Intraductal Papillary Mucinous Neoplasm of the Pancreas: Need for a Tailored Approach to a Rare Entity

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a relatively new entity that has gained increased attention because of its unique features – presence of different subtypes with different malignant potential, biological behavior, and prognosis, higher rates of recurrences and concomitant or metachronous pancreatic duct cancer. It is rare with an incidence of 4 to 5 cases per 100 000. The relative lack of experience significantly hampers decision making for surgery (pancreatic head resection, distal pancreatectomy or enucleation) or follow-up. Herein we present two cases managed by diametrically different tactic according to the risk stratification – distal pancreatectomy with splenectomy and observation, respectively. An up-to-date literature review on the key points in diagnostics, indications for surgery, the extent of surgery, follow-up, and prognosis is provided. The tailored approach based on risk stratification is the cornerstone of management. Absolute indications for surgery are the lesions with high-risk stigmata, whereas the worrisome features should be evaluated by endoscopic ultrasound and fine-needle aspiration. Main duct and mixed type are usually referred to surgery, whereas the management of a branch type is more conservative due to the lower rate of invasive cancer. Strict postoperative follow-up is mandatory even in negative resection margins due to a high risk for recurrences and metachronous lesions. Despite the guidelines, the intraductal papillary mucinous neoplasm remains a major challenge for clinicians and surgeons in the balance the risk/benefit of observation versus resection. Risk stratification plays a key role in decision-making. Future trials need to determine the optimal period of surveillance and the most reliable predictive factors for concomitant pancreatic duct cancer.

Microvascular decompression for trigeminal neuralgia, long-term follow-up results and assessment of possible prognostic factors: a single-center retrospective cross-sectional cohort study

Aim: Prognostic factors detection and analysis of long-term results of microvascular decompression for trigeminal neuralgia. Materials and methods. 161 cases of trigeminal neuralgia (TN) treatment by MVD technique without preliminary invasive interventions within 10 years were analyzed. Two blocks of information were designed which included objective case data (8 factors) and patient satisfaction survey (5 questions). Follow-up minimal cut-off was 1 year (median 5.8 years). The primary end point is the proportion of pain free patients and BNI (Barrow Neurological Institute) score at last follow-up. The secondary end point is the assessment of possible risk factors of treatment failure: symptoms duration, decompression type, affected nerve branches, neurovascular conflict visible on MRI, different indications for surgery. Logit-regression analysis was carried out. Significance level was set at p<0,01. Results. Among the studied factors as predictors for pain recurrence all but one failed to reach significance threshold. Conflict on MRI (p=0,231), involved nerve branches (p=0,340), indications for surgery (p=0,659), number of involved vessels (p=0,834), achieved decompression type (p=0,157), venous compression (p=0,143), gender (p=0,150), affected side (p=0,934) did not reach the significance level. For symptoms duration p=0,0012. Conclusions. As a result of multifactorial analysis of study results, the only significant prognostic factor for treatment failure (pain recurrence or worsening of obtained result) was symptoms duration at the time of surgery.

Computer tomography in diagnostics and treatment of inflammatory complications of diverticular disease of the colon

AIM: to evaluate the role of computed tomography (CT) in the treatment and diagnostic algorithm in patients with complicated diverticular disease (CDD).PATIENTS AND METHODS: during the period from 2014 to 2020, 165 hospitalized patients with complications of CDD included in the study. Fifteen (9.1%) patients were hospitalized for elective indications and 150 (90.9%) as emergencies. The indications for hospitalization were inflammatory complications of CDD. Computed tomography with intravenous contrast was performed in 89 (53.9%) patients. The study was performed on a 64-slice CT “Philips Brilliance 64” with intravenous bolus injection of a low-osmolar iodine-containing contrast agent. The absence of the CT in the remaining patients is due to the presence of classical symptoms of acute diverticulitis with a previously verified diagnosis of CDD, the presence of an informative transabdominal ultrasound, as well as the refusal of patients from CT.RESULTS: the CT allowed to verify the presence of diverticula in the patients, to reveal the distinctive CT signs and pathognomonic symptoms of inflammatory complications of CDD, as well as to establish the severity of the complications that occurred. The specific signs of the destruction of the diverticulum and the complications developed were abdominal mass, abscess, peritonitis, and fistula. Besides the diagnostic value, CT scan permitted to choose the treatment approach and to clarify indications for surgery. Besides that, some CDD complications revealed by CT were considered as a predictor of ineffectiveness of conservative treatment, which requires surgery.CONCLUSION: CT is a valuable diagnostic method for CDD which allows to determine timely the clinical form of inflammatory complication, to find out indications for surgery and to predict high risk of recurrence.

P-BN13 How has the COVID pandemic affected outcomes in Elective Laparoscopic Cholecystectomy?An observational study in a UK Upper GI Surgical Unit

Background COVID-19 has a significant impact on elective surgery for benign disease. When routine services resumed in April 2021, surgeons were faced with higher number of complicated cases. The aim of this study is to examine the effect of COVID-19 related delays on the outcomes of patients undergoing elective laparoscopic cholecystectomy (LC) in an upper gastrointestinal unit in the UK. Methods Data were collected retrospectively on consecutive patients undergoing elective LC between 1/3/19 to 1/5/19 (Pre-COVID) and 1/4/21 to 11/6/21 (resumption of elective operating following COVID). The indications for surgery, intraoperative details, postoperative complications, length of stay (LoS) and 30- day readmission were compared between the two cohorts. We divided indications for surgery as inflammatory (acute cholecystitis, gallstone pancreatitis, CBD stone with cholangitis) vs non-inflammatory (biliary colic, gallbladder polyps, CBD stone without cholangitis). Data were analysed using the Mann-Whitney U-test and Chi-square or Fisher’s exact test. A p value of &lt; 0.05 was used for statistical significance. Results 159 patients were analysed, 106 in Pre-COVID vs 53 in Post-COVID. Both cohorts had similar age, gender, ASA-grade, BMI. 68 (64.2%) of the pre-COVID cohort were operated for a non-inflammatory pathology compared to 19(35.8%) of the post-COVID cohort (p &lt; 0.001). Less patients had total cholecystectomy (subtotal and failed surgery) in the post-COVID cohort [49(92.5%) vs 159 (100%) p = 0.01]. There was no difference in the operating time, conversion to open surgery, the need for drains, and no difference in the Clavien-Dindo grade complications. Two patients in pre- COVID cohort (1.8%) required re-operation for bile-leak and bowel injury and two in the post COVID cohort (3.7%) for bleeding and CBD-injury. There was no difference in day case discharge or 30-day readmission rate. Conclusions Surgery in the post-COVID cohort was associated with a higher incidence of inflammatory biliary disease, subtotal cholecystectomy and procedure abandoned. Although the numbers in our study are small they highlight the need for enhanced preoperative assessment in elective biliary surgery as the NHS emerges from the acute phase of the pandemic.

Orbital Fractures

Orbital fractures are common in facial trauma and can be a challenge to treat. Understanding anatomy of the orbit, the clinical evaluation, indications for surgery, surgical approaches, complications, and postoperative are essential in providing appropriate treatment for patients who have sustained orbital fractures. In this article, the authors review the diagnostic evaluation, acute management, treatment options, and common complications of orbital fractures, as well as recent advancements in orbital fracture repairs.

Survival after surgery for spinal metastatic disease: a nationwide multiregistry cohort study

ObjectivesTo evaluate survival after surgery and indications for surgery due to spinal metastatic disease.DesignA retrospective longitudinal multiregistry nationwide cohort study.Setting19 public hospitals in Sweden with spine surgery service, where 6 university hospitals account for over 90% of the cases.Participants1820 patients 18 years or older undergoing surgery due to spinal metastatic disease 2006–2018 and registered in Swespine, the Swedish national spine surgery registry.InterventionsDecompressive and/or stabilising spine surgery due to spinal metastatic disease.Primary outcomeSurvival (median and mean) after surgery.Secondary outcomesIndications for surgery, types of surgery and causes of death.ResultsThe median estimated survival after surgery was 6.2 months (95% CI: 5.6 to 6.8) and the mean estimated survival time was 12.2 months (95% CI: 11.4 to 13.1). Neurologic deficit was the most common indication for surgery and posterior stabilisation was performed in 70.5% of the cases. A neoplasm was stated as the main cause of death for 97% of the patients.ConclusionBoth median and mean survival times were well above the generally accepted thresholds for surgical treatment for spinal metastases, suggesting that patient selection for surgical treatment on a national level is adequate. Further research on quality of life after surgery and prognostication is needed.

Treatment of the hidden penis in boys

Introduction. “Hidden penis” (HP) is a developmental malformation of the penis characterized by normally developed, but abnormally located cavernous bodies in the surrounding tissues of the symphysis or scrotum, manifested by the visually shortened penis trunk. The most common type is «buried» penis (BP). This pathology requires, as a rule, surgical treatment.Purpose. To assess outcomes of BP treatment with an improved surgical technique.Material and methods. 40 boys, aged from 2 to 16 (average age 9 ± 1.59) and diagnosed with HP, were treated in 2014-2019. BP was diagnosed in 35 children (87.5%), webbed penis (WP) – in five (12.5%). Primary BP was in 18 children (51.4%) and BP in combination with the suprapubic obesity - in 17 patients (48.6%). Two children (5%) were operated after the previous circumcision. Indications for surgery were: congenital primary HP, secondary HP in adolescents with insufficient visualization of the penis, psychological discomfort of the patient and the absence of significant clinical effects after conservative care. The average age of children with primary HP was 3.9 ± 2.48; with secondary HP and pubic obesity - 12 ± 3.84 years. During surgery, circular or circular and ventral midline incisions to the middle of the scrotum were used; they were followed by mobilization of the penis from adhesions, excision of adipose tissue in the bosom, fixation of the pubopenile and penoscrotal angles with a non-absorbable surgical thread. The authors have proposed a new technique for foreskin fixation using 2 ventral and 2 dorsal incisions, through which the skin was sutured to the deep fascia of the penis to prevent its distal slipping.Results. All patients had good anatomical and functional results. The authors describe the developed surgical technique in details; they also make literature review on the discussed problem.Conclusion. In the treatment of HP an improved surgical technique with the additional use of incisions allows you to reliably fix the skin of the foreskin on the trunk of the penis, avoiding its distal displacement.

Herniated discs: when is surgery necessary?

In all levels of disc herniations the absolute surgical indications include deteriorating neurological deficits with myelopathy or cauda equina syndrome. However, this review summarized the relative indications for surgery in each level. In cervical disc herniation (CDH), the indications for surgery consist of six months of persisting symptoms, not responding to conservative treatment. However, high-quality studies are lacking, and a randomized controlled trial is now underway to clarify the indications. In thoracic disc herniation (TDH), the indications for surgery comprise failure of conservative measures and/or worsening neurological symptoms. Moreover, giant calcified thoracic disc herniations or myelopathy signs on magnetic resonance imaging, even in the absence of neurological symptoms, may benefit from surgical treatment as a preventive measure. In lumbar disc herniation (LDH), the indications for surgery include imaging confirmation of LDH, consistent with clinical findings, and failure to improve after six weeks of conservative care. Cite this article: EFORT Open Rev 2021;6:526-530. DOI: 10.1302/2058-5241.6.210020

Clinical Features And Outcomes Of Streptococcus Anginosus Group Infective Endocarditis: A Multicenter Matched Cohort Study

Background Although Streptococcus anginosus group (SAG) endocarditis is considered a severe disease associated with abscess formation and embolic events, there is limited evidence to support this assumption. Methods We performed a retrospective analysis of prospectively collected data from consecutive patients with definite SAG endocarditis in 28 centers in Spain and Italy. A comparison between cases due to SAG endocarditis and viridans group streptococci (VGS) or Streptococcus gallolyticus group (SGG) was performed in a 1:2 matched analysis. Results Of 5,336 consecutive cases of definite endocarditis, 72 (1.4%) were due to SAG and matched with 144 cases due to VGS/SGG. SAG endocarditis was community acquired in 64 (88.9%) cases and affected aortic native valve in 29 (40.3%). When comparing SAG and VGS/SGG endocarditis, no significant differences were found in septic shock (8.3% vs. 3.5%, P = 0.116); valve disorder, including perforation (22.2% vs. 18.1%, P = 0.584), pseudoaneurysm (16.7% vs. 8.3%, P = 0.108), or prosthesis dehiscence (1.4% vs. 6.3%, P = 0.170); paravalvular complications, including abscess (25% vs. 18.8%, P = 0.264) and intracardiac fistula (5.6% vs. 3.5%, P = 0.485); heart failure (34.7% vs. 38.9%, P = 0.655); and embolic events (41.7% vs. 32.6%, P = 0.248). Indications for surgery (70.8% vs. 70.8%; P =1) and mortality (13.9% vs. 16.7%; P = 0.741) were similar between groups. Conclusions SAG endocarditis is an infrequent but serious condition that presents a prognosis similar to that of VGS/SGG

Approaches to common conditions of the gastrointestinal tract in pet hamsters

Hamsters are popular pets in the UK. The Syrian or Golden hamster (Mesocricetus auratus) is the best known species in the pet trade, with a variety of dwarf species also encountered. Gastrointestinal disease occurs frequently, and diarrhoea is a common presenting complaint. This is most often associated with bacterial or parasitic infection, but can also be related to neoplasia or the use of certain antibiotics. Initial stabilisation of the hamster with diarrhoea should include provision of a warm stress-free environment, fluid therapy, nutritional support with an appropriate critical care diet and analgesia. Following a full history and clinical examination, further diagnostic steps include faecal parasitology and microbiology, routine biochemistry and haematology, radiography with or without positive contrast, and abdominal ultrasound. Indications for surgery include evidence of intestinal obstruction or prolapsed intussusception. This article gives an overview of the most common gastrointestinal diseases encountered in hamster species and provides a guide of how to logically approach the investigation and treatment of these cases, achievable in general practice.