"A Space Odyssey" on Laparoscopic Segmental Rectosigmoid Resection for Deep Endometriosis: A Seventeen-year Retrospective Analysis of Outcomes and Postoperative Complications among 3050 Patients Treated in a Referral Center.

STUDY OBJECTIVE: To evaluate the feasibility of laparoscopic rectosigmoid resection for bowel endometriosis (RSE), reporting surgical and short-term postoperative outcomes in a consecutive large series of patients. DESIGN: A retrospective cohort study. SETTING: Third-level national referral center for deep endometriosis (DE). PATIENTS: 3050 patients with symptomatic RSE requiring surgical treatment. INTERVENTIONS: Nerve-sparing laparoscopic resection for RSE perfomed by a multidisciplinary team. After collecting intraoperative surgical characteristics, postoperative complications were collected by evaluating the risk factors associated with their onset. MEASUREMENTS AND MAIN RESULTS: Clavien-Dindo IIIb postoperative complications were noted in 13.1% of patients, with anastomotic leakage and rectovaginal fistula accounting for 3.0% and 1.9%, respectively. Postoperative bladder impairment was observed in 13.9% of patients during hospital discharge but spontaneously decreased to 4.5% at the first evaluation after 30 days, alongside a statistically significant change towards global symptom improvement. Multivariate analyses were done to identify the risk factors for segmental bowel resection in terms of occurrence of postoperative major complications. Ultralow (≤5 cm from the anal verge), low rectal anastomosis (<8 cm, >5 cm), parametrectomy, vaginal resection, and previous surgeries seemed more related to anastomotic leakage, rectovaginal fistula, and bladder retention. CONCLUSIONS: Laparoscopic rectosigmoid resection for RSE seems an effective and feasible procedure. The surgical complication rate is not negligible but could be reduced by implementing a multidisciplinary approach, an endless improvement in nerve-sparing techniques and surgical anatomy, as well as technological enhancements. Real future challenges will be to reduce the time for the first diagnosis of DE and the likelihood of surgical indications.

Evaluation of a predictive model for pancreatic fistula based on amylase value in drains after pancreatic resection.

BACKGROUND: Amylase value in drains (AVD) is a predictor of pancreatic fistula (PF). We evaluated the accuracy of an AVD-based model. METHODS: Two hundred thirty-one patients underwent pancreatoduodenectomy with pancreaticojejunostomy (PDPJ) or pancreatoduodenectomy with duct-to-mucosa (PDDTM) and distal pancreatectomy (DP). Patients with AVD greater than 5,000 U/L on postoperative day (POD) 1 underwent AVD measurement on POD5. RESULTS: Sensitivity and specificity of POD1 AVD greater than 5,000 in predicting PF were 71% and 90%, respectively. The sensitivity and specificity of POD5 AVD greater than 200 were 90% and 83%, respectively. AVD greater than 1,000 (for PDPJ) and 2,000 U/L (PDDTM and DP) represented the most accurate cutoffs on POD1. AVD greater than 200 (PDPJ), 300 (PDDTM), and 50 U/L (DP) represented the cutoffs with the highest sensitivity in predicting PF on POD5. CONCLUSION: AVD-based model for predicting PF after pancreatic resection is an accurate tool, although AVD cutoffs should be evaluated for each type of operation.

Primary retroperitoneal acinar cell cystadenoma.

In this report, we describe a case of hitherto unreported primary retroperitoneal acinar cell cystadenoma that morphologically and immunophenotypically resembled pancreatic acinar cell cystadenoma. Pancreatic acinar cell cystadenoma is a very uncommon benign lesion characterized by acinar cell differentiation, the evidence of pancreatic exocrine enzyme production, and the absence of cellular atypia. Our case occurred in a 55-year-old woman presenting a 10-cm multilocular cystic lesion in the retroperitoneum thought to be a mucinous cystic neoplasm. At laparotomy, the cystic mass, which showed no connection with any organ, was completely resected with a clinical diagnosis of cystic lymphangioma. The diagnosis of retroperitoneal acinar cell cystadenoma was based on the recognition of morphological acinar differentiation, the immunohistochemical demonstration of the acinar marker trypsin, and the absence of cellular atypia. These peculiar features can be used in the differential diagnosis with all the other cystic lesions of the retroperitoneum.

The Dagradi-Serio-Iacono operation central pancreatectomy.

Central pancreatectomy (CP) is a segmental pancreatic resection indicated to remove benign or low-grade malignant tumors of the isthmus and proximal part of the body of the pancreas. The main advantage of this operation compared with major resections is that it permits to spare normal pancreatic parenchyma; moreover, spleen and upper digestive and biliary tracts are saved. The description of the complete operation was reported for the first time by Dagradi and Serio in 1984 and subsequently spread worldwide by Iacono and Serio. In our opinion, it should be called the Dagradi-Serio-Iacono operation, by the names of the surgeons who first performed it (Dagradi and Serio), and by the names of the surgeons responsible for reporting it worldwide with precise indications (Iacono and Serio). Operation requires a midline or a bilateral subcostal incision; the lesser sac is entered through dissection of the transverse colon from the omentum or by transecting the gastrocolic ligament. The pancreatic segment harboring the lesion is then mobilized and its posterior surface carefully dissected from the splenic vein and artery. Subsequently, the pancreatic portion harboring the tumor is isolated at its superior margin from the splenic artery after the pancreas is transacted. The extent of the resection of the central segment is limited on the right by the gastroduodenal artery and on the left by the need to leave at least 5 cm of normal pancreatic remnant. The resected pancreatic specimen is sent to the pathologist for confirmation of diagnosis and to check if the resection margins are adequate. Hemostasis of the two raw surfaces is achieved with interrupted 5 or 4/0 nonabsorbable stitches. When it is not stapled, the Wirsung's duct of the cephalic stump is sutured selectively with a figure-of-eight nonabsorbable stitch. An end-to-end invaginated pancreaticojejunostomy is carried out with a single layer of interrupted stitches. The operation is concluded with the construction of an end-to-side jejuno-jejunostomy about 50 cm distal to the pancreatic anastomosis. Other techniques for reconstruction of the distal stump using jejunum or stomach have been described. One or two soft drains are brought out on the right side. The fluid collected from this drain is checked for amylase level on postoperative days 3, 5, and 7; if the level is low or absent, the drain is removed. Central pancreatectomy is a safe technique for benign or low malignant tumors of the pancreatic neck that allows curing the tumor with evident functional results without increasing the risk for the patient. We can say that CP has a clear role like pancreaticoduodenectomy and distal pancreatectomy and we think that a pancreatic surgeon has to include this procedure in his/her technical skills. In order to obtain excellent results, correct indications and experience in pancreatic surgery are recommended.

Results of pancreaticoduodenectomy for pancreatic cancer: extended versus standard procedure.

In Western experience, the long-term survival benefit after extended pancreaticoduodenectomy (EPD) in patients with pancreatic ductal adenocarcinoma is still controversial. The aim of this work was to evaluate weather EPD for pancreatic ductal adenocarcinoma prolongs long-term survival compared to standard pancreaticoduodenectomy (SPD). From November 1992 to September 1996, we performed pancreatic resections in 30 patients affected by stage I-III pancreatic ductal adenocarcinoma: 13 patients underwent SPD and 17 patients underwent EPD, consecutively. The two groups of patients were similar for all the demographic, clinical, and pathological characteristics, and all the intraoperative factors considered except the number of resected lymph nodes (mean number per case = 34.2 +/- 15.5 in the EPD group versus 12.8 +/- 3.6 in the SPD group, p <0.001) and the operative time (median time per case = 375 minutes in the EPD group versus 270 minutes in the SPD group, p = 0.009). Patients in the two groups experienced a similar postoperative course. The estimated survival probability at 1 and 3 years after operation was 0.76 (95% confidence interval [CI]: 0.49 to 0.90) and 0.24 (95% CI: 0.07 to 0.45) in the EPD group; 0.31 (95% CI: 0.09 to 0.55) and 0.08 (95% CI: 0.00 to 0.29) in the SPD group (p = 0.014). According to a Cox model, the treatment was associated with R0 patients' long-term survival (SPD versus EPD: hazard ratio (HR) = 4.82, 95% CI: 1.66 to 14.00, p = 0.004). Grading of tumor differentiation was confirmed to be a relevant prognostic factor (poor versus moderate: HR = 4.33, 95% CI: 1.49 to 12.61, p = 0.007), whereas type of resection had no significant effect (pylorus-preserving versus hemigastrectomy: HR = 1.49, 95% CI: 0.56 to 3.95, p = 0.42). The proportion of R0 patients with local recurrence was lower in the EPD group (20.0% versus 70.0%, p = 0.034).