New trends in diagnosis and management of gallbladder carcinoma

Gallbladder(GB)carcinoma,although relatively rare,is the most common biliary tree cholangiocarcinoma with aggressiveness and poor prognosis.It is closely associated with cholelithiasis and long-standing large(>3 cm)gallstones in up to 90%of cases.The other main predisposing factors for GB carcinoma include molecular factors such as mutated genes,GB wall calcification(porcelain)or mainly mucosal microcalcifications,and GB polyps≥1 cm in size.Diagnosis is made by ultrasound,computed tomography(CT),and,more precisely,magnetic resonance imaging(MRI).Preoperative staging is of great importance in decisionmaking regarding therapeutic management.Preoperative staging is based on MRI findings,the leading technique for liver metastasis imaging,enhanced three-phase CT angiography,or magnetic resonance angiography for major vessel assessment.It is also necessary to use positron emission tomography(PET)-CT or ^(18)F-FDG PET-MRI to more accurately detect metastases and any other occult deposits with active metabolic uptake.Staging laparoscopy may detect dissemination not otherwise found in 20%-28.6%of cases.Multimodality treatment is needed,including surgical resection,targeted therapy by biological agents according to molecular testing gene mapping,chemotherapy,radiation therapy,and immunotherapy.It is of great importance to understand the updated guidelines and current treatment options.The extent of surgical intervention depends on the disease stage,ranging from simple cholecystectomy(T1a)to extended resections and including extended cholecystectomy(T1b),with wide lymph node resection in every case or IV-V segmentectomy(T2),hepatic trisegmentectomy or major hepatectomy accompanied by hepaticojejunostomy Roux-Y,and adjacent organ resection if necessary(T3).Laparoscopic or robotic surgery shows fewer postoperative complications and equivalent oncological outcomes when compared to open surgery,but much attention must be paid to avoiding injuries.In addition to surgery,novel targeted treatment along with immunotherapy and recent improvements in radiotherapy and chemotherapy(neoadjuvant-adjuvant capecitabine,cisplatin,gemcitabine)have yielded promising results even in inoperable cases calling for palliation(T4).Thus,individualized treatment must be applied.

Current considerations on intraductal papillary neoplasms of the bile duct and pancreatic duct

Pancreatobiliary intraductal papillary neoplasms(IPNs)represent precursors of pancreatic cancer or bile duct cholangiocarcinoma that can be detected and treated.Despite advances in diagnostic methods,identifying these premalignant lesions is still challenging for treatment providers.Modern imaging,biomarkers and molecular tests for genomic alterations can be used for diagnosis and follow-up.Surgical intervention in combination with new chemotherapeutic agents is considered the optimal treatment for malignant cases.The balance between the risk of malignancy and any risk of resection guides management policy;therefore,treatment should be individualized based on a meticulous preoperative assessment of high-risk stigmata.IPN of the bile duct is more aggressive;thus,early diagnosis and surgery are crucial.The conservative management of low-risk pancreatic branch-duct lesions is safe and effective.

Management of obstructed colorectal carcinoma in an emergency setting:An update

Colorectal carcinoma is common,particularly on the left side.In 20%of patients,obstruction and ileus may be the first clinical manifestations of a carcinoma that has advanced(stage II,III or even IV).Diagnosis is based on clinical presentation,plain abdominal radiogram,computed tomography(CT),CT colonography and positron emission tomography/CT.The best management strategy in terms of short-term operative or interventional and long-term oncological outcomes re-mains unknown.For the most common left-sided obstruction,the first choice should be either emergency surgery or endoscopic decompression by self-expen-dable metal stents or tubes.The operative plan should be either one-stage or two-stage resection.One-stage resection with on-table bowel decompression and irrigation can be accompanied or not accompanied by proximal defunctioning stoma(colostomy or ileostomy).Primary anastomosis is more convenient but has increased risks of anastomotic leakage and morbidity.Two-stage resection(Hart-mann’s procedure)is safer and the most widely used despite temporally affecting quality of life.Damage control surgery in high-risk frail patients is less frequently performed since it can be successfully substituted with endoscopic stenting or tubing.For the less common right-sided obstruction,one-stage surgical resection is more beneficial than endoscopic decompression.The role of minimally invasive surgery(laparoscopic or robotic)is a subject of debate.Emergency laparoscopic-assisted management is advantageous to some extent but requires much expertise due to inherent difficulties in dissecting the distended colon and the risk of rup-ture and subsequent septic complications.The decompressing stent as a bridge to elective surgery more substantially decreases the risks of morbidity and mortality than emergency surgery for decompression and has equivalent medium-term overall survival and disease-free survival rates.Its combination with neoadjuvant chemotherapy or radiation may have a positive effect on long-term oncological outcomes.Management plans are crucial and must be individualized to better fit each case.Core Tip:Acute obstruction is common in patients with more advanced colorectal carcinoma and may be the first manifestation mainly of left-sided obstruction and in elderly individuals.Emergency decompression is mandatory.Emergency surgical resection and primary anastomosis accompanied or not accompanied by proximal defunctioning stoma must be the first treatment choice for fit patients under 70 years.Hartmann’s two-stage procedure,although more preferable,must be the second alternative choice.Emergency endoscopic self-expendable metal stents must be preferred in unfit patients as a bridge to surgery and for palliative treatment in all inoperable cases.However,these basic management principles constitute a general direction.Decision-making is important and should be individualized.

Critical considerations for the management of gastrointestinal mixed neuroendocrine non-neuroendocrine neoplasms and pure neuroendocrine carcinomas

Mixed neuroendocrine non-neuroendocrine neoplasms constitute rare tumors that are located mainly in the gastrointestinal(GI)tract and have high degrees of malignancy,and the frequency of these tumors has been increasing.They consist of a neuroendocrine neoplastic component with another component of adenocarcinoma usually and have a dismal prognosis.The rare GI pure neuroendocrine carcinoma is highly aggressive and requires complex and extensive management since a genetic distinction exists between it and GI non-neuroendocrine neoplasms,which are generally slow-growing lesions.The most common GI-mixed neuroendocrine non-neuroendocrine neoplasms are colorectal,followed by gastric,mainly in the gastroesophageal junction.Current imaging modalities of nuclear medicine and radiology play important roles in the accuracy of diagnosis.Liquid biopsy may contribute to early detection and timely diagnosis.Ultrasonography,either endoscopic or abdominal,is a technique that contributes to a diagnosis;additionally,contrast-enhanced ultrasonography is very helpful in followup appointments.Histopathology establishes a definite diagnosis and stage by evaluating the cell differentiation grade and the cell proliferation index Ki67.The genetic profile can be valuable in diagnosis and gene therapy.Surgical resection with wide lymphadenectomy,whenever possible,and adjuvant chemotherapy constitute the main therapeutic management strategies.Targeted therapy and immunotherapy achieve encouraging results.

Current considerations for the surgical management of gallbladder adenomas

Gallbladder adenomas are rare lesions(0.5%)associated with potential malignant transformation,particularly with gallbladder adenomas that are≥1 cm in size.Early detection and management are crucial for preventing lethal carcinoma de-velopment.These polyps can often be distinguished from the more often nonneo-plastic cholesterol pseudopolyps(5%-10%),which are benign.Ultrasonography is the first-line tool for initial diagnosis and follow-up when indicated.The question is whether cholecystectomy is always necessary for all adenomas.The manage-ment of gallbladder adenomas is determined according to the size of the tumor,the growth rate of the tumor,the patient’s symptoms and whether risk factors for malignancy are present.Adenomas≥1 cm in size,an age>50 years and a familial history of gallbladder carcinoma are indications for immediate laparoscopic chole-cystectomy.Otherwise,ultrasound follow-up is indicated.For adenomas 6-9 mm in size,the absence of≥2 mm growth at 6 months,one year,and two years,as well as an adenoma sized<5 mm without existing risk factors indicates that no further surveillance is required.However,it would be preferable to individualize the management in doubtful cases.Novel interventional modalities for preserving the gallbladder need further evaluation,especially to determine the long-term outcomes.

Critical considerations for the management of acute abdomen in transplant patients

The number of solid organ transplantations performed annually is increasing and are increasing in the following order:Kidney,liver,heart,lung,pancreas,small bowel,and uterine transplants.However,the outcomes of transplants are impro-ving(organ survival>90%after the 1st year).Therefore,there is a high probability that a general surgeon will be faced with the management of a transplant patient with acute abdomen.Surgical problems in immunocompromised patients may not only include graft-related problems but also nongraft-related problems.The perioperative regulation of immunosuppression,the treatment of accompanying problems of immunosuppression,the administration of cortisol and,above all,the realization of a rapidly deteriorating situation and the accurate evaluation and interpretation of clinical manifestations are particularly important in these patients.The perioperative assessment and preparation includes evaluation of the patient’s cardiovascular system and determining if the patient has hypertension or suppression of the hypothalamic-pituitary-adrenal axis,or if the patient has had any coagulation mechanism abnormalities or thromboembolic episodes.Immunosuppression in transplant patients is associated with the use of calci-neurin inhibitors,corticosteroids,and antiproliferation agents.Many times,the clinical picture is atypical,resulting in delays in diagnosis and treatment and leading to increased morbidity and mortality.Multidetector computed tomo-graphy is of utmost importance for early diagnosis and management.Transplant recipients are prone to infections,especially specific infections caused by cytomegalovirus and Clostridium difficile,and they are predisposed to intraop-erative or postoperative complications that require great care and vigilance.It is necessary to follow evidence-based therapeutic protocols.Thus,it is required that the clinician choose the correct therapeutic plan for the patient(conservative,emergency open surgery or minimally invasive surgery,including laparoscopic or even robotic surgery).

Current management of concomitant cholelithiasis and common bile duct stones

The management policy of concomitant cholelithiasis and choledocholithiasis is based on a one-or two-stage procedure.It basically includes either laparoscopic cholecystectomy(LC)with laparoscopic common bile duct(CBD)exploration(LCBDE)in the same operation or LC with preoperative,postoperative and even intraoperative endoscopic retrograde cholangiopancreatography-endoscopic sphincterotomy(ERCP-ES)for stone clearance.The most frequently used worldwide option is preoperative ERCP-ES and stone removal followed by LC,preferably on the next day.In cases where preoperative ERCP-ES is not feasible,the proposed alternative of intraoperative rendezvous ERCP-ES simultaneously with LC has been advocated.The intraoperative extraction of CBD stones is superior to postoperative rendezvous ERCP-ES.However,there is no consensus on the superiority of laparoendoscopic rendezvous.This is equivalent to a traditional two-stage procedure.Endoscopic papillary large balloon dilation reduces recurrence.LCBDE and intraoperative ERCP have similar good outcomes.The risk of recurrence after ERCP-ES is greater than that after LCBDE.Laparoscopic ultrasonography may delineate the anatomy and detect CBD stones.The majority of surgeons prefer the transcductal instead of the transcystic approach for CBDE with or without T-tube drainage,but the transcystic approach must be used where possible.LCBDE is a safe and effective choice when performed by an experienced surgeon.However,the requirement of specific equipment and advanced training are drawbacks.The percutaneous approach is an alternative when ERCP fails.Surgical or endoscopic reintervention for retained stones may be needed.For asymptomatic CBD stones,ERCP clearance is the firstchoice method.Both one-stage and two-stage management are acceptable and can ensure improved quality of life.

Update on current diagnosis and management of anaplastic thyroid carcinoma

Well-differentiated thyroid carcinoma has a favorable prognosis with a 5-year survival rate of over 95%.However,the undifferentiated or anaplastic type accounting for<0.2%,usually in elderly individuals,exhibits a dismal prognosis with rapid growth and disappointing outcomes.It is the most aggressive form of thyroid carcinoma,with a median survival of 5 mo and poor quality of life(airway obstruction,dysphagia,hoarseness,persistent pain).Early diagnosis and staging are crucial.Diagnostic tools include biopsy(fine needle aspiration,core needle,open surgery),high-resolution ultrasound,computed tomography,magnetic resonance imaging,[(18)F]fluoro-D-glucose positron emission tomography/computed tomography,liquid biopsy and microRNAs.The BRAF gene(BRAF-V600E and BRAF wild type)is the most often found molecular factor.Others include the genes RET,KRAS,HRAS,and NRAS.Recent management policy is based on surgery,even debulking,chemotherapy(cisplatin or doxorubicin),radiotherapy(adjuvant or definitive),targeted biological agents and immunotherapy.The last two options constitute novel hopeful management modalities improving the overall survival in these otherwise condemned patients.Anti-programmed death-ligand 1 antibody immunotherapy,stem cell targeted therapies,nanotechnology achievements and artificial intelligence implementation provide novel promising alternatives.Genetic mutations determine molecular pathways,thus indicating novel treatment strategies such as anti-BRAF,anti-vascular endothelial growth factor-A,and anti-epidermal growth factor receptor.Treatment with the combination of the BRAF inhibitor dabrafenib and the MEK inhibitor trametinib has been approved by the Food and Drug Administration in cases with BRAF-V600E gene mutations and is currently the standard care.This neoadjuvant treatment followed by surgery ensures a twoyear overall survival of 80%.Prognostic factors for improved outcomes have been found to be younger age,earlier tumor stage and radiation therapy.A multidisciplinary approach is necessary,and the therapeutic plan should be individu alized based on surveillance and epidemiology end results.

Management of infected acute necrotizing pancreatitis

Necrotizing or severe pancreatitis represents approximately 10%-20%of acute pancreatitis.30%-40%of patients with acute necrotizing pancreatitis(ANP)will develop debris infection through translocation of intestinal microbial flora.Infected ANP constitutes a serious clinical condition and is complicated by severe sepsis with high mortality rates of up to 40%despite progress in current intensive care.The timely detection of sepsis is crucial.The Quick Sequential Organ Failure Assessment score,procalcitonin levels>1.8 ng/mL and increased lactates>2 mmol/L(>18 mg/dL),indicate the need for urgent management.The escalated step-by-step management protocol starts with broad-spectrum antibiotics,percutaneous drainage or endoscopic management,and ends with surgical management if needed.The latter includes necrosectomy(either laparoscopic or traditional open surgery),peritoneal lavage and extensive drainage.This management protocol increases the chance of survival to approximately 60%in patients with otherwise fatal cases.Any treatment choice must be individualized,and the timing is critical.

Role of prophylactic central neck lymph node dissection for papillary thyroid carcinoma in the era of de-escalation

Thyroid cancer is the most common endocrine malignancy.While there has been no appreciable increase in the observed mortality of well-differentiated thyroid cancer,there has been an overall rise in its incidence worldwide over the last few decades.Patients with papillary thyroid carcinoma(PTC)and clinical evidence of central(cN1)and/or lateral lymph node metastases require total thyroidectomy plus central and/or lateral neck dissection as the initial surgical treatment.Nodal status in PTC patients plays a crucial role in the prognostic evaluation of the recurrence risk.The 2015 guidelines of the American Thyroid Association(ATA)have more accurately determined the indications for therapeutic central and lateral lymph node dissection.However,prophylactic central neck lymph node dissection(pCND)in negative lymph node(cN0)PTC patients is controversial,as the 2009 ATA guidelines recommended that CND“should be considered”routinely in patients who underwent total thyroidectomy for PTC.Although the current guidelines show clear indications for therapeutic CND,the role of pCND in cN0 patients with PTC is still debated.In small solitary papillary carcinoma(T1,T2),pCND is not recommended unless there are high-risk prediction factors for recurrence and diffuse nodal spread(extrathyroid extension,mutation in the BRAF gene).pCND can be considered in cN0 disease with advanced primary tumors(T3 or T4)or clinical lateral neck disease(cN1b)or for staging and treatment planning purposes.The role of the preoperative evaluation is fundamental to minimizing the possible detrimental effect of overtreatment of the types of patients who are associated with low disease-related morbidity and mortality.On the other hand,it determines the choice of appropriate treatment and determines if close monitoring of patients at a higher risk is needed.Thus,pCND is currently recommended for T3 and T4 tumors but not for T1 and T2 tumors without high-risk prediction factors of recurrence.

Update on the current management of persistent and recurrent primary hyperparathyroidism after parathyroidectomy

Primary hyperparathyroidism(pHPT)is the third most common endocrine disease.The surgical procedure aims for permanent cure,but recurrence has been reported in 4%-10%of pHPT patients.Preoperative localization imaging is highly valuable.It includes ultrasound,computed tomography(CT),single-photonemission CT,sestamibi scintigraphy and magnetic resonance imaging.The operation has been defined as successful when postoperative continuous eucalcemia exists for more than the first six months.Ongoing hypercalcemia during this period is defined as persistence,and recurrence is defined as hypercalcemia after six months of normocalcemia.Vitamin D is a crucial factor for a good outcome.Intraoperative parathyroid hormone(PTH)monitoring can safely predict the outcomes and should be suggested.PTH≤40 pg/mL or the traditional decrease≥50%from baseline minimizes the likelihood of persistence.Risk factors for persistence are hyperplasia and normal parathyroid tissue on histopathology.Risk factors for recurrence are cardiac history,obesity,endoscopic approach and low-volume center(at least 31 cases/year).Cases with double adenomas or four-gland hyperplasia have a greater likelihood of persistence/recurrence.A 6-mo calcium>9.7 mg/dL and eucalcemic parathyroid hormone elevation at 6 mo may be associated with recurrence necessitating long-term follow-up.18F-fluorocholine positron emission tomography and 4-dimensional CT in persistent and recurrent cases can be valuable before reoperation.With these novel advances in preoperative imaging and localization as well as intraoperative PTH measurement,the recurrence rate has dropped to 2.5%-5%.Sixmonth serum calcium≥9.8 mg/dL and parathyroid hormone≥80 pg/mL indicate a risk of recurrence.Negative sestamibi scintigraphy,diabetes and elevated osteocalcin levels are predictors of multiglandular disease,which brings an increased risk of persistence and recurrence.Bilateral neck exploration was considered the gold-standard diagnostic method.Minimally invasive parathyroidectomy and neck exploration are both effective surgical techniques.Multidisciplinary diagnostic and surgical management is required to prevent persistence and recurrence.Long-term follow-up,even up to 10 years,is necessary.

New trends in the surgical management of soft tissue sarcoma: The role of preoperative biopsy

Soft tissue sarcoma(STS)accounts for 1%of all malignant neoplasms in adults.Their diagnosis and management constitute a challenging target.They originate from the mesenchyme,and 50 subtypes with various cytogenetic profiles concerning soft tissue and bones have been recognized.These tumors mainly affect middle-aged adults but may be present at any age.Half of the patients have metastatic disease at the time of diagnosis and require systemic therapy.Tumors above 3-5 cm in size must be suspected of potential malignancy.A thorough history,clinical examination and imaging that must precede biopsy are necessary.Modern imaging techniques include ultrasound,computed tomography(CT),new magnetic resonance imaging(MRI),and positron emission tomography/CT.MRI findings may distinguish low-grade from high-grade STS based on a diagnostic score(tumor heterogeneity,intratumoral and peritumoral enhancement).A score≥2 indicates a high-grade lesion,and a score≤1 indicates a lowgrade lesion.For disease staging,abdominal imaging is recommended to detect early abdominal or retroperitoneal metastases.Liquid biopsy by detecting genomic material in serum is a novel diagnostic tool.A preoperative biopsy is necessary for diagnosis,prognosis and optimal planning of surgical intervention.Core needle biopsy is the most indicative and effective.Its correct performance influences surgical management.An unsuccessful biopsy means the dissemination of cancer cells into healthy anatomical structures that ultimately affect resectability and survival.Complete therapeutic excision(R0)with an acceptable resection margin of 1 cm is the method of choice.However,near significant structures,i.e.,vessels,nerves,an R2 resection(macroscopic margin involvement)preserving functionality but having a risk of local recurrence can be an acceptable choice,after informing the patient,to prevent an unavoidable amputation.For borderline resectability of the tumor,neoadjuvant chemo/radiotherapy has a place.Likewise,after surgical excision,adjuvant therapy is indicated,but chemotherapy in nonmetastatic disease is still debatable.The five-year survival rate reaches up to 55%.Reresection is considered after positive or uncertain resection margins.Current strategies are based on novel chemotherapeutic agents,improved radiotherapy applications to limit local side effects and targeted biological therapy or immunotherapy,including vaccines.Young age is a risk factor for distant metastasis within 6 mo following primary tumor resection.Neoadjuvant radiotherapy lasting 5-6 wk and surgical resection are indicated for highgrade STS(grade 2 or 3).Wide surgical excision alone may be acceptable for patients older than 70 years.However,locally advanced disease requires a multidisciplinary task of decision-making for amputation or limb salvage.

Hepatic ischemia-reperfusion syndrome and its effect on the cardiovascular system: The role of treprostinil, a synthetic prostacyclin analog

Hepatic ischemia-reperfusion syndrome has been the subject of intensive study and experimentation in recent decades since it is responsible for the outcome of several clinical entities,such as major hepatic resections and liver transplantation.In addition to the organ’s post reperfusion injury,this syndrome appears to play a central role in the dysfunction of distant tissues and systems.Thus,continuous research should be directed toward finding effective therapeutic options to improve the outcome and reduce the postoperative morbidity and mortality rates.Treprostinil is a synthetic analog of prostaglandin I2,and its experimental administration has shown encouraging results.It has already been approved by the Food and Drug Administration in the United States for pulmonary arterial hypertension and has been used in liver transplantation,where preliminary encouraging results showed its safety and feasibility by using continuous intravenous administration at a dose of 5 ng/kg/min.Treprostinil improves renal and hepatic function,diminishes hepatic oxidative stress and lipid peroxidation,reduces hepatictoll-like receptor 9 and inflammation,inhibits hepatic apoptosis and restores hepatic adenosine triphosphate(ATP)levels and ATP synthases,which is necessary for functional maintenance of mitochondria.Treprostinil exhibits vasodilatory properties and antiplatelet activity and regulates proinflam-matory cytokines;therefore,it can potentially minimize ischemia-reperfusion injury.Additionally,it may have beneficial effects on cardiovascular parameters,and much current research interest is concentrated on this compound.

Pathophysiological consequences of obstructive jaundice and perioperative management

Background: Obstructive jaundice is a common problem in daily clinical practice. Understanding completely the pathophysiological changes in obstructive jaundice remains a challenge for planning current and future management.Data sources: A Pub Med was searched for relevant articles published up to August 2016. The effect of obstructive jaundice on proinflammatory cytokines, coagulation status, hemodynamics and organ functions were evaluated.Results: The effects of obstructive jaundice included biliary tree, the hepatic cell and liver function as well as systemic complications. The lack of bile in the gut, the disruption of the intestinal mucosal barrier,the increased absorption of endotoxin and the subsequent endotoxemia cause proinflammatory cytokine production(TNF-α, IL-6). Bilirubin induces systemic inflammatory response syndrome which may lead to multiple organ dysfunction syndrome. The principal clinical manifestations include hemodynamic instability and acute renal failure, cardiovascular suppression, immune compromise, coagulation disorders,nutritional impairment, and wound healing defect. The proper management includes full replacement of water and electrolyte deficiency, prophylactic antibiotics, lactulose, vitamin K and fresh frozen plasma,albumin and dopamine. The preoperative biliary drainage has not been indicated in overall, but only in a few selected cases.Conclusion: The perioperative management is an essential measure in improving the outcome after the appropriate surgical operation in jaundiced patients especially those with malignancy.

Role of bevacizumab in colorectal cancer growth and its adverse effects:A review

Angiogenesis affects both wound healing and malignant cell growth through nutrients and oxygen.Vascular endothelial growth factor(VEGF) is the most important element involved in this complex process.Inhibition of VEGF influences angiogenesis and may restrict tumor growth and metastatic ability.Modern antiangiogenic therapy is based on this theory.Bevacizumab is a recombinant humanized monoclonal antibody(immunoglobulin G1) which binds with VEGF-A forming a large molecule.It can not be bound with VEGF tyrosine kinase receptors preventing VEGF-A incorporation;thus its activity is inhibited inducing blockage of VEGFmediated angiogenesis.Bevacizumab,in combination with chemotherapy or other novel targeted therapeutic agents,is currently used more frequently in clinical practice,mainly for managing advanced colorectal cancer.It is also used for managing other malignancies,such as breast cancer,pancreatic cancer,prostate cancer,non small-cell lung cancer,metastatic renal carcinoma and ovarian tumors.Although it is generally considered a safe treatment,there are reports of some rare side effects which should be taken into account.Recent experiments in rats and mice show promising results with a wider therapeutic range.

Advances in prognostic factors in acute pancreatitis:a mini-review

BACKGROUND:Early assessment of the severity of acute pancreatitis is essential to the proper management of the disease.It is dependent on the criteria of the Atlanta classification system.DATA SOURCES:PubMed search of recent relevant articles was performed to identify information about the severity and prognosis of acute pancreatitis.RESULTS:The scoring systems included the Ranson’s or Glasgow’s criteria ≥3,the APACHE II classification system ≥8,and the Balthazar’s criteria ≥4 according to the computed tomography enhanced scanning findings.The single factors on admission included age >65 years,obesity,hemoconcentration(>44%),abnormal chest X-ray,creatinine >2 mg/dl,C-reactive protein>150 mg/dl,procalcitonin >1.8 ng/ml,albumin <2.5 mg/dl,calcium <8.5 mg/dl,early hyperglycemia,increased intra-abdominal pressure,macrophage migration inhibitory factor,or a combination of IL-10 >50 pg/ml with calcium <6.6 mg/dl.CONCLUSION:The prediction of the severity of acute pancreatitis is largely based on well defined multiple factor scoring systems as well as several single risk factors.

Current opinion on lymphadenectomy in pancreatic cancer surgery

BACKGROUND:Adenocarcinoma of the pancreas exhibits aggressive behavior in growth,inducing an extremely poor prognosis with an overall median 5-year survival rate of only 1%-4%.Curative resection is the only potential therapeutic opportunity. DATA SOURCES:A PubMed search of relevant articles published up to 2009 was performed to identify information about the value of lymphadenectomy and its extent in curative resection of pancreatic adenocarcinoma. RESULTS:Despite recent advances in chemotherapy,radio-therapy or even immunotherapy,surgery still remains the major factor that affects the outcome.The initial promising performance in Japan gave conflicting results in Western countries for the extended and more radical pancreatectomy; it has failed to prove beneficial.Four prospective,randomized trials on extended versus standard lymphadenectomy during pancreatic cancer surgery have shown no improvement in long-term survival by the extended resection.The exact lymph node status,including malignant spread and the total number retrieved as well as the lymph node ratio,is the most important prognostic factor.Positive lymph nodes after pancreatectomy are present in 70%.Paraaortic lymph node spread indicates poor prognosis. CONCLUSIONS:Undoubtedly,a standard lymphadenectomy including>15 lymph nodes must be no longer preferred in patients with the usual head location.The extended lymphadenectomy does not have any place,unless in randomized trials.In cases with body or tail location,the radical antegrade modular pancreatosplenectomy gives promising results.Nevertheless,accurate localization and detailed examination of the resected specimen are required for better staging.

Autoimmune pancreatitis versus pancreaticcancer: a comprehensive review withemphasis on differential diagnosis

BACKGROUND: Autoimmune pancreatitis (AIP) is a rare form of chronic pancreatitis with a discrete pathophysiology occasional diagnostic radiological findings, and characteristic histological features. Its etiology and pathogenesis are still under investigation, especially during the last decade Another aspect of interest is the attempt to establish specific criteria for the differential diagnosis between autoimmune pancreatitis and pancreatic cancer, entities that are frequently indistinguishable. DATA SOURCES: An extensive search of the PubMed database was performed with emphasis on articles about the differential diagnosis between autoimmune pancreatitis and pancreatic cancer up to the present. RESULTS: The most interesting outcome of recent research is the theory that autoimmune pancreatitis and its various extra-pancreatic manifestations represent a systemic fibro inflammatory process called IgG4-related systemic disease The diagnostic criteria proposed by the Japanese Pancreatic Society, the more expanded HISORt criteria, the new definitions of histological types, and the new guidelines of the International Association of Pancreatology help to establish the diagnosis of the disease types. CONCLUSION: The valuable help of the proposed criteria for the differential diagnosis between autoimmune pancreatitis and pancreatic cancer may lead to avoidance of pointless surgical treatments and increased patient morbidity.

Role of stenting in the palliation of gastroesophageal junction cancer: A brief review

Gastroesophageal junction cancer has an increasing in-cidence in western countries. It is inoperable when firstmanifested in more than 50% of cases. So, palliationis the only therapeutic option for the advanced diseaseto relieve dysphagia and its consequences in weakenedpatients with an estimated mean survival under 6 mo.This article has tried to identify trends focusing on cur-rent information about the best palliative treatment,with an emphasis on the role of stenting. Self-expand-ing stent placement, either metal or plastic, is the mainmanagement option. However, this anatomical loca-tion creates some particular problems for stent safetyand effectiveness which may be overcome by properlydesigned novel stents. The stents ensure a good qual-ity of life and must be preferred over other alterna-tive methods of loco-regional modalities, i.e., externalradiation, laser thermal or photodynamic therapy. Al-though stent placement is generally a simple, safe andeffective method, there are sometimes complications,increasing the morbidity and mortality rate. Bypassoperative procedures have now been abandoned as afirst choice. The stomach instead of the colon must beused for a bypass operation when it is needed. Chemo-therapy, despite the toxicity, and intraluminal radiation(brachytherapy) have a well-defined role.

Current surgical management of pancreatic endocrine tumor liver metastases

BACKGROUND: The management of metastatic disease in pancreatic endocrine tumors (PETs) demands a multidisciplinary approach and the cooperation of several medical specialties. The role of surgery is critical, even when a radical excision cannot always be achieved. DATA SOURCES: A PubMed search of relevant articles published up to February 2011 was performed to identify current information about PET liver metastases regarding diagnosis and management, with an emphasis on surgery. RESULTS: The early diagnosis of metastases and their accurate localization, most commonly in the liver, is very important. Surgical options include radical excision, and palliative excision to relieve symptoms in case of failure of medical treatment. The goal of the radical excision is to remove the primary tumor bulk and all liver metastases at the same time, but unfortunately it is not feasible in most cases. Palliative excisions include aggressive tumor debulking surgeries in well-differentiated carcinomas, trying to remove at least 90% of the tumor mass, combined with other additional destructive techniques such as hepatic artery embolization or chemoembolization to treat metastases or chemoembolization to relieve symptoms in cases of rapidly growing tumors. The combination of chemoembolization and systemic chemotherapy results in better response and survival rates. Other local destructive techniques include ethanol injection, cryotherapy and radiofrequency ablation. CONCLUSION: It seems that the current management of PETs can achieve important improvements, even in advanced cases.