Iatrogenic bile duct injuries: Etiology, diagnosis and management

Iatrogenic bile duct injuries (IBDI) remain an important problem in gastrointestinal surgery. They are most frequently caused by laparoscopic cholecystectomy which is one of the commonest surgical procedures in the world. The early and proper diagnosis of IBDI is very important for surgeons and gastroenterologists, because unrecognized IBDI lead to serious complications such as biliary cirrhosis, hepatic failure and death. Laboratory and radiological investigations play an important role in the diagnosis of biliary injuries. There are many classifications of IBDI. The most popular and simple classification of IBDI is the Bismuth scale. Endoscopic techniques are recommended for initial treatment of IBDI. When endoscopic treatment is not effective, surgical management is considered. Different surgical reconstructions are performed in patients with IBDI. According to the literature, Roux-en-Y hepaticojejunostomy is the most frequent surgical reconstruction and recommended by most authors. In the opinion of some authors, a more physiological and equally effective type of reconstruction is end-to-end ductal anastomosis. Long term results are the most important in the assessment of the effectiveness of IBDI treatment. There are a few classifications for the long term results in patients treated for IBDI; the Terblanche scale, based on clinical biliary symptoms, is regarded as the most useful classification. Proper diagnosis and treatment of IBDI may avoid many serious complications and improve quality of life.

Biliary cysts: Etiology, diagnosis and management

Biliary cysts (BC) are rare dilatations of different parts of a biliary tract. They account for approximately 1% of all benign biliary diseases. BC occur the most frequently in Asian and female populations. They are an important problem for pediatricians, gastroenterologists, radiologists and surgeons. Clinical presentation and management depend on the BC type. Cholangiocarcinoma is the most serious and dangerous BC complication. The other complications associated with BC involve cholelithiasis and hepatolithiasis, cholangitis, acute and chronic pancreatitis, portal hypertension, liver fibrosis and secondary liver cirrhosis and spontaneous cyst perforation. Different BC classifications have been described in the literature. Todani classification dividing BC into five types is the most useful in clinical practice. The early diagnosis and proper treatment are very important, because BC are associated with a risk of carcinogenesis. A malignancy risk increases with the age. Radiological investigations (ultrasonography, computed tomography, endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography) play an important role in BC diagnostics. Currently, prenatal diagnosis using ultrasonography is possible. It allows to differentiate biliary disorders in fetals and to perform the early surgical treatment that improves results. In most patients, total cyst excision with Roux-Y hepaticojejunostomy is the treatment of choice. Surgical treatment of BC is associated with high success rate and low morbidity and mortality. The early treatment is associated with a lower number of complications. Patients following BC surgery require permanent and careful postoperative observation using laboratory and imaging investigations because of possibility of biliary anastomosis stricture and biliary cancer in tissue remnant.

Hepaticojejunostomy vs. end-to-end biliary reconstructions in the treatment of iatrogenic bile duct injuries

BACKGROUND

Retrospective comparison of short- and long-term results and quality of life in patients treated for iatrogenic bile duct injuries (IBDI) with Roux-Y hepaticojejunostomy (HJ) or end-to-end ductal anastomosis (EE).

METHODS

Between January 1990 and March 2005, 94 patients underwent reconstructive surgery for IBDI: 49, Roux-Y HJ, and 45, EE.

RESULTS

Early postoperative complications were observed in 12 (24.5%) patients undergoing HJ and three (6.7%) undergoing EE (p = 0.0239). Reoperations in the early postoperative period were performed in four (8%) patients after HJ and in zero patients after EE. Following HJ, one (2%) hospital death occurred due to acute circulatory insufficiency. Long-term results were evaluated in 69 (72%) patients. Postoperative mean weight gain was significantly higher after EE than HJ (p = 0.0191). Recurrent stricture was observed in two (5.3%) patients after HJ and three (9.6%) after EE (p = 0.6509). Terblanche long-term results were comparable in both groups (p = 0.3173). Good Karnofsky quality of life was comparable in both groups (p = 0.8377).

CONCLUSIONS

More early complications occurred after HJ than after EE. Long-term results were comparable after both reconstructive methods. After EE, patients achieved a higher weight gain than after HJ. Quality of life in both groups was comparable.

Nutritional Support in Patients with Severe Acute Pancreatitis-Current Standards

Severe acute pancreatitis (SAP) leads to numerous inflammatory and nutritional disturbances. All SAP patients are at a high nutritional risk. It has been proven that proper nutrition significantly reduces mortality rate and the incidence of the infectious complications in SAP patients. According to the literature, early (started within 24-48 h) enteral nutrition (EN) is optimal in most patients. EN protects gut barrier function because it decreases gastrointestinal dysmotility secondary to pancreatic inflammation. Currently, the role of parenteral nutrition (PN) in SAP patients is limited to patients in whom EN is not possible or contraindicated. Early versus delayed EN, nasogastric versus nasojejunal tube for EN, EN versus PN in SAP patients and the role of immunonutrition (IN) in SAP patients are discussed in this review.

The Role of Immunonutrition in Patients Undergoing Pancreaticoduodenectomy

Pancreaticoduodenectomy (PD) is one of the most difficult and complex surgical procedures in abdominal surgery. Malnutrition and immune dysfunction in patients with pancreatic cancer (PC) may lead to a higher risk of postoperative infectious complications. Although immunonutrition (IN) is recommended for enhanced recovery after surgery (ERAS) in patients undergoing PD for 5-7 days perioperatively, its role in patients undergoing pancreatectomy is still unclear and controversial. It is known that the proper surgical technique is very important in order to reduce a risk of postoperative complications, such as a pancreatic fistula, and to improve disease-free survival in patients following PD. However, it has been proven that IN decreases the risk of infectious complications, and shortens hospital stays in patients undergoing PD. This is a result of the impact on altered inflammatory responses in patients with cancer. Both enteral and parenteral, as well as preoperative and postoperative IN, using various nutrients, such as glutamine, arginine, omega-3 fatty acids and nucleotides, is administered. The most frequently used preoperative oral supplementation is recommended. The aim of this paper is to present the indications and benefits of IN in patients undergoing PD.

End-to-end ductal anastomosis in biliary reconstruction: indications and limitations

End-to-end ductal anastomosis is a physiologic biliary reconstruction that is commonly used in liver transplantation and less frequently in the surgical treatment of iatrogenic bile duct injuries. Currently, end-to-end ductal anastomosis is the biliary reconstruction of choice for liver transplantation in most adult patients. In recent years, it has also been performed for liver transplantation in children and in select patients with primary sclerosing cholangitis. The procedure is also performed in some patients with iatrogenic bile duct injuries, as it establishes physiologic bile flow. Proper digestion and absorption as well as postoperative endoscopic access are possible in patients who undergo end-to-end ductal anastomosis. It allows endoscopic diagnostic and therapeutic procedures in patients following surgery. This anastomosis is technically simple and associated with fewer early postoperative complications than the Roux-en-Y hepaticojejunostomy; however, end-to-end ductal anastomosis is not possible to perform in all patients. This review discusses the indications for and limitations of this biliary reconstruction, the technique used in liver transplantation and surgical repair of injured bile ducts, suture types and use of a T-tube.

Precut sphincterotomy: A reliable salvage for difficult biliary cannulation

Even experienced endoscopists have 90% success in achieving deep biliary cannulation with standard methods. Biliary cannulation may become difficult in 10%-15% of patients with biliary obstruction and precut (access) sphincterotomy is frequently chosen as a rescue treatment in these cases. Generally, precut sphincterotomy ensures a rate of 90%-100% successful deep biliary cannulation. The precut technique has been performed as either a fistulotomy with a needle knife sphincterotome or as a transpapillary septotomy with a standard sphincterotome. Both methods have similar efficacy and complication rates when administered to the proper patient. Although precut sphincterotomy ensures over 90% success of biliary cannulation, it has been characterized as an independent risk factor for pancreatitis. The complications of the precut technique are not limited to pancreatitis. Two more important ones, bleeding and perforation, are also reported in some publications as being observed more commonly than during standard sphincterotomy. It is also reported that precut sphincterotomy increases morbidity when performed in patients without dilatation of their biliary tract. Nevertheless, precut sphincterotomy is a good alternative as a rescue method in the setting of a failed standard cannulation method. This paper discusses the technical details, timing, efficacy and potential complications of precut sphincterotomy.

Pancreatic intraductal papillary mucinous neoplasms: Current diagnosis and management

Intraductal papillary mucinous neoplasms (IPMNs) represent approximately 1% of all pancreatic neoplasms and 25% of cystic neoplasms. They are divided into three types: main duct-IPMN (MD-IPPMN), branch duct-IPMN (BD-IPMN), and mixed type-IPMN. In this review, diagnostics, including clinical presentation and radiological investigations, were described. Magnetic resonance imaging is the most useful for most IPMNs. Management depends on the type and radiological features of IPMNs. Surgery is recommended for MD-IPMN. For BD-IPMN, management involves surgery or surveillance depending on the tumor size, cyst growth rate, solid components, main duct dilatation, high-grade dysplasia in cytology, the presence of symptoms (jaundice, new-onset diabetes, pancreatitis), and CA 19.9 serum level. The patient’s age and comorbidities should also be taken into consideration. Currently, there are different guidelines regarding the diagnosis and management of IPMNs. In this review, the following guidelines were presented: Sendai International Association of Pancreatology guidelines (2006), American Gastroenterological Association guidelines, revised international consensus Fukuoka guidelines (2012), revised international consensus Fukuoka guidelines (2017), and European evidence-based guidelines according to the European Study Group on Cystic Tumours of the Pancreas (2018). The Verona Evidence-Based Meeting 2020 was also presented and discussed.

Associations between Nutritional and Immune Status and Clinicopathologic Factors in Patients with Pancreatic Cancer: A Comprehensive Analysis

The aim of this study was to assess and analyze the nutritional status (NS) and immune status of pancreatic cancer (PC) patients. The retrospective analysis included 80 PC patients undergoing curative pancreatic resection in the Department of Digestive Tract Surgery of the Medical University (Katowice, Poland). Patients were divided by the tumor location (proximal vs. distal), age (≤65 years vs. >65 years), Nutritional Risk Score 2002 (NRS 2002) (<3 vs. ≥3), prognostic nutritional index (PNI) (<45 vs. ≥45), and the presence of postoperative complications (no-complication vs. complication) as well as the use of neoadjuvant chemotherapy (no neoadjuvant chemotherapy vs. neoadjuvant chemotherapy) into two subgroups, which were compared. Significantly higher weight loss was related to the proximal tumor location (p = 0.0104). Significantly lower serum total protein (p = 0.0447), albumin (p = 0.0468), hemoglobin (p = 0.0265) levels, and PNI (p = 0.03) were reported in older patients. The higher nutritional risk according to NRS 2002 was significantly associated with higher age (p = 0.0187), higher weight loss (p < 0.01), lower body mass index (BMI) (p = 0.0293), lower total lymphocyte count (p = 0.0292), longer duration of hospitalization (p = 0.020), neoadjuvant chemotherapy (p < 0.01), and preoperative biliary drainage (p = 0.0492). The lower PNI was significantly associated with higher weight loss (p = 0.0407), lower serum total protein and albumin concentration, lymphocyte count (p < 0.01) and higher neutrophil/lymphocyte (NLR), monocyte/lymphocyte (MLR), platelet/lymphocyte (PLR) ratios, and duration of hospitalization (p < 0.01). In the multiple logistic regression analysis, BMI ≥ 30 kg/m2 (OR: 8.62; 95% CI: 1.24-60.04; p = 0.029521) and NRS 2002 ≥ 3 (OR: 2.87; 95% CI: 0.88-9.33; p = 0.048818) predicted postoperative complications. In the multiple linear regression analysis, the higher NRS 2002 score was linked with the longer duration of hospitalization (b = 7.67948; p = 0.043816), and longer duration of postoperative hospitalization was associated with a higher complication rate (b = 0.273183; p = 0.003100). Nutritional impairment correlates with a systemic inflammatory response in PC patients. Obesity (BMI ≥ 30 kg/m2) and malnutrition (NRS 2002 ≥ 3) predict postoperative complications, which are associate with a longer hospital stay. Assessment of nutritional and immune status using basic diagnostic tools and PNI and immune ratio (NLR, MLR, PLR) calculation should be the standard management of PC patients before surgery to improve the postoperative outcome.

Hepatectomy for bile duct injuries: When is it necessary?

Iatrogenic bile duct injuries (IBDI) are still a challenge for surgeons. The most frequently, they are caused by laparoscopic cholecystectomy which is one of the commonest surgical procedure in the world. Endoscopic techniques are recommended as initial treatment of IBDI. When endoscopic treatment is not effective, surgery is considered. Different surgical biliary reconstructions are performed in most patients in IBDI. Roux-Y hepaticojejunostomy is the commonest biliary reconstruction for IBDI. In some patients with complex IBDI, hepatectomy is required. Recently, Li et al analyzed the factors that had led to hepatectomy for patients with IBDI after laparoscopic cholecystectomy (LC). Authors concluded that hepatectomy might be necessary to manage early or late complications after LC. The study showed that proximal IBDI (involving hepatic confluence) and IBDI associated with vascular injuries were the two independent risk factors of hepatectomy in this series. Authors distinguished two main groups of patients that require liver resection in IBDI: those with an injury-induced liver necrosis necessitating early intervention, and those in whom liver resection is indicated for treatment of liver atrophy following long-term cholangitis. In this commentary, indications for hepatectomy in patients with IBDI are discussed. Complex biliovascular injuries as indications for hepatectomy are presented. Short- and long-term results in patients following liver resection for IBDI are also discussed. Hepatectomy is not a standard procedure in surgical treatment of IBDI, but in some complex injuries it should be considered.

The Association between Carotenoids and Head and Neck Cancer Risk

Head and neck cancer (HNC) includes oral cavity cancer (OCC), pharyngeal cancer (PC), and laryngeal cancer (LC). It is one of the most frequent cancers in the world. Smoking and alcohol consumption are the typical well-known predictors of HNC. Human papillomavirus (HPV) is an increasing etiological factor for oropharyngeal cancer (OPC). Moreover, food and nutrition play an important role in HNC etiology. According to the World Cancer Research Fund and the American Institute for Cancer Research, an intake of non-starchy vegetables and fruits could decrease HNC risk. The carotenoids included in vegetables and fruits are well-known antioxidants which have anti-mutagenic and immune regulatory functions. Numerous studies have shown the relationship between carotenoid intake and a lower HNC risk, but the role of carotenoids in HNC risk is not well defined. The goal of this review is to present the current literature regarding the relationship between various carotenoids and HNC risk.

The influence of nutritional status on the incidence of postoperative complications in patients following distal pancreatectomy

Introduction

Malnutrition is a common problem in hospitalised patients. The immunological, inflammatory, and nutritional status of patients significantly influences the postoperative outcome.

Aim

To assess and analyse the influence of the nutritional status on postoperative complications in patients following distal pancreatectomy.

Material and methods

The analysis included 50 patients operated in a large centre of gastrointestinal surgery. The clinicopathological parameters were analysed, and the nutritional status was assessed. The prognostic nutritional index (PNI) was calculated as 10 × serum albumin (g/dl) + 0.005 × total lymphocyte count (per mm³). The immunological parameters, neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and lymphocyte/monocyte ratio (LMR) were calculated. Patients were divided into two groups according to the presence of early postoperative complications: those without postoperative complications and those with postoperative complications.

Results

Early postoperative complications were observed in 15 (30.0%) patients undergoing distal pancreatectomy. Postoperative pancreatic fistula (POPF) was the most frequent complication noted in 11 (22%) patients. Significantly higher Nutritional Risk Screening (NRS) 2002 (p = 0.005) and lower PNI (median value: 56 vs. 41, p = 0.0003) were noted in patients with postoperative complications. In laboratory results, the significantly lower total lymphocyte count (median value: 2.4 vs. 1.4 per mm³, p = 0.01) and serum level of albumin (median value: 4.7 vs. 3.3 g/dl, p = 0.0003) were noted in the complications group.

Conclusions

Nutritional status significantly influences the incidence of postoperative complications in patients following distal pancreatectomy. Assessment of nutritional status using PNI calculation should be the standard management of patients before surgical treatment.

Total Pancreatectomy with Autologous Islet Cell Transplantation-The Current Indications

Total pancreatectomy is a major complex surgical procedure involving removal of the whole pancreatic parenchyma and duodenum. It leads to lifelong pancreatic exocrine and endocrine insufficiency. The control of surgery-induced diabetes (type 3) requires insulin therapy. Total pancreatectomy with autologous islet transplantation (TPAIT) is performed in order to prevent postoperative diabetes and its serious complications. It is very important whether it is safe and beneficial for patients in terms of postoperative morbidity and mortality, and long-term results including quality of life. Small duct painful chronic pancreatitis (CP) is a primary indication for TPAIT, but currently the indications for this procedure have been extended. They also include hereditary/genetic pancreatitis (HGP), as well as less frequent indications such as benign/borderline pancreatic tumors (intraductal papillary neoplasms, neuroendocrine neoplasms) and “high-risk pancreatic stump”. The use of TPAIT in malignant pancreatic and peripancreatic neoplasms has been reported in the worldwide literature but currently is not a standard but rather a controversial management in these patients. In this review, history, technique, indications, and contraindications, as well as short-term and long-term results of TPAIT, including pediatric patients, are described.

Gastrointestinal image: a true giant transverse colon diverticulum

Giant colonic diverticulum is an extremely rare condition in colonic diverticular disease. More than 90% of giant colonic diverticula are found in the sigmoid colon. Inflammatory and pseudodiverticula are the most frequent. Only one case of a true diverticulum of the transverse colon has been reported in the literature.

CASE REPORT

We report a case of a 22-year-old woman presenting with constipation and meteorism from childhood. A plain abdominal X-ray showed a round radiolucent air-filled cyst. Barium enema revealed a single, large diverticulum of the transverse colon. An extended right hemicolectomy with primary end-to-end anastomosis was performed. The postoperative course was uneventful, and she was discharged in 1 week without any complications. Histopathology showed a true diverticulum containing all layers of the colon.

Association between acute pancreatitis and COVID-19 infection: What do we know?

The disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also called coronavirus disease 2019 (COVID-19), first originated in Wuhan, China, displaying atypical pneumonia-like respiratory symptoms in affected patients. SARS-CoV-2 primarily attacks the respiratory system, and the most common symptoms include cough, shortness of breath, and fever. However, its impact on the digestive system has been shown, and various clinical gastrointestinal manifestations of this disease have been recognized. Some reports have shown acute pancreatitis (AP) as the initial symptom in patients with COVID-19. AP may be a consequence of direct pancreatic damage by the virus because pancreatic acinar cells contain angiotensin-converting enzyme 2 receptor proteins, and SARS-CoV-2 can bind to these receptors, causing pancreatic injury. Moreover, AP may be a secondary indicator of cytokine storms and altered inflammatory responses. Our review of the literature shows that SARS-CoV-2 appears to be a new etiological infectious factor related to AP. In this manuscript, a comprehensive review of case reports and case series of patients with AP and COVID-19 is presented. All reports on COVID-19-associated AP are summarized. All cases are thoroughly analyzed and discussed in-depth.

Nutritional Status and Its Detection in Patients with Inflammatory Bowel Diseases

Malnutrition is an important issue in patients with inflammatory bowel diseases (IBDs) including Crohn's disease (CD) and ulcerative colitis (UC). It is caused by altered digestion and absorption within the small bowel, inadequate food intake, and drug-nutrient interactions in patients. Malnutrition is an essential problem because it is related to an increased risk of infections and poor prognosis in patients. It is known that malnutrition is also related to an increased risk of postsurgery complications in IBD patients. Basic nutritional screening involves anthropometric parameters with body mass index (BMI) and others (fat mass, waist-to-hip ratio, muscle strength), medical history concerning weight loss, and biochemical parameters (including the Prognostic Nutritional Index). Besides standard nutritional screening tools, including the Subjective Global Assessment (SGA), Nutritional Risk Score 2002 (NRS 2002), and Malnutrition Universal Screening Tool (MUST), specific nutritional screening tools are used in IBD patients, such as the Saskatchewan Inflammatory Bowel Disease-Nutrition Risk Tool (SaskIBD-NR Tool and IBD-specific Nutritional Screening Tool). There is a higher risk of nutrient deficiencies (including iron, zinc, magnesium) and vitamin deficiencies (including folic acid, vitamin B12 and D) in IBD patients. Therefore, regular evaluation of nutritional status is important in IBD patients because many of them are undernourished. An association between plasma ghrelin and leptin and nutritional status in IBD patients has been observed. According to some authors, anti-tumor necrosis factor (anti-TNFα) therapy (infliximab) can improve nutritional status in IBD patients. On the other hand, improvement in nutritional status may increase the response rate to infliximab therapy in CD patients. Optimization of nutritional parameters is necessary to improve results of conservative and surgical treatment and to prevent postoperative complications in patients with IBDs. This review presents basic nutritional screening tools, anthropometric and laboratory parameters, dietary risk factors for IBDs, common nutrient deficiencies, associations between anti-TNFα therapy and nutritional status, selected features regarding the influence of nutritional status, and surgical outcome in IBD patients.

Quality-of-life assessment in the treatment of iatrogenic bile duct injuries: hepaticojejunostomy versus end-to-end biliary reconstructions

BACKGROUND

Assessment and comparison of quality of life (QOL) in patients treated for iatrogenic bile duct injuries (IBDI) with Roux-en-Y hepaticojejunostomy (HJ) or end-to-end ductal anastomosis (EE).

METHODS

The Medical Outcomes Study Short Form 36v2 (SF-36v2) Health Survey and the Karnofsky score were used. Comparative analysis of QOL was performed in 41 patients following reconstructive surgery for IBDI between 1990 and 2005: 22 - HJ and 21 - EE.

RESULTS

Seven of eight values were comparable in both analysed groups: role-physical, bodily pain, general health, vitality, social functioning, role-emotional and mental health index. Physical functioning was significantly better in patients following EE (P = 0.04). Physical component summary (P = 0.11) and mental component summary (P = 0.92) in both groups were comparable. QOL according to the Karnofsky scale was comparable in both groups (P = 0.294).

CONCLUSIONS

Physical functioning was significantly better in patients after EE. Other values of QOF according to the SF-36v2 and the Karnofsky score were comparable in both groups.

Nutritional Support in Head and Neck Radiotherapy Patients Considering HPV Status

Malnutrition is a common problem in patients with head and neck cancer (HNC), including oropharyngeal cancer (OPC). It is caused by insufficient food intake due to dysphagia, odynophagia, and a lack of appetite caused by the tumor. It is also secondary to the oncological treatment of the basic disease, such as radiotherapy (RT) and chemoradiotherapy (CRT), as a consequence of mucositis with the dry mouth, loss of taste, and dysphagia. The severe dysphagia leads to a definitive total impossibility of eating through the mouth in 20–30% of patients. These patients usually require enteral nutritional support. Feeding tubes are a commonly used nutritional intervention during radiotherapy, most frequently percutaneous gastrostomy tube. Recently, a novel HPV-related type of OPC has been described. Patients with HPV-associated OPC are different from the HPV− ones. Typical HPV− OPC is associated with smoking and alcohol abuse. Patients with HPV+ OPC are younger and healthy (without comorbidities) at diagnosis compared to HPV− ones. Patients with OPC are at high nutritional risk, and therefore, they require nutritional support in order to improve the treatment results and quality of life. Some authors noted the high incidence of critical weight loss (CWL) in patients with HPV-related OPC. Other authors have observed the increased acute toxicities during oncological treatment in HPV+ OPC patients compared to HPV− ones. The aim of this paper is to review and discuss the indications for nutritional support and the kinds of nutrition, including immunonutrition (IN), in HNC, particularly OPC patients, undergoing RT/CRT, considering HPV status.

A jejunal gastrointestinal stromal tumor with massive gastrointestinal hemorrhage treated by emergency surgery: A case report

BACKGROUND

A jejunal gastrointestinal stromal tumor (GIST) is a rare neoplasm of the gastrointestinal (GI) tract. Massive bleeding due to a jejunal GIST is a diagnostic and therapeutic challenge. It may be a life-threatening GIST complication that requires urgent intervention. Acute GI bleeding, which requires urgent surgical intervention, is a very rare clinical manifestation of GIST. A jejunal GIST with massive hemorrhage with coronavirus disease 2019 in a male patient in older age with many comorbidities has been not reported in the worldwide literature.

METHODS

In this case report, we present an 80-year-old man who was admitted to surgery due to abdominal pain, melena, and hematochezia for several hours. An upper endoscopy and colonoscopy were inconclusive. A multidetector contrast-enhanced computed tomography (CT) of the abdominal and pelvic cavity showed concentric irregular thickening in the distal jejunum.The histopathological finding showed a GIST measuring 6 cm with a mitotic index 2/50 high power fields. The patient's hemodynamic condition deteriorated despite initial conservative treatment including a blood transfusion. Therefore, patient underwent the emergency surgery 24 hours after admission: partial jejunal resection with the tumor followed by primary end-to-end anastomosis.

RESULTS

The mass was removed completely. There were no surgical complications in the postoperative course. On the first postoperative day, a severe acute respiratory syndrome coronavirus 2 polymerase chain reaction test was performed due to a persistent dry cough, which yielded a positive result. After 14 days, the patient died due to pneumonia and circulatory failure.

CONCLUSIONS

This case indicates that jejunal GIST can present as massive lower gastrointestinal bleeding and urgent surgery can successfully stop bleeding and save the patient's life. The CT scan was the most effective investigation to find the source of GI bleeding in this case. Therefore, we suggest performing CT in patients with acute massive lower gastrointestinal bleeding when the source of bleeding is not visible on endoscopy, and urgent surgical jejunal resection to stop life-threatening bleeding caused by a jejunal GIST.

Is endoscopic therapy the treatment of choice in all patients with chronic pancreatitis?

Chronic pancreatitis (CP) is a progressive inflammatory disease of the pancreas characterized by destruction of the pancreatic parenchyma with subsequent fibrosis that leads to pancreatic exocrine and endocrine insufficiency. Abdominal pain and local complications (bile duct or duodenal stenosis and pancreatic tumor) secondary to CP are indications for therapy. At the beginning, medical therapy is used. More invasive treatment is recommended for patients with pancreatic duct stones (PDS) and pancreatic obstruction in whom standard medical therapy is not sufficient. Recently, Clarke et al assessed the long-term effectiveness of endoscopic therapy (ET) in CP patients. The authors compared ET with medical treatment. They reported that ET was clinically successful in 50% of patients with symptomatic CP. In this commentary, current CP treatment, including indications for ET and surgery in CP patients, is discussed. Recommendations for endoscopic treatment of CP according to the European Society of Gastrointestinal Endoscopy Clinical Guidelines are reviewed. Different surgical methods used in the treatment of CP patients are also discussed. ET is the most useful in patients with large PDS, pancreatic duct obstruction and dilation. It should be the first-line option because it is less invasive than surgery. Surgery should be the first-line option in patients in whom ET has failed or in those with a pancreatic mass with suspicion of malignancy. ET is a very effective and less invasive procedure, but it cannot be recommended as the treatment of choice in all CP patients.

Vascular Resection in Pancreatectomy—Is It Safe and Useful for Patients with Advanced Pancreatic Cancer?

Simple Summary

Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease with poor prognosis and increased incidence. Surgical resection R0 remains the most important treatment to prolong survival in PDAC patients. In borderline and locally advanced cancer, vascular resection and reconstruction during pancreatectomy enables achieving R0 resection. This study is a comprehensive review of the literature regarding the role of venous and arterial resection with vascular reconstruction in the treatment of pancreatic cancer.

Abstract

Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease with poor prognosis and increased incidence. Surgical resection R0 remains the most important treatment to prolong survival in PDAC patients. In borderline and locally advanced cancer, vascular resection and reconstruction during pancreatectomy enables achieving R0 resection. This study is a comprehensive review of the literature regarding the role of venous and arterial resection with vascular reconstruction in the treatment of pancreatic cancer. The literature review is focused on the use of venous and arterial resection with immediate vascular reconstruction in pancreaticoduodenectomy. Different types of venous and arterial resections are widely described. Different methods of vascular reconstructions, from primary vessel closure, through end-to-end vascular anastomosis, to interposition grafts with use autologous veins (internal jugular vein, saphenous vein, superficial femoral vein, external or internal iliac veins, inferior mesenteric vein, and left renal vein or gonadal vein), autologous substitute grafts constructed from various parts of parietal peritoneum including falciform ligament, cryopreserved and synthetic allografts. The most attention was given to the most common venous reconstructions, such as end-to-end anastomosis and interposition graft with the use of an autologous vein. Moreover, we presented mortality and morbidity rates as well as vascular patency and survival following pancreatectomy combined with vascular resection reported in cited articles.

Analysis of surgical outcomes in 102 patients with renal cell carcinoma with venous tumor thrombus: A retrospective observational single-center study

The aim of the study was to assess short- and long-term results following radical nephrectomy with renal vein and inferior vena cava thrombectomy in patients with renal cell cancer with venous thrombus and to investigate impact of various demographical, clinical and histological factors on overall survival (OS). The medical records of 102 adult patients with renal cell cancer with venous thrombus admitted for surgery in Department of General, Vascular and Transplant Surgery from 2012 to 2019 were retrospectively analyzed. The tumor was more frequently located on the right side compared to the left one (55 vs. 47). According to Neves Zincke classification, the levels of venous thrombus were as follows: 1 to 48 (47%), 2 to 47 (46%), 3 to 6 (6%), and 4 to 1 (1%). Postoperative complications were noted in 16 (15.7%) patients. One (3%) patient (Neves Zincke 2) died of intraoperative pulmonary embolism during hospitalization. Clear cell carcinoma was the most common pathological type reported in 92 (90.2%) patients. Thirty nine (38.2%) patients were alive at the time of last follow-up. The median OS was 21.50 (0-101.17) months. The 1-year OS was 75.5%. Significantly better OS (median 38.03 months) was noted in patients with RCC Neves Zincke 1 compared to OS (median 14.79 months) in patients with Neves Zincke 2-4 VT (P = .008). Higher tumor staging (T3 vs. T4) (P = .038), nodal staging (N0 vs. N1) (P = .0008), Fuhrman histological grading (G1-2 vs. G3-4) (P = .033) were associated with a shorter OS. Patients with renal cell cancer with venous thrombus, with an acceptable perioperative risk, should be treated surgically, because radical nephrectomy with thrombectomy performed in a high volume surgical center is a safe procedure. Neves Zincke 2-4 venous thrombus, higher tumor and nodal staging, as well higher Fuhrman histological grading are associated with a shorter OS.

Comparison of Selected Immune and Hematological Parameters and Their Impact on Survival in Patients with HPV-Related and HPV-Unrelated Oropharyngeal Cancer

Simple Summary

This is a research article on oropharyngeal cancer (OPC). The aim of the study was to assess and compare basic immune parameters and ratios in patients with Human Papilloma Virus (HPV)+ and HPV− OPC, before and after radiotherapy (RT) or chemoradiotherapy (CRT), and to investigate their impact on overall survival (OS) and disease-free survival (DFS). The higher neutrophil-lymphocyte ratio (NLR) and systemic immune inflammation (SII) are significant adverse prognostic factors for HPV+ OPC patients, because they are significantly associated with both inferior OS and DFS in this group, whereas the higher platelet cells (PLT) count is significant adverse prognostic factor for HPV− OPC patients, because it is significantly associated with inferior OS and DFS in this group. This study confirmed that determination of HPV etiology as well as analysis of various hematological and immune parameters should be a standard management in OPC patients in order to properly treat them for improved prognosis.

Abstract

Several immune and hematological parameters are associated with survival in patients with oropharyngeal cancer (OPC). The aim of the study was to analyze selected immune and hematological parameters of patients with HPV-related (HPV+) and HPV-unrelated (HPV−) OPC, before and after radiotherapy/chemoradiotherapy (RT/CRT) and to assess the impact of these parameters on survival. One hundred twenty seven patients with HPV+ and HPV− OPC, treated with RT alone or concurrent chemoradiotherapy (CRT), were included. Patients were divided according to HPV status. Confirmation of HPV etiology was obtained from FFPE (Formalin-Fixed, Paraffin-Embedded) tissue samples and/or extracellular circulating HPV DNA was determined. The pre-treatment and post-treatment laboratory blood parameters were compared in both groups. The neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), monocyte/lymphocyte ratio (MLR), and systemic immune inflammation (SII) index were calculated. The impact of these parameters on overall (OS) and disease-free (DFS) survival was analyzed. In HPV+ patients, a high pre-treatment white blood cells (WBC) count (>8.33 /mm³), NLR (>2.13), SII (>448.60) significantly correlated with reduced OS, whereas high NLR (>2.29), SII (>462.58) significantly correlated with reduced DFS. A higher pre-treatment NLR and SII were significant poor prognostic factors for both OS and DFS in the HPV+ group. These associations were not apparent in HPV− patients. There are different pre-treatment and post-treatment immune and hematological prognostic factors for OS and DFS in HPV+ and HPV− patients. The immune ratios could be considered valuable biomarkers for risk stratification and differentiation for HPV− and HPV+ OPC patients.

The assessment of serum concentration of adiponectin, leptin and serum carbohydrate antigen-19.9 in patients with pancreatic cancer and chronic pancreatitis

Pancreatic cancer and chronic pancreatitis are still significant diagnostic and clinical problems. The clinical impact of preoperative serum carbohydrate antygen 19-9 (CA 19-9) levels have been disscussed. The aim of this study was a comparative analysis of the concentrations in serum of adipocytokines: adiponectin and leptin and CA 19-9 in patients with pancreatic cancer (PC), chronic pancreatitis (CP) and control group (CG). The study was performed in a group of 90 patients. Group 1 consisted of 30 patients with PC, group 2 consisted of 30 patients with CP. There was no coincidence of pancreatic cancer in CP group. Group 3 (CG) consisted of 30 persons and were recruited among patients operated for cholelithiasis. The serum samples were taken from patients and the concentration of adiponectin, leptin, CA 19-9 and CEA were evaluated. The revealed concentrations levels of the adiponectin were significantly higher in the PC serum samples compared to the CP and CG. There was no significant correlation between increased adiponectin concentration and body fat mass in the PC group. The concentration of leptin was significantly lower in CP serum samples compared to PC and CG. The concentration of leptin was similar in the PC and CG. The concentration of leptin was mainly dependent on body fat mass and fat distribution. Additionally, measurement of waist circumference and body composition was recorded using bioelectrical impedance analysis.

CONCLUSIONS

significantly higher concentration levels of adiponectin in the PC group, independent of body fat mass, may play a potential role as a new tumor marker in PC and might be useful in the differential diagnosis between PC and CP, but this statement needs further investigation. To our knowledge, this was the first study evaluating not only body mass index but also the content and distribution of body fat in patients with PC and CP.