common than it has been considered. The development of gastrointestinal stromal tumors and other neoplasms may involve the same carcinogenic agents.

[Late malignant melanoma metastases within the abdominal cavity imitating clinically and pathologically a gastrointestinal stromal tumor]. / Pózne przerzuty czerniaka zlosliwego do jamy brzusznej imitujace klinicznie i patologicznie guz stromalny przewodu pokarmowego.

Melanoma is a malignant skin neoplasm that often metastasizes within the abdominal cavity. Melanoma metastases can develop even many years after the primary treatment. Clinical course, microscopic histology, and immunohistochemical profile of melanoma may imitate a gastrointestinal stromal tumor (GIST). We report a case of 55-year old man with a history of melanoma treatment 23 years earlier who presented with recurrent duodenal bleeding from a neoplastic tumor that was primarily diagnosed as GIST The histology of the tumor was reviewed and confirmed the diagnosis of metastatic melanoma.

[Seminoma metastases as a retroperitoneal space tumor]. / Guz w przestrzeni zaotrzewnowej bedacy przerzutem nasieniaka.

This is a case report of a testicular tumor, probably seminoma, presenting a retroperitoneal mass. The patient underwent surgical removal of tumor and the possibility of testicular tumor on the basis of histological examination was assumed. However, the histological examination of the testicle did not confirm the diagnosis of seminoma. The patient did not give consent for adjuvant chemotherapy. He has been remaining under clinical follow-up.