Surgical treatment of the pancreatic stump: preventive strategies of pancreatic fistula after pancreatoduodenectomy for cancer.

BACKGROUND: The institutions with high volume of pancreatic surgery report morbidity rate from 30% to 50% and mortality less than 5% after pancreaticoduodenectomy (PD). At the present, the most significant cause of morbidity and mortality is pancreatic fistula (PF). AIM: The purpose of the study is to identify the most important clinical factors which may predict PF development and eventually suggest alternative approaches to the pancreatic stump management. PATIENTS AND METHODS: A retrospective analysis of a clinical data base of a tertiary care Hospital was performed. From 2002 to 2012 a single Surgeon prospectively performed 150 pancreaticoduodenectomies for cancer. Four different techniques were used: end to end pancreaticojejunostomy, end to side pancreaticojejunostomy, pancreatic duct occlusion and duct to mucosa anastomosis. The intraoperative gland texture was classified as soft, firm and hard. The duct size was preoperatively (CT scan) and intraoperatively recorded and classified: < 3 mm small, 3-6 mm medium, > 6 mm large. The histopathological characteristic of the gland fibrosis was graduate as low 1, moderate 2, high 3. CONCLUSION: Relationships between pre and intraoperative duct size measurement, pancreatic texture and pancreatic fibrosis grading were highly significant. Small duct and soft pancreas with low grade fibrosis are the most important risk factors for pancreatic fistula development. The proper selection of pancreatic stump management or the decision to refer the high risk patients to high volume Center can be suggested by the elevated correspondence of pre and intraoperative duct diameter with the related pancreatic fibrosis grade and gland consistency. Preoperative assessment of the pancreatic duct makes possible to predict the risk of pancreatic fistula.

The success rate of identification of the sentinel lymph node in breast cancer: our training series.

A new phase of breast conserving surgery has started very recently, aimed at eliminating axillary dissection in node-negative patients by using the sentinel lymph node (SN) technique. Between November 1998 and January 2000 we performed 151 operations for breast cancer on 145 patients. We performed axillary lymphoscintigraphy using 99Tc-labeled human serum albumin microcolloidal particles injected subdermally in 50 patients who met our selection criteria. In this series we focused on the success rate of scintigraphic and surgical sentinel node identification. The number of scintigraphic identifications of the SN was 44 (88%). Only forty-three cases were evaluable, as in one case mapping showed an internal mammary hot node. All SNs were located at the first level. After removal of the SN complete axillary dissection was performed. Eighteen patients (41.8%) had metastatic disease in the axilla. There were five (11.6%) false negatives: two in T2 tumors, one in a T4 tumor and two in T1c tumors. We consider this series as our training series. Our results are similar to those reported in the literature. We believe that the most reasonable approach to SN biopsy is a two-step procedure: the ideal candidates are patients with T1 cancer who can undergo the operation in an outpatient setting under local anesthesia and sedation. Complete axillary dissection is performed only if paraffin sections and immunohistochemistry show metastatic disease.

Primary plasmacytoma of the testis. A case report.

The authors describe a case of multiple myeloma that developed several extraskeletal localizations. They evaluated the relation between the onset of the testicular tumor and the following myeloma characteristics: tumor burden, clinical phase, response to therapy and prognostic significance. The patient presented a rapid and dramatic clinical evolution of the disease with extensive spread also to the soft tissues of the abdominal wall. Chemotherapy did not achieve any effect and the patient died due to progression of the myeloma.

Polyarticular pigmented villonodular synovitis associated with multiple congenital anomalies. A case of Noonan-like/multiple giant cell lesion syndrome.

A case of polyarticular pigmented villonodular synovitis associated with many congenital phenotypic peculiarities (such as shortness, blue sclerae, flattened nose, low-set ears, hypertelorism, curly hair and pulmonary stenosis) is described. The presence of many of the typical signs of the Noonan syndrome and the histological finding of giant cells on the synovial biopsy led to the diagnosis of Noonan-like/multiple giant cell lesion syndrome.

Working formulation nomenclature of heart transplant pathology: A retrospective evaluation of 1037 endomyocardial biopsies.

Working Formulation (WF) was recently introduced by the International Society for Heart Transplantation to grade acute cellular rejection, as well as additional lesions observed in endomyocardial biopsies (EMBs). The aim of this study was to evaluate the actual advantages of this grading system in terms of feasibility and predictive value. To this purpose, we reclassified 1037 EMBs performed in our heart transplantation units according to the WF. Our results show that multifocal mild rejection (grade IA), when worsening, tends to progress to multifocal moderate (3A), whereas diffuse mild (1B) generally worsens to diffuse moderate (3B), thus following the same focal or diffuse pattern. Unifocal moderate rejection (grade 2) has a peculiar behavior, in that it almost always resolves, though in our units it is treated the same way as is grade 113. Finally, we found a significant relationship between Quilty B effect and chronic rejection. In conclusion, this retrospective study shows that WF is effective in using both qualitative and quantitative criteria and, particularly, in separating focal and diffuse forms of rejection and devoting a distinct grade to unifocal moderate rejection.

Non-Ebstein concomitant dysplasia of tricuspid and mitral valves in newborns.

This paper describes 2 cases of tricuspid valvular dysplasia (TVD) associated with aortic stenosis and mitral incompetence in newborns. Mitral regurgitation was due to dysplasia, which resembles its tricuspid counterpart and should be termed 'mitral valve dysplasia'. This association of tricuspid and mitral valve dysplasia has been reported only once before. The concomitance of mitral and tricuspid incompetence is noteworthy, since mitral regurgitation can produce left heart failure and mask tricuspid valve disease.