Clinical relevant pancreatic fistula after pancreatoduodenectomy: when negative amylase levels tell the truth

Drain Amylase level are routinely determined to diagnose pancreatic fistula after Pancreatocoduodenectomy. Consensus is lacking regarding the cut-off value of amylase to diagnosis clinically relevant postoperative pancreatic fistulae (POPF). The present study proposes a model based on Amylase Value in the Drain (AVD) measured in the first three postoperative days to predict a POPF. Amylase cut-offs were selected from a previous published systematic review and the accuracy were validated in a multicentre database from 12 centres in 2 countries. The present study defined POPF the 2016 ISGPS criteria (3 times the upper limit of normal serum amylase). A learning machine method was used to correlate AVD with the diagnosis of POPF. Overall, 454 (27%) of 1638 patients developed POPF. Machine learning excluded a clinically relevant postoperative pancreatic fistulae with an AUC of 0.962 (95% CI 0.940-0.984) in the first five postoperative days. An AVD at a cut-off of 270 U/L in 2 days in the first three postoperative days excluded a POPF with an AUC of 0.869 (CI 0.81-0.90, p < 0.0001). A single AVD in the first three postoperative days may not exclude POPF after pancreatoduodenectomy. The levels should be monitored until day 3 and have two negative values before removing the drain. In the group with a positive level, the drain should be kept in and AVD monitored until postoperative day five.

[Intestinal perforation due to accidental ingestion of foreign bodies]

Usually the ingested foreign bodies (IFB) pass the gastrointestinal tract making no lesions. Sometimes IFB could lead to a gastrointestinal perforation. The most frequently perforating IFB are chicken or fish bones and toothpicks, while risks factors are mental retardation, alcohol or drug abuse, denture usage, quick eating or habitual chewing of toothpicks. The accidentally ingestion in a high risk patient with unclear symptoms, added to a low sensitive diagnostic imaging, lead to intraoperative diagnosis in one half cases of gastrointestinal perforation by IFB. Furthermore the surgical treatment range between the less minimal invasive laparoscopic IFB extraction and intraabdominal hole suture to a laparotomic bowel or colic resection. Herein we describe our experience in 3 cases of gastrointestinal perforation by IFB have been diagnosed at surgery and treated by IFB extraction and hole suture (in 2 patients; 1 laparoscopy, 1 laparotomy) or open right emicolectomy (1 patient).

[The importance of using the cerebral function monitor (CFM) in the neurological prognosis of neonates in intensive care]

Cerebral function monitor (CFM), unlike traditional EEG, allows a long-term evaluation of electric brain activity, without interfering with the nursing of the newborn in the intensive care unit. Our aim was to evaluate the prognostic value of CFM for neurological outcome. We studied 102 newborns (gestational age 34.5 +/- 4.36 weeks; weight 1980 +/- 720 grams) by Multitrace CFM (Lectromed) 5 hours daily in the first week following admission. The patients also underwent cerebral echography, EEG and neurological follow-up to the 24th month. CFM was found to correlate well with the EEG recorded 3 months later. The persistence for at least one week of an I.C. tracing or the normalization of initial tracing have a good prognostic value (positive predictive value 95.23%), a persistently pathologic registration has a negative prognostic value (negative predictive value 85.18%), that even increases if cerebral echographic alterations are demonstrated (98.57%). The association of CFM and ultrasound abnormalities determines a relative risk for neurological motor impairment of 69.14, whereas CFM alone gives a relative risk of 6.4.

[Paraesophageal hiatal hernia]

Paraesophageal hiatal hernia is an uncommon disease but it frequently presents in aged people, causing chronic vague abdominal symptoms up to surgical emergencies from incarceration, strangulation or obstruction. The authors describe the physiopathology and clinical anatomical features of paraesophageal hiatal hernia. Important diagnostic radiological and instrumental aspects are then illustrated, versus sliding esophageal hiatal hernia. There are followed by a description of possible complications of this lesion and therapeutic implications.

[Postoperative complications after thyroid surgery. Review of the literature and personal experience]

The authors make a review of the literature on the complications which occur after thyroidectomy. They report, moreover, a study carried out on 192 thyroidectomy performed between January 1992 and May 1995. The surgical technique employed foresees the systematic search for and saving of laryngeal nerves fibers and the parathyroid gland. Results were the incidence of postoperative hypocalcemia and of permanent hypocalcemia. The authors also analyse problems related to laryngeal nerves in matters of thyroid surgery. After a short introduction on surgical anatomy, attention is drawn to the "recurrent nerve risk" but also the superior laryngeal nerve too, often injured with modifications of the vocal tone and serious consequences for particular professional groups.

[Postoperative pain control]

Pain was and in part still is a constant feature of surgical practice: before, during and after surgery. To start with painful symptoms represent a fundamental diagnostic element, given that in over 60% of cases pain is the primary indication for surgery. During the operation, pain used to constitute the main impediment to the surgeon's activities, until the introduction of ether and the birth of modern anesthesia. Lastly, the postoperative period is also painful so much so that whereas until fifty years ago patients were above all afraid of the operation, patients nowadays are concerned about the pain during the days after the operation. Moreover, over 50% of patients undergoing surgery are unsatisfied with the treatment of postoperative pain, in spite of the fact that drugs are available which enable us to control it. The authors studied the quality of postoperative analgesia in 357 patients, who received treatment with ketorolac tromethamine 30 mg i.v. on leaving the operating theatre, and subsequently i.m. every 8 hours starting from 3 hours after surgery. The use of ketorolac tromethanine demonstrated effective analgesia and was well accepted by patients, without revealing any particular collateral effects.

[Role of dietary prevention in newborns at risk for atopy. Results of a follow-up study]

The Authors have studied the role of various preventing diet for a primary prophylaxis of allergy in 125 newborns at risk of atopy: 30 exclusively breast-fed, 50 hypoallergenic milk fed, 30 soy milk fed, and 15 with conventional milk formula. IgE values were determined at 5 days, 6 months, and 12 months of age, IgE values at 5 days were compared to newborns not at atopic risk. The clinical follow-up lasted 4 years. Total IgE values at 5 days were significantly higher in new-born at atopic risk. Only breast-feeding subjects had IgE normal values at six months. Allergic symptoms were observed in 14% of infants with a guided diet and in 53% of infants with a conventional diet. Breast fed subjects had atopic disorders in only 8% of cases, subjects with hypoallergenic formula in 12% while soja milk fed in 25%. The Authors stress the role of breast feeding in preventing allergic disorders in subjects at atopic risk or, when human milk misses, of a hypoallergenic formula, more than soy milk and conventional formula and confirm the possibility of diet and ambiental prophylaxis of allergy.

[Acute abdomen caused by the rupture of a solitary non-parasitic cyst of the liver]

A rare case of acute abdomen caused by the rupture of a solitary, non-parasitic cyst of the liver is reported. Considering the rarity of the event, it was considered interesting to examine the anatomo-pathological, clinical and diagnostic aspects as well as the various surgical and other treatment possibilities for these conditions. Stress is also laid on the fact that surgical treatment is only indicated in the case of complications, while in uncomplicated forms the treatment of choice of alcoholisation.