Meso-pancreatectomy for pancreatic neuroendocrine tumor

Diabetes Mellitus Secondary to Endocrine Diseases: An Update of Diagnostic and Treatment Particularities

Secondary diabetes mellitus is frequently ignored in specialized literature. In this narrative review, the main endocrinopathies accompanied by increased glycemic values are identified, as well as the mechanisms by which the excess or deficiency of certain hormones impact beta cell function or insulin resistance. The main endocrinopathies (acromegaly, Cushing's syndrome, Basedow-Graves' disease, pheochromocytoma, somatostatinoma and glucagonoma) and their characteristics are described along with the impact of hormone changes on blood sugar, body mass index and other parameters associated with diabetes. The overall information regarding the complex molecular mechanisms that cause the risk of secondary diabetes and metabolic syndrome is of crucial importance in order to prevent the development of the disease and its complications and particularly to reduce the cardiovascular risk of these patients. The purpose of this study is to highlight the particular features of endocrine pathologies accompanied by an increased risk of developing diabetes, in the context of personalized therapeutic decision making. The epidemiological, physiopathological, clinical and therapeutic approaches are presented along with the importance of screening for diabetes in endocrine diseases.

Application of Somatostatin, Chemotherapy Combined with TAE in Heterogeneous Glucagonoma Presented with Necrolytic Migratory Erythema

Glucagonoma, a rare neuroendocrine tumor of the pancreas, which is often misdiagnosed because of non-characteristic clinical manifestations. In addition, the treatment has not been well established for this disease so far. We here report a case of glucagonoma previous misdiagnosed as recurrent erythema. In this case, necrolytic migratory erythema was the main clinical manifestation, and he received surgical resection after admission although with liver metastasis. Postoperative pathological results showed that the heterogeneity of proliferative index in primary (Ki-67: 5~10%) and metastatic (Ki-67: 25~30%) tumors were obviously observed. One month postoperatively, abdominal CT and MRI showed multiple liver metastasis (type III) again. Interestingly, the skin rash was obviously improved after treatment with somatostatin combined with chemotherapy (octreotide, temozolomide and capecitabine). Subsequently, the patient received transarterial embolization (TAE). Up to now, no progression was noted for liver metastasis. Due to its rarity, clinical diagnosis is challenging; thus, further understanding of the disease by clinicians is helpful for early diagnosis and treatment, so as to improve the prognosis of patients.

Spleen-preserving distal pancreatectomy and lymphadenectomy for glucagonoma syndrome: A case report

RATIONALE

Glucagonoma is a rare type of functional pancreatic neuroendocrine tumor that is characterized by distinctive clinical manifestations; among these, necrolytic migratory erythema represents the hallmark clinical sign of glucagonoma syndrome and is usually presented as the initial complaint of patients.

PATIENT CONCERNS

A 30-year-old male patient was admitted to our hospital with a complaint of diffuse erythematous ulcerating skin rash for more than 10 months. He also complained of hyperglycemia and a weight loss of 15 kg in those months.

DIAGNOSIS

This patient underwent a contrast-enhanced computed tomography scan which showed a pancreatic body mass measuring approximately 6 cm with low density accompanied by partial calcification in plain scanning images and uneven enhancement in strengthening periods. In addition, laboratory tests indicated elevated fasting blood glucagon (1109 pg/mL, normal range: 50-150 pg/mL) levels. Glucagonoma syndrome was ultimately diagnosed in clinical.

INTERVENTION

Spleen-preserving distal pancreatectomy was conducted and postoperative pathology revealed the presence of glucagonoma.

OUTCOMES

The patient recovered uneventfully with the glucagonoma syndrome disappeared soon after surgery, and the postoperative plasma glucagon decreased to a normal level. Follow-up showed no recurrence for 5 years since the surgery.

LESSONS

The treatment of glucagonoma should be directed according to the stage at which the disease is diagnosed. Surgery is currently the only method available to cure the tumor, although medications are given to patients who present with advanced glucagonoma and who are not candidates for operation. Multidisciplinary therapy and multimodality treatment are advised, although these have been systematically evaluated to a lesser degree.

Excellence and safety in surgery require excellent and safe tutoring

The surgical education in Italy has always been a very important issue. The aim of this article is to bring together the feedback of the definitions of the various components of the learning scheme and to evaluate the importance of the legal point.

In March 2016 we performed a literature review. We have also examinated the internet pages of the Italian Department of Education, Health and Medical Order.

In Italy the tutor had an unclear role from a legal point of view. He is the person who must be able to perform a specific procedure with expert technical and who must know how to stop the student if this is about to perform a dangerous maneuver. In Italy the ability to work for the trainee is limited in all reality, it depends on several factors including the increase of numbers of medical-legal disputes, the timing, the commitment it requires mentoring and a lack of mentors.

Conclusion: In surgery, the problem is greater because of the increasingly of medico-legal implications that we are after surgical procedure. It would be necessary to define a role of the tutor in a regular protocol and a proper assessment of his performance.

Use of a simplified consent form to facilitate patient understanding of informed consent for laparoscopic cholecystectomy

Background

Surgical informed consent forms can be complicated for patients to read and understand. We created a consent form with key information presented in bulleted texts and diagrams combined in a graphical format to facilitate the understanding of information during the verbal consent discussion.

Methods

This prospective, randomized study involved 70 adult patients awaiting cholecystectomy for gallstones. Consent was obtained after standard verbal explanation using either a graphically formatted (study group, n=33) or a standard text document (control group, n=37). Comprehension was evaluated with a 9-item multiple-choice questionnaire administered before surgery and factors affecting comprehension were analyzed.

Results

Comparison of questionnaire scores showed no effect of age, sex, time between consent and surgery, or document format on understanding of informed consent. Educational level was the only predictor of comprehension.

Conclusions

Simplified surgical consent documents meet the goals of health literacy and informed consent. Educational level appears to be a strong predictor of understanding.

The learning curve of laparoscopic holecystectomy in general surgery resident training: old age of the patient may be a risk factor?

A well-designed learning curve is essential for the acquisition of laparoscopic skills: but, are there risk factors that can derail the surgical method? From a review of the current literature on the learning curve in laparoscopic surgery, we identified learning curve components in video laparoscopic cholecystectomy; we suggest a learning curve model that can be applied to assess the progress of general surgical residents as they learn and master the stages of video laparoscopic cholecystectomy regardless of type of patient.

Electronic databases were interrogated to better define the terms “surgeon”, “specialized surgeon”, and “specialist surgeon”; we surveyed the literature on surgical residency programs outside Italy to identify learning curve components, influential factors, the importance of tutoring, and the role of reference centers in residency education in surgery. From the definition of acceptable error, self-efficacy, and error classification, we devised a learning curve model that may be applied to training surgical residents in video laparoscopic cholecystectomy.

Based on the criteria culled from the literature, the three surgeon categories (general, specialized, and specialist) are distinguished by years of experience, case volume, and error rate; the patients were distinguished for years and characteristics. The training model was constructed as a series of key learning steps in video laparoscopic cholecystectomy. Potential errors were identified and the difficulty of each step was graded using operation-specific characteristics. On completion of each procedure, error checklist scores on procedure-specific performance are tallied to track the learning curve and obtain performance indices of measurement that chart the trainee’s progress.

Conclusions. The concept of the learning curve in general surgery is disputed. The use of learning steps may enable the resident surgical trainee to acquire video laparoscopic cholecystectomy skills proportional to the instructor’s ability, the trainee’s own skills, and the safety of the surgical environment. There were no patient characteristics that can derail the methods. With this training scheme, resident trainees may be provided the opportunity to develop their intrinsic capabilities without the loss of basic technical skills.

Self-gripping mesh versus fibrin glue fixation in laparoscopic inguinal hernia repair: a randomized prospective clinical trial in young and elderly patients

Laparoscopic transabdominal preperitoneal inguinal hernia repair is a safe and effective technique. In this study we tested the hypothesis that self-gripping mesh used with the laparoscopic approach is comparable to polypropylene mesh in terms of perioperative complications, against a lower overall cost of the procedure. We carried out a prospective randomized trial comparing a group of 30 patients who underwent laparoscopic inguinal hernia repair with self-gripping mesh versus a group of 30 patients who received polypropylene mesh with fibrin glue fixation. There were no statistically significant differences between the two groups with regard to intraoperative variables, early or late intraoperative complications, chronic pain or recurrence. Self-gripping mesh in transabdominal hernia repair was found to be a valid alternative to polypropylene mesh in terms of complications, recurrence and postoperative pain. The cost analysis and comparability of outcomes support the preferential use of self-gripping mesh.

Learning curve for endorectal ultrasound in young and elderly: lights and shades

Aim of the study is to highlight difficulties faced by an inexperienced surgeon in approaching endorectal-ultrasound, trying to define when learning curve can be considered complete. A prospective analysis was conducted on endorectal-ultrasound performed for subperitoneal rectal adenocarcinoma staging in the period from January 2008 to July 2013, reported by a single surgeon of Department of Oncology, Section of General Surgery, "San Luigi Gonzaga" Teaching Hospital, Orbassano (Turin, Italy); the surgeon had no previous experience in endorectal-ultrasound. Fourty-six endorectal-ultrasounds were divided into two groups: early group (composed by 23 endorectal-ultrasounds, made from January 2008 to May 2009) and late group (composed by 23 endorectal-ultrasound, carried out from June 2009 to July 2013). In our experience, the importance of a learning curve is evident for T staging, but no statystical significance is reached for results deal with N stage. We can conclude that ultrasound evaluation of anorectal and perirectal tissues is technically challenging and requires a long learning curve. Our learning curve can not be closed down, at least for N parameter.

Laparoscopic perspectives for distal biliary obstruction

BACKGROUND

In patients affected by distal biliary obstruction deemed unsuitable for pancreatoduodenectomy, biliary diversion is the only proposable option. Defined goals of this treatment are: relief from jaundice preventing its related complications, reduction of in-hospital stay and adequate control of pain. Palliation can be obtained either by surgical or conservative procedures (endoscopic stenting or percutaneous treatment). Considering early complications' incidence, surgical approach has always been reserved for low surgical risk patients with longer survival perspectives, while recently developed long-lasting patency stents enlarged mini-invasive application resort. Comparative studies on these therapeutic options favour the conservative one in respect of conventional open surgery, but data on minimally invasive surgery to pursue palliative aims are lacking. We present our six-years casuistic and results referring to laparoscopic biliary diversions.

METHODS

We analyzed results obtained in distal biliary neoplastic obstruction management between December 2008 and November 2014. During this period, selected patients considered unsuitable for pancreatoduodenectomy were scheduled to receive a laparoscopic biliary decompression. Perioperative variables and 30-days postoperative outcomes have been prospectively collected.

RESULTS

In the six-years period, 12 patients affected by distal biliary neoplastic obstruction were submitted to laparoscopic palliative bypass. Four procedures were proposed for distal biliary cancer, one for advanced periampullary cancer and seven for pancreatic head cancer. Ten hepatico-jejunal bypasses and two choledochoduodenostomies have been performed. No conversions to open surgery were encountered in this series. Main operative time was 85 min, main blood loss was 75 ml and main hospitalization was 4.5 days. According to Clavien Dindo Classification one class II and one class IIIb complications occurred.

CONCLUSIONS

Although the restricted number of patients, our results suggest that laparoscopic biliary bypass could be a valid option in managing distal biliary obstructions, resulting in low perioperative morbidity, effective long term palliation of symptoms and improved quality of life.