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Background/Aims: At present, benefits of surgical resection and appropriate selection criteria in patients affected by both hepatic and pulmonary metastases of colorectal cancer (CRC) are under discussion. Our analysis focused on a surgical series of such patients and our final aim consisted in identifying potential prognostic factors. Methods: Eighty-five patients undergoing resection of both hepatic and pulmonary metastases at 2 Healthcare Institutions from January 1993 to June 2015 were retrospectively reviewed as concerned clinical information, surgical notes and pathological features. Patient, treatment, and outcome variables were analyzed by use of log-rank tests, Cox regression, and Kaplan-Meier methods. Results: Liver turned out as the first site of metastasis in 75% patients, lung in 13% patients, and both sites in 12% patients. Multiple hepatic metastases were detected in 67% patients and pulmonary metastases in 31% patients. Two hundred eighteen surgical interventions were performed (mean 2.56 for each patient). Overall survival (OS) rates at 3-, 5-, and 10-year follow-up from colorectal resection were 94, 79, and 38% respectively. Median OS was 8.31 years. Survival turned out significantly longer for patients with disease-free interval (DFI) exceeding 1 year between first metastasectomy and diagnosis of second metastases and in patients affected by metachronous pulmonary metastases. Conclusions: Surgical resection of both hepatic and pulmonary metastases of CRC represents a safe and effective treatment. It might lead to rewarding long-term survival rates in high selected patients. Shorter DFIs between first metastasectomy and diagnosis of second metastases can determine worse prognoses. In addition, poor outcomes could be predicted also for patients affected by synchronously detected pulmonary CRC metastases, although further confirmatory analyses are strongly required.

We read with pleasure papers by Cai et al . and Jia et al . published in HepatoBiliary Surgery and Nutrition , 2018, Volume 7, Issue 2 and 4, respectively (1,2). Both papers introduced comprehensive up-to-date literature reviews on indications and patient selection, surgical instruments, techniques, and outcomes of laparoscopic liver resections (LLRs) (1,2).

Background Duodenal stump fistula (DSF) remains one of the most serious complications following subtotal or total gastrectomy, as it endangers patient’s life. DSF is related to high mortality (16–20%) and morbidity (75%) rates. DSF-related morbidity always leads to longer hospitalization times due to medical and surgical complications such as wound infections, intra-abdominal abscesses, intra-abdominal bleeding, acute pancreatitis, acute cholecystitis, severe malnutrition, fluids and electrolytes disorders, diffuse peritonitis, and pneumonia. Our systematic review aimed at improving our understanding of such surgical complication, focusing on nonsurgical and surgical DSF management in patients undergoing gastric resection for gastric cancer. Methods We performed a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines. PubMed/MEDLINE, EMBASE, Scopus, Cochrane Library and Web of Science databases were used to search all related literature. Results The 20 included articles covered an approximately 40 years-study period (1979–2017), with a total 294 patient population. DSF diagnosis occurred between the fifth and tenth postoperative day. Main DSF-related complications were sepsis, abdominal abscess, wound infection, pneumonia, and intra-abdominal bleeding. DSF treatment was divided into four categories: conservative (101 cases), endoscopic (4 cases), percutaneous (82 cases), and surgical (157 cases). Length of hospitalization was 21–39 days, ranging from 1 to 1035 days. Healing time was 19–63 days, ranging from 1 to 1035 days. DSF-related mortality rate recorded 18.7%. Conclusions DSF is a rare but potentially lethal complication after gastrectomy for gastric cancer. Early DSF diagnosis is crucial in reducing DSF-related morbidity and mortality. Conservative and/or endoscopic/percutaneous treatments is/are the first choice. However, if the patient clinical condition worsens, surgery becomes mandatory and duodenostomy appears to be the most effective surgical procedure.

Colonoscopy is one of the most widely used procedures in medical practice for the diagnosis and treatment of many benign and malignant diseases of the colorectal tract. Colonscopy has become the reference procedure for screening and surveillance of colorectal cancer. The overall rate of adverse events is estimated to be about 2.8 per 1,000 procedures, while complications requiring hospitalization are about 1.9 per 1,000 colonoscopies. Mortality from all causes and colonoscopy-specific mortality are estimated to be 0.07 and 0.007%, respectively. An exceptional fearsome postcolonoscopy complication is colon ischemia (CI); only few cases have been reported worldwide. We present the case of a 43-year-old woman who presented to the emergency department complaining of abdominal pain; fever and rectal bleeding appeared 12 h after a voluntary ‘screening’ colonoscopy. She had no risk factors for CI. Her laboratory tests showed alterations in inflammatory markers and a computed tomography scan showed a circumferential thickening in the left colon and free fluid in the abdomen. After 12 h of observation and conservative therapy, the clinical state of the patient worsened with the rising of signs of peritonitis. Laparoscopy showed that colon infarction extended from the distal third of the transverse colon to the proximal rectum. Laparotomy, resection of the pathological colon and terminal colostomy were performed. The specimen examined confirmed an extended ischemic colitis and transmural infarction on the antimesocolic side, in the absence of a vasculitis. The patient underwent recanalization after 8 months. CI after colonoscopy is a rare and alarming complication that must be known and taken into account in the differential diagnosis of symptomatic cases after colonoscopy, particularly in patients with known risk factors. The diagnosis is mainly based on clinical data, imaging and especially endoscopy. Treatment is almost always conservative but, in some cases in which the pathological process appears irreversible, surgery becomes mandatory.

Highlights • Contribute to the comprehension of rare mestatic disease in clear cell renal carcinoma. • Underline that non only primary tumors develop in the gallbladder. • Increasing suspect of metastatic disease in patients with renal cell carcinoma will improve medical care of this patients., Introduction Clear cell renal cell carcinoma (ccRCC) is well known for its propensity to metastasize to unusual sites, even after 10 years. Gallbladder metastases are extremely rare, being found in approximately 0.6% of cases, at autopsy. Case presentation A 51-year-old man with a history of right ccRCC underwent total nephrectomy with extended lymphadenectomy, in another Hospital. Three years later, he was hospitalized at our Hospital, with gallbladder metastasis detected during a follow-up CT scan. At clinical examination, the patient did not present any symptoms or signs of gallbladder disease. Several imaging tests were performed to better characterize the lesion. A successful cholecystectomy and hepatic resection of 4b segment were performed, obtaining a R0 resection. The clinical course was uneventful, without any complications. After a 7-month follow-up, the patient is free from disease. Discussion A typical metastases are those located in a site other than thoracic, skeletal, hepatic, adrenal or encephalic tissue. Cholecystectomy with R0 resection has demonstrated to be the only factor increasing survival, mainly in isolated cases of metastasis, providing an overall 35–60% survival rate at 5 years. Conclusion In the follow-up of patients with a positive history of renal cell carcinoma specially clear cell subtype, all new finding should be taken into account as possible metastases. We ought to consider US and CT-scan behavior of gallbladder metastatic disease in order to orientate our diagnosis. Surgery for metastatic gallbladder disease of renal origin seems to be a feasible therapy which is capable of increasing patients’ overall survival.

In a previous issue of the Journal, Zhong et al. reported a retrospective study that compared the perioperative outcomes of the mesh-reinforced pancreaticojejunostomy with conventional pancreaticojejunostomy. They concluded that mesh-reinforced pancreaticojejunostomy was a safe and effective technique, as it provided a safe anchor site for suture, thus reducing the risk of pancreatic leakage. Considering these encouraging results, we present a further simple technique using ligamentum teres hepatis wrap around pancreatojejunostomy for prevention of postoperative pancreatic fistula after pancreaticoduodenectomy.

Solid pseudopapillary neoplasm (SPN) is an extremely rare pancreatic epithelial neoplasm with low malignancy that affects mainly young females. It is characterized by a good prognosis, even in the presence of metastases. SPNs have a particular avidity for 18F-fluorodeoxyglucose (18F-FDG). Nonetheless, there are very few papers in the literature on the use of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F- FDG PET/CT) in the diagnosis and staging of SPNs. A 23-year-old woman presented to our attention with gastric outlet obstruction due to a bulky solid pseudopapillary neoplasm of the pancreatic head. A 18F-FDG PET/CT showed a marked 18F-FDG uptake at the pancreatic head with no abnormal metabolic activity in other abdominal organs. Given the particular avidity for 18F-FDG, SPNs can be easily recognized on 18F-FDG PET/CT. However, this exam is not useful in differentiating this neoplasm from other malignant pancreatic solid lesions, but it could give a contribution to the staging by the ability to identify potential metastases or recurrences.

Background Perivascular epithelioid cell tumor (PEComa) is a rare mesenchymal tumor, with distinctive morphology and expression of myo-melanocytic markers. Current scientific literature reported just 24 cases of pancreatic PEComas. With our systematic review, we aimed at improving our understanding of the disease, focusing on the knowledge gained on epidemiology, etiology, clinical presentation, diagnosis, treatment and prognosis. Methods Based on the PRISMA guidelines, a systematic research was carried out on PubMed/MEDLINE, Web of Science, Scopus, EMBASE, and EBSCO using the search terms: (“perivascular epithelioid cell tumor” OR ″PEComa”) and (“pancreas “OR″ pancreatic”). Results The 4th-6th decades of life and female sex (86.9%) turned out as the most affected. Pancreatic head was the most involved site (50%), with a single lesion in almost all cases. The diagnosis was only obtained after histopathological examination (70.8%). The clinical presentation was non-specific, abdominal pain being the main symptom (60.9%). At immunohistochemistry, PEComa showed benign epithelioid predominance and a strong positivity for HMB-45, Melan-A, and α-SMA. Surgical resection was performed in almost all cases, while for one patient the multidisciplinary group chose just endoscopic and imaging follow-up, based on the benign nature of the lesion. Conclusions The biological characteristics of pancreatic PEComa remain an enigma. Its prognosis seems to depend on whether atypical (“worrisome”) histological features are available or not. Surgery turned out as the most appropriate treatment, without reaching any agreement on surgery timing. Further studies on larger population are needed to better understand the biological features of pancreatic PEComa, in order to set up guidelines in the diagnosis, treatment and follow-up.

Duodenal stump fistula (DSF) remains one of the most serious complications following subtotal or total gastrectomy, as it endangers patient's life. DSF is related to high mortality (16-20%) and morbidity (75%) rates. DSF-related morbidity always leads to longer hospitalization times due to medical and surgical complications such as wound infections, intra-abdominal abscesses, intra-abdominal bleeding, acute pancreatitis, acute cholecystitis, severe malnutrition, fluids and electrolytes disorders, diffuse peritonitis, and pneumonia. Our systematic review aimed at improving our understanding of such surgical complication, focusing on nonsurgical and surgical DSF management in patients undergoing gastric resection for gastric cancer.We performed a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines. PubMed/MEDLINE, EMBASE, Scopus, Cochrane Library and Web of Science databases were used to search all related literature.The 20 included articles covered an approximately 40 years-study period (1979-2017), with a total 294 patient population. DSF diagnosis occurred between the fifth and tenth postoperative day. Main DSF-related complications were sepsis, abdominal abscess, wound infection, pneumonia, and intra-abdominal bleeding. DSF treatment was divided into four categories: conservative (101 cases), endoscopic (4 cases), percutaneous (82 cases), and surgical (157 cases). Length of hospitalization was 21-39 days, ranging from 1 to 1035 days. Healing time was 19-63 days, ranging from 1 to 1035 days. DSF-related mortality rate recorded 18.7%.DSF is a rare but potentially lethal complication after gastrectomy for gastric cancer. Early DSF diagnosis is crucial in reducing DSF-related morbidity and mortality. Conservative and/or endoscopic/percutaneous treatments is/are the first choice. However, if the patient clinical condition worsens, surgery becomes mandatory and duodenostomy appears to be the most effective surgical procedure.

BACKGROUND: Morbidity following pancreatectomy is commonly due to leakage of exocrine secretions resulting in abscess or pancreatic fistula (PF). Previously, we authored a double-blind randomized controlled trial demonstrating perioperative pasireotide administration lowers abscess or PF formation by over 50%. Accordingly, we adopted pasireotide usage as standard practice following pancreatectomy in October 2014 and hypothesized a similar PF/abscess rate reduction would be observed. STUDY DESIGN: A prospectively maintained database was queried for all patients who underwent pancreatectomy between October 2014 and July 2017. Pasireotide was administered preoperatively and twice daily for 7 days postoperatively or until discharge. The primary outcome was clinically-relevant PF/abscess requiring procedural intervention, identical to the prior trial outcome. Logistic regression was utilized to compare outcomes to the placebo arm of the prior randomized trial and to control known PF risk factors. RESULTS: During the 34-month study period, 652 patients underwent pancreatectomy (211 distal pancreatectomy, 441 pancreaticoduodenectomy). Compared to the historical placebo group (N=148), the observational group had an increased prevalence of higher ASA scores (69% vs. 54%, p

Renal cell carcinoma (RCC) represents 2% of all cancers, being the clear cell subtype the most common among renal tumors (70-80%). RCC is well know for its capacity to metastasize in an early stage of the disease, gallbladder metastases are consider extremly rare. The symptomatology goes from asymptomatic to cholecystitis like-symptoms. Ultrasonography, may be often, the first diagnostic tool, tumors can appear under different hyperechoic masses without acoustic shadowing. Metastasectomy has gained a wide consensus because of the possibility of extending survival, keeping in mind the importance of selection of the ideal candidate for it. The surgical procedure will be chosen upon the extent of the disease, it may go from a simple cholecystectomy to a cholecystectomy associated with a wedge/right hepatic lobectomy for curative purposes.

Background: Primary abdominal pregnancies are potentially life-threatening, particularly without an accurate preoperative diagnosis. Case: A 41-year-old woman presented to the emergency room with 2 days-lasting left upper quadrant abdominal pain, irradiated to the left shoulder. An urine b-human chorionic gonadotropin test was positive. Transvaginal sonography raised a suspicion of ectopic pregnancy. The patient was then submitted to abdominal laparoscopy that revealed no sign of active bleeding or ectopic pregnancy. Because of worsening of abdominal pain and progressive anaemia, the patient underwent abdominal ultrasound and multislice computerized tomography scan (TC) that showed the presence of a mass at the superior splenic pole with haemoperitoneum. The patient was taken to the operating room and submitted to a laparoscopic total splenectomy. The post-operative course was uneventful, and the patient was discharged 8 days after intervention. Conclusion: Abdominal pregnancy should be considered in the differential diagnosis of acute abdomen in women of reproductive age. Abdominal ultrasound and computerized tomography studies must be performed before operative treatment if an ectopic pregnancy is suspected and no intrauterine gestational sac could be showed on transvaginal sonography.

Endoscopic removal of sharp and pointed foreign bodies in the upper gastrointestinal tract still poses technical difficulties. Overtubes may be uncomfortable to the patients and only objects fitting within a lumen of about 11-15 mm can be removed. We present here our preliminary experience with a commercially available new endoscopic end protector hood having the unique characteristic of maintaining its bell portion inverted during the progression of the scope through the gut and flipping back to its original shape during withdrawal through the lower esophageal sphincter. This prevents exposure of the esophageal and pharyngeal wall to injuries from the edges of the foreign body. We used this device to remove nine large sharp or pointed gastroesophageal foreign bodies in six consecutive patients in whom conventional techniques were considered unsafe or not technically feasible owing to the size and shape of the objects. In all cases, removal was successful and easily performed without bowel damage. We believe that this device enhances the safe removal of a wide variety of potentially dangerous gastroesophageal foreign bodies.