Current Surgical Concepts and Future Perspectives in the Treatment of Borderline Resectable and Potentially Resectable Locally Advanced Pancreatic Cancer.

Pancreatic ductal adenocarcinoma (PDAC) represents an aggressive tumor with a low five-year survival rate of less than 10%. Only 20% of patients are estimated to be eligible for upfront curative resection at the time of presentation. The larger group of borderline resectable (BRPC) and locally advanced pancreatic cancers (LAPC) had much poorer outcomes in the past. Although there are improvements for the multimodal therapy of PDAC, surgery remains the single hope for a cure. Combined with adjuvant and/ or neoadjuvant treatment, pancreatic surgery can enhance five-year survival by up to 20%. However, pancreatic resection is widely associated with a high risk of complications and is regarded as one of the most complex surgical procedures. TRIANGLE operation should be added to pancreatic surgery armamentarium as a key procedure, with the potential to increase the number of harvested lymph nodes, reduce the complications rate, and better radical treatment efficacy for BRPC and LAPC be converted to resectability after neoadjuvant treatment (NAT). More and more aggressive pancreatectomy has become justified in the context of NAT. Further technical standardization and optimal neoadjuvant strategy are mandatory for the global dissemination of aggressive pancreatectomies. This review summarizes the surgical treatment for BRPC and potentially resectable LAPC based on the current literature, focusing on the "TRIANGLE "concept of pancreatic surgery.

Significance of Biomarkers in Early Diagnosis of Abdominal Sepsis.

INTRODUCTION/OBJECTIVE: Peritonitis is one of the most important sources of abdominal sepsis. Since intra-abdominal infection leads to the activation of the inflammatory response, this suggested that some of these mediators could be used as markers of the severity of newly formed sepsis, but primarily to identify or rule out new-onset sepsis. The aim of this study was to evaluate the sensitivity and specificity of serum markers of inflammation: C-reactive protein, procalcitonin and serum amyloid A in the serum of patients with diffuse secondary peritonitis. Methods: The prospective cohort study was conducted at the Clinic for Emergency Surgery of the Clinical Center of Serbia in Belgrade. The study group consisted of 100 patients aged 18 to 70 years, with signs of acute abdomen due to diffuse secondary peritonitis. Results: CRP and PCT are so far among the most valuable preoperative markers for distinguishing sepsis from SIRS. On the first postoperative day the analysis of the relationship between sensitivity and specificity at the different breakpoints used indicates a greater diagnostic accuracy and greater sensitivity of SAA compared to CRP and PCT. In the remaining postoperative period in our study, the ROC curve mostly coincided with the diagonal line, so CRP, PCT, and SAA had little diagnostic accuracy. CONCLUSION: The results of our study suggest that finding a specific marker for the diagnosis of abdominal sepsis, a marker that would differentiate between SIRS and sepsis, pre- and postoperatively, would be very useful.

Is Colorectal Cancer Stage Affected by COVID-19 Pandemic?

Background: Causing healthcare systems overload, COVID-19 pandemic has a huge influence on patients with colorectal cancer. The aim of our study was to assess the potential impact of COVID-19 on the stage of colorectal cancer. Methods: In our retrospective study, two groups of patients operated for colorectal cancer were analyzed at the Clinic for Surgery "Nikola Spasic", Zvezdara University Medical Center. The study group consisted of 49 patients operated in the period from March 15, 2020 to April 2021, during COVID-19 pandemic. The control group consisted of 152 patients, who were operated on in the period from January 1, 2019. to December 31, 2019. Results: There were no difference in surgical approach, prevalence of stoma, percentages of postoperative complications and rates of hospital readmission between both groups. T4b tumor stage was statistically significant more common in the study group (12.2% vs 3.3%, p=0.027). Locally advanced tumors, stage IIC, were statistically significantly more common in the group of patients operated on during the COVID-19 pandemic (10.2% vs 1.3%, p=0.01). Conclusion: Higher number of locally advanced tumors in study group could probably be caused by the impact of the COVID-19 pandemic on healthcare system.

[Surgical treatment of liver injury--5-year experience].

Due to improved methods of treatment and management of hemorrhage, the mortality from liver injuries has decreased significantly over the past few decades. In spite of that, liver injuries still represent diagnostic and therapeutic challenge. This retrospective study included 197 patients surgically treated because of trauma of the liver at The Clinic for Emergency Surgery, during the period 2004-2009. The results showed significant difference in mortality rates in cases of penetrating wounds compared to blunt trauma and gunshot wounds. The severity of injury evaluated by Organ Injury Scale was significantly higher in gunshot wounds compared to blunt and penetrating trauma. The correlation of severity of injuries and mortality rates showed that the mortality is significantly lower in patients with grade 1, 2, and 3 injuries compared to grades 4 and 5 (p = 0.016). Specific complication rate was 28.4%, while mortality rate was 21.8%. The results reflect diagnostic and treatment problems, as well as the importance of multidisciplinary approach to the patients with liver trauma.

[Surgical treatment of pancreatic injuries in severe abdominal trauma].

In spite of its low incidence, pancreatic injuries hold important place in abdominal trauma because of diagnostic difficulties, severe potential complications, therapeutic challenges, and high mortality rates. These injuries are related with specific morbidity and are very often accompanied with injuries of other organs. This retrospective study included 31 patients treated at The Clinic for Emergency Surgery of Clinical Center of Serbia during the period of 2004-2009 with intraoperativelly confirmed diagnosis of pancreatic trauma. The most common mechanism of injury was blunt trauma (83.9%). Among available diagnostic methods, abdominal ultrasound was characterized with high incidence of false-negative findings (33.3%) while for CT it was at 16.6%. The type of surgical procedure was related to degree and severity of injury. Specific complications occurred in 22.6% of patients, while mortality rate was 25.8%. The creation of unambiguous algorithms for optimal treatment of patients with pancreatic trauma require multi-centric prospective studies.

[Laparoscopy in the evaluation of blunt abdominal trauma].

Laparoscopic diagnostics provides fast, reliable, clear, and obvious information on extent and depth of abdominal organs injury with minimizing additional trauma to the patient. It is performed without any specific preparations and, if needed, it may be promptly converted into conventional laparotomy. Through use of optical equipment with various refraction angles and through variable patient positioning, laparoscopic technique enables visualization of whole abdominal cavity. In approximately 20% of cases of unclear findings, and after other performed diagnostic procedures, laparoscopy provides definitive diagnosis. Abdominal surgeons are familiar with this method, making interpretaion of the results very fast and reliable and, what is the most important, this method avoids additional trauma caused by conventional laparotomy.

[Damage control surgery--our experience].

Damage control surgery represents widely implemented technique of treatment of seriously injured patients all over the world. In medical facilities with large number of seriously injured patients, type of injuries often imposes method of damage control surgery as ultimate way in treating such patients. In Emergency center from 2005-2009. 895 patients had been operated because of the trauma to the abdomen and thorax. Method of damage control surgery had been implented on 41 patients (4.6% of all operated patients). 18 patients died, and 30 seriously injured patients that hadn't been treated according to this method had died in operating room. Likewise, 11 non-trauma patients were treated according to the principles of damage control surgery because of uncontrolled bleeding. The greatest challenge today is defining criteria for choosing right patients for damage control surgery.

[Oversights in the care of severe injuries].

Question of missed injuries is more often a question of human errors: task execution errors, procedural errors, communication errors, decision errors and noncompliance. Missed injuries are those which are not idetified in the first three days of hospitalisaation. This theme is not popular among physicians. Literature data mention percent from 3-29% missed injuries overall. The underlying causes errors are: false attributin, false negative prediction and false lebeling. False attribution involves a tendency to incorrectly link a clinical observation with an arroneous cause. This tendency also ignores one of the fundamental principles of the management of traumatic injury: that the index of suspicion should proceed on the basis of assumed wors resonable case scenario. Weaknesses of trauma systems: high patients volume, high-risk patients, long hours, changing set of resources, and problems sush bad admission planing, defficite anamnesis, defficite diagnostic procedures, bad communication, improvisation etc.

Hepatic abscess secondary to a rosemary twig migrating from the stomach into the liver.

The ingestion of a foreign body that penetrates the gastric wall and migrates to the liver, where it causes an abscess is uncommon. A case of an ingested rosemary twig perforating the gastric antrum, then migrating to the liver, complicated by hepatic abscess and Staphylococcus aureus sepsis is reported. A 59-year-old man without a history of foreign body ingestion was admitted to our hospital because of sepsis and epigastralgia, which had progressively worsened. No foreign body was identified at preoperative imaging, but a rosemary twig was discovered during laparotomy. The liver abscess and sepsis were controlled successfully with surgery and antibiotics. This unusual condition should be kept in mind when dealing with cases of hepatic abscess, or even sepsis of unknown origin. Despite the improvement of non-surgical techniques such as percutaneous drainage and interventional endoscopy, surgery still remains important in the treatment of hepatic abscess caused by an ingested foreign body.

Planned staged reoperative necrosectomy using an abdominal zipper in the treatment of necrotizing pancreatitis.

PURPOSE: The optimal operative treatment for severe necrotizing pancreatitis (SNP) still remains controversial. This article describes the operative approach with a planned staged necrosectomy using the "zipper" technique. METHODS: Between 1996 and 2000, 35 patients with SNP were treated with this approach. The patient demographics, etiology and severity of SNP, hospital course, and outcome were recorded and comparisons of several parameters were made between the patients who survived and those who died. RESULTS: Hospital mortality was 34%. A total of 16 fistulae developed in 11 patients (31%), recurrent intra-abdominal abscesses in 4 (11%), and hemorrhaging in 5 (14%). The patients who died compared with those who survived had a higher Acute Physiology and Chronic Health Evaluation (APACHE)-II score on admission (14.5 vs 9, P < 0.001), extrapancreatic extension of necrosis more often (100% vs 65%, P = 0.02), and developed postoperative hemorrhaging more often (33% vs 4%, P = 0.038). A multivariate logistic analysis revealed an APACHE-II score of > 13 on admission (P = 0.018) and an extension of necrosis behind both paracolic gutters (P < 0.001) to both be prognostic factors for mortality. CONCLUSIONS: Severe necrotizing pancreatitis still carries significant morbidity and mortality. This surgical approach facilitates the removal of all devitalized tissue and seems to decrease the incidence of recurrent intra-abdominal infection requiring reoperation. An APACHE-II score of > or = 13 and an extension of necrosis behind both paracolic gutters was thus found to signify a worse outcome.

[Relation of pathoanatomic substrate and incidence of bacterial infection in the acute biliary tract disease].

Acute biliary diseases have become the most common indication for major abdominal surgery. We investigated 60 patients who underwent surgery for the acute biliary diseases, within 48 hours from the onset of the illness (group I), and over longer preoperative interval (48 h up to 5 days) (group II). Surgical specimen (gallbladder) was histologically examined. Samples for microbiological exams were obtained from gallbladder, common bile duct, Lund's node, gallbladder bed and peritoneal cavity. Positive bile cultures were found in 43% of group I, and in 70% of group II (p<0.05). Microbiological analysis revealed 13 different species, mostly Gram negative aerobic rods (69%). The incidence of bacteriobilia was in correlation with HP of lesions (79% in the acute and 18% in chronic lesions; p<0.01), what testified the importance of time interval and role of bacterial factor in the acute biliary pathology. Septic complications strictly occurred in patients with positive biliary findings. Early surgical treatment eliminates focus, and stops further development of intraabdominal and systemic septic complications. Correlation between bacteriobilia and septic sequelae calls for prophylactic use of antibiotics.

[Solid cystic pseudopapillary tumor of the pancreas]. / Solidni cisticni pseudopapilarni tumor pancreasa.

Solid-cystic-pseudopapillary tumor (SCPT) of the pancreas, described by Frantz (1959), is a very rare clinical pathologic entity with relatively low grade malignant potential. The tumor is more frequent in the body and tail of the pancreas. The majority of patients are young females. About 60% of patients are asymptomatic. Complications such as rupture, bleeding or secondary infections are rare. Metastases of the tumor and local recurrence after surgical treatment are also rare. Prognosis is excellent after complete surgical removal. It is difficult to make a preoperative diagnosis of pancreatic SCPT. The exact diagnosis is based on histological findings. Differential diagnosis should consider pancreatoblastoma, non neoplastic cysts, pancreatic pseudo-cysts and hydatid cyst. This is a case report of 39-year old woman who was admitted to our institution with abdominal discomfort and palpable abdominal mass in the upper abdomen. US and CT scan revealed round neoformation of 60 mm in diameter located in the body of the pancreas. Imaging features were not specific enough to allow for precise diagnosis. Curative R0 left spleno-hemipancreatectomy was performed. Histology of the resected specimen revealed solid and cystic-pseudopapillary tumor of the pancreas. The patient was discharged on postoperative day 7 in a good condition. The patient is well 48 months after the operation, with no impairment of pancreatic endocrine or exocrine function.

[Anatomic segmental resection of the liver in surgical treatment of colorectal metastatic lesions]. / Anatomske segmentne resekcije jetre u hirurskom lecenju kolorektalnih metastatskih lezija.

The prime role of hepatic resection in the management of colorectal cancer metastatic to the liver is firmly established. At least a third of patients who undergo liver resection for colorectal metastases can expect to survive five years. Since 1999, 106 hepatic metastases were resected in 42 patients (synchr. 8, metachr. 34, pts.). We performed 12 monosegmentectomies (S2-S8), 4 bisegmentectomies (S4b, S5 and S5, S6), 6 sectorectomies (right posterior, left paramedian, left lateral), 3 polysegmentectomies (S4b, S5, S6), 8 bilateral sectionectomies (S2, S3 and S6, S7) and in 9 cases multiple segmentectomies. In 4 cases initially unresectable colorectal metastases were downstaged by transcatheter HAI regional chemotherapy (Implantoflx), and after that successfully resected. We favour vascular inflow occlusion through selective division of appropriate portal pedicle at the porta hepatis or by transparenchymal approach. Median blood loss was 330 +/- 160 ml. The complication rate amounted to 9.52% (bile fistula, abscess collection). No method related lethality occurred. During the follow-up period we registered tumor recurrence rate of 19.1% (8 pts.), of which two patients were subjected to liver re-resection. Overall 3-year survival rate (Kaplan-Meier) is 38.9%. Multivariate analysis shows a significant correlation between 3-year survival and solitary (p-0.031) and unilobar metastases (p-0.014).