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(1) Background: The jejunum is primarily used for distal pancreatic stump anastomoses after central pancreatectomy (CP). The study aimed to compare duct-to-mucosa (WJ) and distal pancreatic invagination into jejunum anastomoses (PJ) after CP. (2) Methods: All patients with CP and jejunal anastomoses (between 1 January 2002 and 31 December 2022) were retrospectively assessed and compared. (3) Results: 29 CP were analyzed: WJ—12 patients (41.4%) and PJ—17 patients (58.6%). The operative time was significantly higher in the WJ vs. PJ group of patients (195 min vs. 140 min, p = 0.012). Statistically higher rates of patients within the high-risk fistula group were observed in the PJ vs. WJ group (52.9% vs. 0%, p = 0.003). However, no differences were observed between the groups regarding the overall, severe, and specific postpancreatectomy morbidity rates (p values ≥ 0.170). (4) Conclusions: The WJ and PJ anastomoses after CP were comparable in terms of morbidity rates. However, a PJ anastomosis appeared to fit better for patients with high-risk fistula scores. Thus, a personalized, patient-adapted technique for the distal pancreatic stump anastomosis with the jejunum after CP should be considered. At the same time, future research should explore gastric anastomoses’ emerging role.

From a technical point of view, enucleation can be challenging for a few locations with hard access, such as the posterior pancreatic head, particularly for deeply-located lesions, in close relationship with the main pancreatic duct (MPD). The risk of MPD injuries with secondary pancreatic fistula is high in these specific situations. Hereby we describe a technique of posterior pancreatic head enucleation in a 48-year-old male patient diagnosed with a deeply-located branch duct type intraductal papillary mucinous neoplasm (BD-IPMN). A posterior pancreatic head enucleation of the BD-IPMN was performed along with segmental resection of the MPD and end-to-end anastomosis, with protection by a plastic stent passing both through the MPD anastomosis and major duodenal papilla. No protective pancreatico-jejunostomy was necessary. A grade B pancreatic fistula complicated the postoperative course, and a grade A delayed gastric emptying, both conservatively managed. Enucleation of deeply-located tumors at the dorsal pancreatic head is challenging but feasible and safe. Segmental resection of the MPD with end-to-end anastomosis protected by a transpapillary plastic stent for injuries during enucleation can be safely performed. Thus, the operative time during enucleation is reduced, and the potential morbidity of a pancreaticojejunostomy is eliminated.

Purpose Incidence, risk factors, and clinical consequences of pancreatic fistula (POPF) after D1+/D2 radical gastrectomy have not been well investigated in Western patients, particularly those from Eastern Europe. Materials and Methods A total of 358 D1+/D2 radical gastrectomies were performed by surgeons with high caseloads in a single surgical center from 2002 to 2017. A retrospective analysis of data that were prospectively gathered in an electronic database was performed. POPF was defined and graded according to the International Study Group for Pancreatic Surgery (ISGPS) criteria. Uni- and multivariate analyses were performed to identify potential predictors of POPF. Additionally, the impact of POPF on early complications and long-term outcomes were investigated. Results POPF was observed in 20 patients (5.6%), according to the updated ISGPS grading system. Cardiovascular comorbidities emerged as the single independent predictor of POPF formation (risk ratio, 3.051; 95% confidence interval, 1.161-8.019; P=0.024). POPF occurrence was associated with statistically significant increased rates of postoperative hemorrhage requiring re-laparotomy (P=0.029), anastomotic leak (P=0.002), 90-day mortality (P=0.036), and prolonged hospital stay (P

AIM To identify risk factors for clinically relevant complications after spleen-preserving distal pancreatectomy (SPDP). No previous studies explored potential predictors of morbidity after SPDP. METHODS The data of 41 patients who underwent a SPDP in a single surgical center between 2000 and 2015 were retrospectively reviewed from a prospectively maintained electronic database established in our Department of Surgery. The database included demographic, clinical, bioumoral, pathological, intraoperative and postoperative parameters. Uni- and multivariate analyses were performed to assess potential predictors of clinically relevant morbidity. Postoperative morbidity was defined as in-hospital complications and mortality was assessed at 90 d. Clinically relevant morbidity was defined as complication ≥ grade 2 Dindo. RESULTS Overall morbidity rate was 34.1% (14 patients): grade I (6 patients, 14.6%), grade II (2 patients, 4.8%), grade IIIa (1 patient, 2.4%), and grade IIIb (5 patients, 12.2%). A number of 5 patients (12.2%) required re-laparotomy for postoperative complications. There was no postoperative mortality. Thus, at least one clinically relevant complication occurred in 8 patients (19.5%). Univariate analysis identified male gender (P = 0.034), increased body mass index (P = 0.002) and neuroendocrine pathology (P = 0.013) as statistically significant risk factors. Multivariate analysis identified male gender [odds ratio (OR): 1.29, 95%CI: 1.07-1.55, P = 0.005] and increased body mass index (OR: 23.18, 95%CI: 1.72-310.96, P = 0.018) as the only independent risk factors of clinically relevant morbidity after SPDP. CONCLUSION Male gender and increased body mass index are independently associated with increased risk of clinically relevant morbidity after SPDP. These findings may assist a surgeon in clinical decision-making to better select patients suitable for SPDP.

This study is aimed at investigating tumoral and inflammatory cells and the significance of the prognostic factors of pancreatic ductal adenocarcinoma (PDAC); it is also aimed at determining the role of immunohistochemistry in the diagnosis and prognosis of this neoplasm. Materials and Methods. 230 cases of pancreatic ductal adenocarcinoma were included in the study group; these cases were selected from the archives of the Department of Pathology of the Fundeni Clinical Institute over a ten-year period. Immunohistochemistry was performed using the following antibodies: MUC 1, CD 34, Factor VIII, CD 68, MMP-7, CEA, p21, p53, and Ki 67. Results. There were 133 male (57.8%) and 97 female (42.2%) patients included in this study, with ages between 20 and 81 years old (mean age: 58.2 years) and with tumors located in the pancreatic head ( n = 196 ; 85.2%), pancreatic body ( n = 12 ; 5.2%), and pancreatic tail ( n = 20 , 8.7%), as well as panpancreatic tumors ( n = 2 ; 0.9%). Patients presented with early stages (IA and IB), with low pathologic grade (G1), with small size tumors (less than 1-1.5 cm), with tumors located in the head of the pancreas, (p53: negative; p21: positive; and CD 68: positive in peritumoral tissue), with low nuclear index ( Ki 67 < 10 % ), without metastases at the time of surgery (had a better prognosis), and with a survival rate of about 7 months. Conclusions. Immunohistochemistry is useful for an accurate diagnosis, differential diagnosis, and establishment of additional factors that might have a prognostic importance. It is recommended to study peritumoral tissue from the quantitative and qualitative points of view to increase the number of prognostic factors. This study represents a multidisciplinary approach, and it is a result of teamwork; it presents histopathological methods of examination of this severe illness and describes only a part of the scientific effort to determine the main pathological mechanisms of this neoplasm.

Background The aim of the study was to evaluate the current opinion and clinical decision-making process of international pancreatologists, and to systematically identify key study questions regarding the diagnosis and treatment of chronic pancreatitis (CP) for future research. Methods An online survey, including questions regarding the diagnosis and treatment of CP and several controversial clinical case vignettes, was send by e-mail to members of various international pancreatic associations: IHPBA, APA, EPC, ESGE and DPSG. Results A total of 288 pancreatologists, 56% surgeons and 44% gastroenterologists, from at least 47 countries, participated in the survey. About half (48%) of the specialists used a classification tool for the diagnosis of CP, including the Mayo Clinic (28%), Mannheim (25%), or Buchler (25%) tools. Overall, CT was the preferred imaging modality for evaluation of an enlarged pancreatic head (59%), pseudocyst (55%), calcifications (75%), and peripancreatic fat infiltration (68%). MRI was preferred for assessment of main pancreatic duct (MPD) abnormalities (60%). Total pancreatectomy with auto-islet transplantation was the preferred treatment in patients with parenchymal calcifications without MPD abnormalities and in patients with refractory pain despite maximal medical, endoscopic, and surgical treatment. In patients with an enlarged pancreatic head, 58% preferred initial surgery (PPPD) versus 42% initial endoscopy. In patients with a dilated MPD and intraductal stones 56% preferred initial endoscopic ± ESWL treatment and 29% preferred initial surgical treatment. Conclusion Worldwide, clinical decision-making in CP is largely based on local expertise, beliefs and disbeliefs. Further development of evidence-based guidelines based on well designed (randomized) studies is strongly encouraged.

Introduction: SARS-CoV-2 infection represented a huge burden on the healthcare systems worldwide during the pandemic year 2020. Perioperative infection with SARS-CoV-2 was previously associated with increased mortality and morbidity rates for few surgical procedures, but data about pancreatic resections are scarce. The study aims to assess the impact of perioperative SARS-CoV-2 infection on early outcomes after pancreatico-duodenectomies. Methods: The data of 50 patients with pancreatico-duodenectomies performed during the pandemic year 2020 at our institution were retrospectively assessed from a prospective electronic database. The patients were divided into two groups: with and without perioperative SARS-CoV-2 infection. Demographic, clinical, bioumoral, pathological, intraoperative and early postoperative outcomes were compared between the groups, with the appropriate statistical tests. All patients were negative for SARS-CoV-2 infection at RT-PCR test 48 hours prior to surgery. Results: A number of 8 patients (16%) were diagnosed with SARS-CoV-2 infection at a median POD 11 (range, 6 – 32 POD). Perioperative SARS-CoV-2 infection was only associated with statistically significant increased overall length of hospital stays (33 vs. 15 days, p < 0.0001) but not with increased intensive care unit stay, overall or severe morbidity, clinically relevant pancreatic fistulae, delayed gastric emptying, hemorrhage, bile leak, pulmonary complications or in-hospital mortality rates (p values ≥ 0.062, ns). Conclusion: Perioperative SARS-CoV-2 infection was not associated with increased morbidity or mortality rates after pancreatico-duodenectomies. However, significant prolonged overall hospital stays were observed. The data should be interpreted with caution due to the limited number of patients.

At the moment, surgery is considered the only therapeutic approach offering a chance of long-term survival in patients diagnosed with perihilar cholangiocarcinoma (PHC). Curative intent surgery for PHC has experienced significant technical improvements over the years, from simple bile duct resection to complex surgical procedures including lymph nodes dissection, major hepatectomies and, sometimes, vascular resections. The modern surgical approach of PHC is associated with significantly improved survival rates, albeit with increased postoperative morbidity. The initial Western experience with major hepatectomies for PHC was not encouraging, as it was associated with unacceptably high mortality rates. Currently the mortality rates after surgery for PHC have significantly decreased, but it appears that the mortality rates in Western centres still remain higher, compared with the East Asian centres. The differences of outcomes between East Asian and Western centres are explained not only by the management of PHC but also by patient characteristics. En bloc caudate lobectomy as part of radical resections for PHC has been reported in clinical practice nearly three decades ago. The rationale of en bloc caudate lobectomy is based on the pattern of tumour spread in PHC, taking in consideration the fact that caudate lobe invasion appears to be a frequent event in patients resected for PHC. While en bloc caudate lobectomy in the context of curative intent surgery for PHC has been discussed in a host of publications so far, the currently available literature reached conflicting results regarding its overall impact on the patient. Therefore, the aim of this paper is to review the current relevant literature pertaining to the impact of en bloc caudate lobectomy in the context of curative intent surgery for PHC.

Central pancreatectomy (CP) is the alternative to distal pancreatectomy (DP) for specific pathologies of the mid-pancreas. However, the benefits of CP over DP remain controversial. This study aims to compare the two procedures by conducting a meta-analysis of all published papers. A systematic search of original studies comparing CP vs. DP was performed using PubMed, Scopus, and Cochrane Library databases up to June 2018. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) checklist was followed. Twenty-one studies were included (596 patients with CP and 1070 patients with DP). Compared to DP, CP was associated with significantly higher rates of overall and severe morbidity (p

Background/ Aim: Restorative proctocolectomy (RPC) is a complex surgical procedure used to treat patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The present study aims to assess the technical issues and early outcomes of RPC for FAP and UC, in a relatively large single-team series of patients. Patients and Methods: The data of all patients with RPC performed by a single surgical team between 1991 and 2018 were retrospectively assessed from a prospectively maintained electronic database. Results: The study group included 77 patients with RPC, and 70.1% have had FAP. The average number of RPC per year was 3.3 for the surgical team and 4.3 for the institution. A J pouch was performed in 93.5% of the patients. A hand-sewn reservoir was made in 76.6% of the patients. A hand-sewn ileal pouch-anal anastomosis was performed in 81.8% of the patients. A diverting ileostomy was performed in 92.2% of the patients. Mucosectomy was performed in 84.4% of the patients. The early morbidity rate was 36.4%, with severe complications rate of 13%. The main complications were pouch-related septic complications (18.2%), wound infections (9.1%), small-bowel obstruction (6.5%) and hemorrhage (6.5%). Conclusions: Although a RPC remains an uncommon surgical procedure in Romania, however, the early outcomes of the present series are comparable to those reported in high volume centers. Good outcomes after RPC can be obtained if such complex surgical procedures are performed by dedicated surgical teams, with high case-load.

Agenesis of the right liver is a rare congenital anomaly which can be associated with an ectopic gallbladder. Hereby, it is presented the case of a 39-year-old man investigated for right upper quadrant abdominal pain and diagnosed at computed tomography with a cystic liver mass initially considered as hydatid cyst. At laparotomy, it was discovered agenesis of the right liver and the presumed hydatid cyst was a retrohepatic gallbladder with lithiasis. Cholecystectomy was performed with an uneventful outcome. Reassessment of the computed tomography images by an experienced radiologist confirmed the intraoperative diagnosis. Although agenesis of the right liver with retrohepatic gallbladder is an exceptional appearance, surgeons should be aware of this anomaly because it can raise challenging issues of diagnosis and surgical planning during cholecystectomy.

We report the case of a 55-year-old-male with a large cell metastatic pancreatic neuroendocrine carcinoma treated for 14 months with lanreotide autogel having a stable disease (SD) and not responding to chemotherapy. The somatostatin analogues (SSA) were introduced after an episode of diarrhea and controlled the disease. Progression-free survival (PFS) as determined by Computerized Tomography (CT) scans was obtained for 14 months. After more than a year, the patient's health state deteriorated along with progressive disease. The capecitabine-temozolomide regimen was challenged, but after three cycles, a rapid clinical decline was noted. Conclusion This unexpected event (diarrhea) in the course of the disease could represent the beginning of carcinoid syndrome. While the lanreotide autogel helped the episode of diarrhea pass, it also helped gain control over the disease itself.

Introduction: Gastric cancer is a rare cause of upper digestive hemorrhage. Associated co-morbidities may have a detrimental effect on both early and long-term outcomes after surgery for gastric cancer. Association of gastric adenocarcinoma with hemophilia A and angiodysplasia was not previously reported, and the impact on postoperative outcome is not known. Case Report: A 49-year-old male with inherited hemophilia A presented with upper digestive hemorrhage and severe anemia, and was diagnosed with gastric carcinoma. The patient underwent total gastrectomy with splenectomy and D2 lymph nodes dissection. The postoperative outcome was complicated by digestive hemorrhage due to the presence of lesions of angiodysplasia of the cecum and jejunum that were successfully treated with coils mounted by the interventional radiologic approach. During the pre and postoperative periods, the patient received human coagulation factor VIII and developed auto-antibodies against factor VIII. Thus, human coagulation factor VIII administration was stopped and replaced with factor eight inhibitor bypassing activity (FEIBA). The patient was discharged at home on postoperative day 41, without any signs of bleeding. Conclusion: To the best of our knowledge, this is the first reported association of gastric adenocarcinoma, hemophilia A and angiodysplasia. All these lesions may lead to digestive hemorrhage and can pose very difficult problems of decision for diagnosis and therapy. A multidisciplinary approach including hematologist, surgeon, anesthesiologist, endoscopist and the interventional radiologist is mandatory to have a proper diagnosis and management for these patients.

A deep vein thrombosis was rarely associated with uterine myomas. Hereby, it is presented the case of a 40-year-old woman in which the clinical manifestation of the deep vein thrombosis revealed the further diagnosis of a large uterine myoma. The diagnosis, management and clinical outcome of the patient are emphasized and discussed. The management of a patient with a uterine myoma and deep vein thrombosis is challenging and implies a multidisciplinary team.

Introduction: Invasion of portal vein (PV)/ superior mesenteric vein (SMV) in pancreatic ductal adenocarcinoma (PDAC) is no longer a contraindication for resection when reconstruction is technically feasible. However, the literature data reached conflicting conclusions regarding the early and long-term outcomes of patients with venous resection and pancreatectomies for PDAC. The study aims to present the outcomes in a large series of patients with pancreatectomies and associated PV/ SMV resection for PDAC, in a single center experience. Patients Methods: The data of 100 patients with pancreatectomies and PV and/ or SMV resection performed between 2002 and 2016 (February, 1st) were retrospectively analyzed from a prospectively maintained electronic database, which included 474 pancreatectomies for PDAC. Only patients with a final pathological diagnosis of PDAC were included in the present study. Results: Overall, 21.1% of patients with pancreatectomies for PDAC required a venous resection (100 patients out of 474 patients). Segmental resection was performed in 77 patients (out of 100 patients with pancreatectomies and venous resection - 77%), while 23 patients (23%) have had tangential venous resection. In the group of patients with segmental venous resection, reconstruction was made by end-to-end anastomosis in 53 patients (out of 77 patients - 68.8%), while in 24 patients (out of 77 patients - 31.2%) a graft interposition was necessary. Negative resections margins were obtained in 63 patients (63%). Histological tumor invasion of the resected vein was confirmed in 64 patients (64%). Postoperative complications occurred in 47 patients (47%), with severe complications (i.e., Dindo-Clavien grade III-V) in 19 patients (19%). Postoperative pancreatic fistulae, delayed gastric emptying and post-pancreatectomy hemorrhage rates were 9%, 20% and 15%, respectively. PV/ SMV thrombosis occurred in 5 patients (5%). The 90-day mortality rate in the group of patients with venous only resection, without any associated procedures, was 8%. Adjuvant treatment was performed in 63 patients (63%), while only 2 patients (2%) underwent neoadjuvant chemotherapy. Median follow-up time was 105 months (range, 3 - 186 months), with a median overall survival time of 13 months (range, 3 - 186 months). In the group of patients with negative resection margins, the median overall survival time was 16 months (range, 3 - 186 months). Conclusions: PV/ SMV resection during pancreatectomies for PDAC is technically feasible, and grafts are rarely required for venous reconstruction. However, venous resection is associated with high postoperative complications rates, and the mortality rate is not neglectable. The main goal of such complex procedure is to obtain negative resection margins, a situation associated with encouraging survival rates.

Pancreatic cancer (i.e., pancreatic ductal adenocarcinoma, PDAC) is an important healthcare issue and a highly lethal disease. Thus, almost 80% of patients with PDAC will die within one year after diagnosis. Several factors including smoking, obesity, advanced age, diabetes mellitus and chronic pancreatitis have been associated with increased risk of PDAC. Hepatitis B virus (HBV) infection is also considered as a risk factor for PDAC development in some studies. However, the role of HBV infection in PDAC is poorly explored. The present paper reviews the current relevant literature exploring the impact of HBV infection in PDAC. Assessment of HBV infection impact in PDAC is challenging because its effects could be easily underestimated. Indeed, the role played by occult B infection (OBI) and intrinsic difficulties to detect HBV antigens or DNA in pancreatic tissue remains major limitations to further progress. To date a significant proportion of available literature suggests the potential oncogenic role of HBV in PDAC but experimental evidences remain scarce. Remarkably, it appears that HBV infection might influence some clinical and pathological features of patients with PDAC. Future researches to better define the role of HBV infection in developing PDAC are urgently needed.

CONTEXT: Pancreatic neuroendocrine tumours (PanNETs) are rare pancreatic neoplasms. PanNETs can be treated by multimodal approach including surgery, locoregional and systemic therapy. OBJECTIVE: The aim of the present study is to evaluate predictive factors of overall survival in patients with PanNETs surgically treated at a single center. SUBJECTS AND METHODS: The study group consisted of 120 patients with PanNETs who had undergone surgery at the Center of Digestive Diseases and Liver Transplantation of Fundeni Clinical Institute, Bucharest, Romania. Surgical resection of the primary tumor was performed in 110 patients. RESULTS: Tumor size > 2 cm (p=0.048) (90% CI) lymph node involvement (p=0.048), ENET grade (p20%) (p

In the original article, the institutional author the E-AHPBA DP-CAR study group was misspelled. It is correct as reflected here. The original article has also been corrected.

Introduction: The safety of portal vein resection (PVR) during surgery for perihilar cholangiocarcinoma (PHC) has been demonstrated in Asia, America, and Western Europe. However, no data about this topic are reported from Eastern Europe. The aim of the present study is to comparatively assess the early and long-term outcomes after resection for PHC with and without PVR. PATIENTS AND METHODS The data of 21 patients with PVR were compared with those of 102 patients with a curative-intent surgery for PHC without PVR. The appropriate statistical tests were used to compare different variables between the groups. Results: A PVR was performed in 17% of the patients. In the PVR group, significantly more right trisectionectomies (p=0.031) and caudate lobectomies (0.049) were performed and, as expected, both the operative time (p=0.015) and blood loss (p=0.002) were significantly higher. No differences between the groups were observed regarding the severe postoperative morbidity and mortality rates, and completion of adjuvant therapy. However, in the PVR group the postoperative clinicallyrelevant liver failure rate was significantly higher (p=0.001). No differences between the groups were observed for the median overall survival times (34 vs. 26 months, p = 0.566). A histological proof of the venous tumor invasion was observed in 52% of the patients with a PVR and was associated with significantly worse survival (p=0.027). CONCLUSION A PVR can be safely performed during resection for PHC, without significant added severe morbidity or mortality rates. However, clinically-relevant liver failure rates are significantly higher when a PVR is performed. Furthermore, increased operative times and blood loss should be expected when a PVR is performed. Histological tumor invasion of the portal vein is associated with significantly worse survival.

Background The impact of splenectomy on outcomes after distal pancreatectomy was assessed in the present study, with a special emphasis on the postoperative systemic inflammatory response. Methods Thirty-three patients with spleen-preserving distal pancreatectomy—Kimura technique (SPDP group) were compared with a group of distal pancreatectomies with splenectomy (DPS group). The two groups were 1:1 matched for age, gender, co-morbidities and pathology. Results No differences between the groups were observed regarding the overall/severe/infectious morbidity, pancreatic fistulae and postoperative diabetes rates (P-values ≥ 0.475). An increased blood loss (P = 0.031) and need for intraoperative transfusions (P = 0.004) was observed in the DPS group. Postoperative platelet count and platelet-tolymphocyte ratio were significantly higher in the DPS group (P < 0.001). Conclusion Spleen removal during DP is not associated with a higher morbidity but with an increased blood loss and need for intraoperative transfusions. Although the postoperative systemic inflammatory response is higher when the splenectomy is performed, the number of postoperative infectious complications is not influenced. Preservation of the spleen during DP for benign and low-grade malignant tumor of the distal pancreas appears to be worthy and should be the first option whenever is technically feasible and it can be safely achieved.

Resection for hilar cholangiocarcinoma is the single hope for long-term survival. Ninety patients underwent curative intent surgery for hilar cholangiocarcinoma between 1996 and 2012. The potential prognostic factors were assessed by univariate (Kaplan–Meier curves and log-rank test) and multivariate analyses (Cox proportional hazards model). The median overall and disease-free survivals were 26 and 17 months, respectively. The multivariate analysis identified R0 resection (HR = 0.03, 95 % CI 0–0.19, p

The Bouveret syndrome is an exceptional complication of the gallbladder lithiasis. Hereby it is described the case of a patient with a history of gallstones complicated on the long-term outcome with gastric outlet obstruction, due to a large gallstone of the duodenum, migrated via a cholecysto-duodenal fistula. The clinical, radiological features and the patient management are described.

We measured the serum concentration of a panel of inflammatory cytokines and evaluated their association with circulating proangiogenic biomarkers and with outcome in patients with pancreatic ductal adenocarcinoma (PDAC).We collected serum samples from 36 patients with PDAC, 9 patients with chronic pancreatitis, and 22 healthy volunteers as a control. Inflammatory cytokines and proangiogenic biomarkers were measured using the multianalyte xMAP array and carcinoembryonic antigen (CEA) and carbohydrate 19-9 by immunoassay.Patients with PDAC had higher circulating levels of interleukin 6 (IL-6) than those of patients with pancreatitis or healthy individuals and higher levels of IL-10 and tumor necrosis factor α (TNF-α) compared with those of healthy individuals. In patients with PDAC, circulating IL-6, TNF-α, IL-1β, and IL-10 correlated with serum concentrations of vascular endothelial growth factor and basic fibroblast growth factor; circulating IL-6, IL-1β, and TNF-α correlated with carbohydrate 19-9; and IL-8, IL-10, and TNF-α correlated with CEA levels. Circulating IL-8, TNF-α, and CEA; tumor stage; and lymph node metastases were associated with a poor outcome.The results of this exploratory study indicate that inflammatory cytokines should be pursued as potential prognostic biomarkers as well as targets for therapy in larger studies in PDAC.

Background/aims Neuroendocrine tumours occur very rarely in the ampulla of Vater and their clinical behaviour is unknown. The aim of this study is to assess the clinico-pathological features, surgical approach and prognosis of these patients. Methods Six patients with neuroendocrine tumours of the ampulla of Vater treated with curative intent surgery at a single centre were retrospectively analysed. A univariate analysis of potential prognostic factors was also performed (data provided from the present study and literature review). Results Pancreaticoduodenectomy was curative in all the patients. Overall and disease-free survival rates were significantly better for G1/G2 tumours (p = 0.006 and p = 0.004, respectively). Although frequent, lymph node metastases did not influenced both overall (p = 0.760) and disease-free survival rates (p = 0.745). No significant differences of survival were observed in patients with ENETS stage I/II disease, as compared to ENETS stage III disease (p = 0.169 and p = 0.137, respectively). No differences were observed according to UICC staging system (p = 0.073 and p = 0.177, respectively). Tumours that are less than 2 cm or limited to the ampulla appear to have a better prognosis. Conclusion The WHO 2010 classification appear to accurately predict patient prognosis, while the ENETS or UICC staging systems have a limited value (especially in regard to lymph node metastases). Radical surgery (i.e. pancreaticoduodenectomy with lymphadenectomy) should be the standard approach in most patients with NET of the ampulla of Vater because this procedure removes all the potential tumour-bearing tissue.

The aim of the present study is to compare the postoperative and long-term outcomes of central pancreatectomy (CP) and spleen-preserving distal pancreatectomy (SPDP).Clinical, pathological and long-term data were compared between 22 patients who underwent CP and 25 patients who underwent SPDP (2002-2012).The median length of resected pancreas was 8.5 cm in the SPDP group and 5 cm in the CP group (p0.001). The median estimated blood loss was significantly lower in the CP group (p = 0.019). Morbidity was 50% for CPs and 40% for SPDPs (p = 0.564). The rate of pancreatic fistulae was 36% for CPs and 40% for SPDPs (p = 0.530). The rate of new-onset diabetes was nil in the successful CP group and 16% in the SPDP group (p = 0.111).Morbidity and pancreatic fistula rates are not higher after CP when compared to SPDP. The loss of normal pancreatic tissue is significantly lower for CP, and thus there is potentially better preservation of the pancreatic endocrine functions. CP should be considered only in selected cases when preservation of the pancreas is of utmost importance, especially for lesions situated at the level of the pancreatic neck.

I appreciate so much the invitation to comment on the article of Nakata and co-workers (1). In this systematic review and meta-analysis are comparatively assessed the outcomes of minimally invasive distal pancreatectomy, with and without spleen preservation (1). Furthermore, in the subgroup of patients with spleen preservation, the outcomes of splenic vessel preservation technique were compared to those of the technique in which the splenic artery and vein are resected (1).

Pancreatic ductal adenocarcinoma (PDAC) is a disease with a grim prognosis. Pancreatectomy represents the single hope for long-term survival in a patient with PDAC. Recurrence is a common event after curative-intent surgery for PDAC, mainly related to incomplete removal at the site of resection margins; medial/ superior mesenteric margins are the most often positive. The concept of total mesopancreas excision (TMpE) in PDAC was proposed in analogy to the concept of total mesorectal excision for rectal cancer, to better control loco-regional recurrence. This paper aims to discuss the current evidence for the value of TMpE in PDAC.

Background: Surgery is the main component of the multimodality treatment of gastric cancer (GC). The present study aims to comparatively assess the early and long-term outcomes after D1 and D2 lymph node dissection. Furthermore, the impact of surgeon case-load on the long-term survival after D2 gastrectomies is also explored. Methods: A number of 773 patients with curative-intent surgery for GC adenocarcinoma (1997 - 2010: 325 patients with D1 lymphadenectomy, 448 patients with D2 lymphadenectomy) were included. Results: No statistically significant differences of overall morbidity rates were observed between the D1 and D2 groups of patients (16.3%for D1 group vs. 18.8% for D2 group, p = 0.39). However, statistically significant higher rates of post operative pancreatic fistulae rates were observed in the D2 group of patients (3.2% for D1 group vs. 7.9% for D2 group, p 0.001). Interestingly, statistically significant higher rates of mortality were observed for the D1 group of patients (8.9% for D1 group vs. 2.9% for D2 group, p 0.001). The 5-year survival rate was statistically significant higher in the D2 group of patients (median overall survival time of 18 months for D1 group vs. 60 months for D2 group, p 0.001). A statistically significant correlation (p=0.005, r=0.571) was observed between the overall survival time and the number of D2 lymphadenectomies performed by each surgeon. Conclusions: D2 lymph node dissection is associated with statistically significant improved longterm survivals at the expense of higher postoperative pancreatic fistulae rates, compared to D1 surgery. However, no increased mortality rates were observed in the D2 group of patients. D2 radical gastrectomies should be performed in high-volume centers by high case-load surgeons.

International audience; Genomic analysis of hepatocellular carcinoma (HCC) has been shown to provide clues about local risk factors. In the last decades, the mortality from malignant liver tumors increased sharply in Romania, where both hepatitis viruses and environmental pollutants are known to be highly prevalent. To date, HCC from this country has not been subject to molecular characterization. We analyzed a series of 48 consecutive HCC cases. Point mutations were searched in 9 nuclear genes and the mitochondrial D-loop. Oxidative stress response was monitored through measurement of gene expression (NRF2, KEAP1, SRXN1, and CES1) by qRT-PCR. An atypical mutation spectrum was observed, as more than 40% of DNA changes were oxidative stress-associated T>C or T>G lesions (T>S). These mutations affected primarily genes encoding for β-catenin and NRF2 (P

Introduction: In the modern context of multimodal treatment strategies for cancer patients with systemic disease, the dogma that surgery has a limited role is becoming less and less valid. Although a "œcurative" approach is not possible for the majority of the cases, however, some patients with limited systemic disease and favorable tumor biology could benefit from an aggressive combined cytotoxic and surgical strategy. Case report A 48-year-old patient was diagnosed with an invasive ductal carcinoma with the immunohistochemistry positive for estrogen and progesterone receptors, positive Her2 and three liver metastases. After nine cycles of chemotherapy, a favorable tumor response was identified at the level of the primary tumor as well as for the liver lesions: two of the metastases have disappeared, and the third one decreased in dimensions. The patient was operated in our unit, a lumpectomy together with a level II axillary lymph nodes dissection and a non-anatomic resection of the segment V of the liver was performed. Conclusions: A subgroup of patients with stage IV breast cancer with limited liver metastases and no extrahepatic disease might benefit from an aggressive combined cytotoxic and surgical strategy regarding disease control and overall survival.

Backgrounds/aims Standard pancreatic resections are the current approach for patients with resectable, isolated pancreatic metastases of other neoplasms. However, the role of parenchyma-sparing pancreatectomies for such pathology is poorly investigated. The aim of the present study is to assess the oncological safety of central pancreatectomies for pancreatic metastases of other neoplasms. Methods A literature search was performed in order to identify patients with central pancreatectomies for pancreatic metastases of other neoplasms. The available data of the patients were extracted and analyzed. Results A total number of 16 patients were identified. Renal carcinoma was the primary origin for the largest number of these patients (11 patients - 69%). The mean overall survival time was 109 months, with 1-, 5- and 10-year survival rates of 100%, 84%, and 60%, respectively. Conclusions Although not often performed, a central pancreatectomy appears to be an oncologically safe surgical procedure in select patients with pancreatic metastases of other neoplasms of the pancreatic body and isthmus. However, no definitive conclusions should be drawn, based on the data provided in the present study, due to the limited number and heterogeneity of the patients.

Background/aim Major hepatectomies are widely used in curative-intent surgery for perihilar cholangiocarcinoma, but morbidity rates are high. The aim of the study is to explore potential predictors for clinically relevant complications after major hepatectomies for perihilar cholangiocarcinoma. Methods Seventy patients were included. Univariate and multivariate analyses were performed for risk factors of morbidities using the International Study Group of Liver Surgery definitions. Results Severe morbidity rate was 36.5%. Clinically relevant posthepatectomy liver failure, bile leak, and hemorrhage rates were 24%, 22%, and 8.5%, respectively. A neutrophil-to-lymphocyte ratio > 3.3 is an independent prognostic factor for severe complications (hazard ratio = 1.258; 95% confidence interval 1.008–1.570; p = 0.042) while the number of blood units > 3 is an independent prognostic factor for clinically relevant liver failure (hazard ratio = 1.254; 95% confidence interval 1.082–1.452; p = 0.003). Biliary drainage and portal vein resection were not statistically correlated with any postoperative complication ( p ≥ 0.101). Significantly higher bilirubinemia levels were observed in patients with postoperative hemorrhage ( p = 0.023). Conclusion Clinically relevant morbidity rates after major hepatectomies for perihilar cholangiocarcinoma are high. Liver failure represents the main complication and is correlated with the number of transfused blood units. A patient with increased bilirubinemia appears to have a high risk for postoperative hemorrhage. Biliary drainage and portal vein resection does not appear to have a detrimental effect on morbidities. Neutrophil-to-lymphocyte ratio is a novel independent predictor for severe morbidity after major hepatectomies for perihilar cholangiocarcinoma and may contribute to better and informed decision-making.

The surgical approach for hilar cholangiocarcinoma (HC) has largely evolved, and increased resectability rates are reported. Large series of patients with resections for HC were published in the last years, and potential predictors for survival were explored. However, the usefulness of these predictors in clinical decision making is controversial. The aim of the present review is to explore the main prognostic factors after curative-intent surgery for HC, as emerged from the current literature. Furthermore, the impact of these predictors on clinical decision making is assessed. An aggressive surgical approach has improved the survival rates in patients with HC and implies bile duct resection associated with liver resection and loco-regional lymph node dissection. The AJCC staging system remains the main tool to assess the prognosis after resection of HC. Margin-negative resections and absence of lymph node metastases are the main prognostic factor after curative-intent surgery for HC. Response to chemotherapy is also a prognostic factor. Markers of systemic inflammatory response might predict prognosis of patients with HC, but their usefulness in clinical decision making remains unclear.

The global risk of hepatocellular carcinoma (HCC) is largely due to hepatitis B virus (HBV) and hepatitis C virus (HCV) infections. In recent years, however, an increased prevalence of non-viral HCC has been noted. The clinical impact of the presence/absence of viral infections in HCC remains controversial. The present study aimed to assess the effect of hepatitis viruses on demographics, clinical and pathological features and long-term outcome in a large cohort of Romanian patients who underwent surgery for HCC.The study included 404 patients with HCC who had undergone resection, transplantation or radiofrequency ablation at a single institution between 2001 and 2010. The patients were divided into four groups: 85 patients with hepatitis B virus infection (HBV group), 164 patients with hepatitis C virus infection (HCV group), 39 patients with hepatitis B and C virus co-infection (HBCV group), and 116 patients without viral infection (non-BC group).The patients of both HBV (56.0+/-11.3 years) and HBCV groups (56.0+/-9.9 years) were significantly younger than those of the HCV (61.0+/-8.5 years, P=0.001) and non-BC groups (61.0+/-13.0 years, P=0.002). Interestingly, the prevalence of liver cirrhosis was significantly lower in the non-BC group (47%) than in any other subsets (72%-90%, P0.002). Furthermore, the non-BC patients were more advanced according to the Barcelona Clinic Liver Cancer stages than the patients of the HCV or HBCV groups (P0.020); accordingly, they were more frequently assessed beyond the Milan criteria than any other groups (P=0.001). No significant differences in the disease-free or overall survival rates were observed among these groups.Patients with non-viral HCC are diagnosed at advanced ages and stages, a situation plausibly due to the poor effectiveness of cancer surveillance in community practice. The presence of viral infections does not appear to impair the long-term prognosis after surgical treatment in patients with HCC; however, there is a trend for worse disease-free survival rates in HBCV patients, though statistical significance was not reached.

Bile duct cysts are a rare medical condition and are more frequent in children. However, the disease is becoming increasingly common in adults. The modified Todani classification, which is based on anatomical characteristics, is the current standard classification method. However, this classification does not take the following factors into consideration: different epidemiology, pathogenesis, risk of malignant transformation, clinical and imaging aspects, and different therapeutical approaches for all the bile duct cysts. Thus, some clinicians denied its clinical significance and viability. Moreover, some rare variants (i.e., cystic duct cysts) of bile duct cysts were initially not included and were subsequently categorized as type VI. Although it clusters different diseases, the Todani classification of bile duct cysts should also be used in clinical practice because it is simple, reproducible and widely agreed upon, thereby allowing an appropriate comparative analysis between different series of patients who are classified based on this scheme. Exceptional, cystic duct cysts should be included in the Todani classification (as a subtype of type II BDC rather than as a "new" type VI) so that the gastroenterologists, radiologists and surgeons are aware of this variation.

Central pancreatectomy is a pancreas-sparing alternative to standard pancreatic resections in selected cases. Although associated with high morbidity, the risk factors for surgical complications of this procedure are not yet defined.The clinicopathological and perioperative data of 24 patients who underwent central pancreatectomies (2002-2010) were correlated with surgical complications.The overall morbidity rate was 54% (pancreatic fistula, 40%). In a univariate analysis, age over 40 years, body mass index ≥30kg/m2, smoking and American Society of Anesthesiologists III scores were significantly correlated with increased morbidity. In a multivariate analysis, a significant correlation with the development of complications was found for body mass index ≥30kg/m2 and age over 40 years.Certain patient-related factors (older age, obesity and smoking) appear to have a negative impact on early postoperative outcome after central pancreatectomy. For patients with these factors, an alternative distal pancreatectomy should be considered. Central pancreatectomy should be tailored not only to the pathology but also to the patient profile.

Pancreatic head cancer is a disease with a dismal prognosis, even after curative intent surgery, Resection represents the only hope for long-term survival. The negative resection margins (R0 resection) represent a strong independent prognostic factor. Up to 80% of so-called curative resections are, in fact, non-curative (with microscopically positive margins). The area most involved in positive resection margins is the meso-pancreas. Thus, the local recurrence is up to 80% within one year after resection. The term meso-pancreas was recently proposed to emphasize this area's role in positive resection margins, local recurrence after pancreatoduodenectomy and prognosis. Total meso-pancreas excision is presumed to decrease the rate of R1 resection and improve survival and is facilitated by a posterior/artery first approach.

Long-term functional results after standard pancreatic resections are a major concern, especially in children. An alternative pancreas-sparing procedure (such as central pancreatectomy) should be taken into consideration whenever it is feasible, and a prolonged survival is expected. Pancreatoblastoma is an unusual malignant tumor in childhood. However, in initially resectable tumors, the 15-year survival is more than 80%. Thus, there is a potential role of a conservative pancreatic resection in successful treatment of pancreatoblastoma. The management in a case of a 16-year-old girl with a pancreatoblastoma in the body of pancreas is presented. Complete surgical resection by central pancreatectomy followed by chemotherapy led to a prolonged disease-free survival, with good functional results. Central pancreatectomy could be an alternative surgical technique in some selected cases of pancreatoblastoma, having the lowest incidence of postoperative exocrine and endocrine insufficiency rate and offering the best nutritional status.

Obstruction of the hepatic hilum in patients without prior surgery is generally due to hilar adenocarcinoma (Klatskin tumor). However, not all the hilar strictures are malignant. Although uncommon, benign strictures of the proximal bile duct should be taken into consideration in differential diagnosis of Klatskin tumors, since the incidence could reach up to 25% of patients with presumed Klatskin tumor diagnosis. This group of benign proximal bile duct strictures (Klatskin-mimicking lesions) is usually represented by segmental fibrosis and non-specific chronic inflammation. The clinical and imaging features can not differentiate between benign and malignant strictures. Herein, we present a case series of three patients with benign proximal bile duct strictures (representing 4.1% of 73 patients resected with presumptive preoperative diagnosis of Klatskin tumor) and literature review. There are presented the clinical and biochemical features, imaging preoperative workup, surgical treatment and histological analysis of the specimen, along with postoperative outcome. For benign strictures of the hilum limited resections are curative. However, despite new diagnosis tools developed in the last years, patients with hilar obstructions still require unnecessary extensive resections due to impossibility of excluding the malignancy. In all cases of proximal bile duct obstruction presumed malignant, they should be managed accordingly, even with the risk of over-treatment for some benign lesions.