BACKGROUND Pancreatectomy with concomitant portomesenteric vein resection(PVR)enables patients with portomesenteric vein(PV)involvement to achieve radical resection of pancreatic ductal adenocarcinoma,however,early re...BACKGROUND Pancreatectomy with concomitant portomesenteric vein resection(PVR)enables patients with portomesenteric vein(PV)involvement to achieve radical resection of pancreatic ductal adenocarcinoma,however,early recurrence(ER)is frequently observed.AIM To predict ER and identify patients at high risk of ER for individualized therapy.METHODS Totally 238 patients undergoing pancreatectomy and PVR were retrospectively enrolled and were allocated to the training or validating cohort.Univariate Cox and LASSO regression analyses were performed to construct serum recurrence score(SRS)based on 26 serum-derived parameters.Uni-and multivariate Cox regression analyses of SRS and 18 clinicopathological variables were performed to establish a Nomogram.Receiver operating characteristic curve analysis was used to evaluate the predictive accuracy.Survival analysis was performed using Kaplan-Meier method and log-rank test.RESULTS Independent serum-derived recurrence-relevant factors of LASSO regression model,including postoperative carbohydrate antigen 19-9,postoperative carcinoembryonic antigen,postoperative carbohydrate antigen 125,preoperative albumin(ALB),preoperative platelet to ALB ratio,and postoperative platelets to lymphocytes ratio,were used to construct SRS[area under the curve(AUC):0.855,95%CI:0.786–0.924].Independent risk factors of recurrence,including SRS[hazard ratio(HR):1.688,95%CI:1.075-2.652],pain(HR:1.653,95%CI:1.052-2.598),perineural invasion(HR:2.070,95%CI:0.827-5.182),and PV invasion(HR:1.603,95%CI:1.063-2.417),were used to establish the recurrence nomogram(AUC:0.869,95%CI:0.803-0.934).Patients with either SRS>0.53 or recurrence nomogram score>4.23 were considered at high risk for ER,and had poor long-term outcomes.CONCLUSION The recurrence scoring system unique for pancreatectomy and PVR,will help clinicians in predicting recurrence efficiently and identifying patients at high risk of ER for individualized therapy.展开更多
Pneumatosis intestinalis and portomesenteric vein gas are rare and potentially severe radiological findings that occur both in pediatric and adult populations.They actually are radiographic signs of underlying intra-a...Pneumatosis intestinalis and portomesenteric vein gas are rare and potentially severe radiological findings that occur both in pediatric and adult populations.They actually are radiographic signs of underlying intra-abdominal pathology,abnormality or diagnostic medical interference.If combined with other radiological or clinical signs of intestinal ischemia or sepsis,the prognosis is dismal and urgent laparotomy is mandatory.We report two cases of surgical treatment with ominous outcome in an effort to characterize this finding correctly as an absolute surgical indication or as an additional diagnostic criterion that simply marks a further breakdown of the systems in patients with a long list of severe medical conditions.展开更多
BACKGROUND Mesenteric ischemia represents an uncommon complication of splanchnic vein thrombosis,and it is less infrequently seen in young women using oral contraceptives.Diagnosis is often delayed in the emergency ro...BACKGROUND Mesenteric ischemia represents an uncommon complication of splanchnic vein thrombosis,and it is less infrequently seen in young women using oral contraceptives.Diagnosis is often delayed in the emergency room;thus,surgical intervention may be inevitable and the absence of thrombus regression or collateral circulation may lead to further postoperative ischemia and a fatal outcome.CASE SUMMARY We report a 28-year-old female patient on oral contraceptives who presented with acute abdominal pain.Her physical examination findings were not consistent with her symptoms of severe pain and abdominal distention.These findings and her abnormal blood tests raised suspicion of acute mesenteric ischemia(AMI)induced by splanchnic vein thrombosis.Contrast-enhanced abdominal computed tomography revealed ischemia of the small intestine with portomesenteric and splenic vein thrombosis(PMSVT).We treated the case promptly by anticoagulation after diagnosis.We then performed delayed segmental bowel resection after thrombus regression and established collateral circulation guided by collaboration with a multidisciplinary team.The patient had an uneventful postoperative course and was discharged 14 d after surgery and took rivaroxaban orally for 6 mo.In subsequent follow-up to date,the patient has not complained of any other discomfort.CONCLUSION AMI induced by PMSVT should be considered in young women who are taking oral contraceptives and have acute abdominal pain.Prompt anticoagulation followed by surgery is an effective treatment strategy.展开更多
Objective: Obesity has become a worldwide epidemic that is directly related to chronic tissue inflammation and impaired fibrinolysis, both of which lead to an increased risk of thrombosis. The management of complicati...Objective: Obesity has become a worldwide epidemic that is directly related to chronic tissue inflammation and impaired fibrinolysis, both of which lead to an increased risk of thrombosis. The management of complications after bariatric surgery is still a challenge. The study aims to report the incidence of portomesenteric venous thrombosis (PMVT) in patients undergoing bariatric surgery. Introduction: Bariatric surgery is the procedure of choice for the treatment of obesity type III. Despite the safe technique, the surgeon must be aware of the risks linked to laparoscopy such as the PMVT. Computed tomography (CT) with intravenous contrast was the imaging method of choice for diagnosis. Materials and Methods: We performed a retrospective analysis of 4790 patients from August 1999 to June 2020 was observed the incidence of PMVT in this group. Of all patients, 72.8% were female and 27.2% male. The mean age was 46.3 years (34 - 72) and the mean BMI before bariatric surgery was 41.4 kg/m<sup>2</sup>. Results: The study showed an incidence of PMVT of 0.12% (N = 6), portal vein thrombosis was of 0.10% (n = 5) and 0.03% of MVT (n = 1). Of these, 72.5% (n = 3473 patients) underwent laparoscopic gastric bypass, 23.6% (n = 1131 patients) were submitted to the laparoscopic sleeve gastrectomy and 3.8% (n = 186 patients) to other procedures. The mean postoperative hospital stay for bariatric surgery was 3.3 days. The average time of hospital stay of patients complicated with PMVT range from 5 to 14 days. No patient died of complications related to PMVT. Conclusion: Portomesenteric vein thrombosis is a rare presentation after laparoscopic bariatric surgery. However, it is a serious complication that has a high index of suspicion for making its diagnosis. Conservative treatment using anticoagulants and thrombolytics is effective, it should always be considered the main treatment option. However, these patients must be followed up in the long term, as late complications can occur in high numbers of patients.展开更多
Pneumatosis intestinalis(PI) is a striking radiological diagnosis. Formerly a rare diagnostic finding, it is becoming more frequently diagnosed due to the wider availability and improvement of computed tomography scan...Pneumatosis intestinalis(PI) is a striking radiological diagnosis. Formerly a rare diagnostic finding, it is becoming more frequently diagnosed due to the wider availability and improvement of computed tomography scan imaging. Once associated only with poor outcome, its clinical and prognostic significance nowadays has to be cross-referenced to the nature of the underlying condition.Multiple mechanisms of pathogenesis have been debated and multiple causes have been detected during the years. All this contributes to creating a broad range of clinical and radiological presentations. The management of patients presenting PI is related to the determining cause if it is identified. Otherwise, in particular if an association with portal venous gas and/or pneumoperitoneum is present, the eventual decision between surgery and non-operative management is challenging,even for stable patients, since this clinical condition is traditionally associated to intestinal ischemia and consequently to pending clinical collapse if not treated.Considering the wide variety of origin and outcomes, PI still remains for surgeons a demanding clinical entity. The manuscript is an updated narrative review and gives some suggestions that may help make the decisional process easier,identifying patients who can benefit from surgical intervention and those who can benefit from non-operative management avoiding unnecessary procedures.展开更多
Intestinal occlusion by internal hernia is not a rare complication(0.2%-5%)after Laparoscopic Roux-en-Y-GBP(LGBP)with higher morbidity and mortality related to mesenteric vessels involvement.In our Center,from October...Intestinal occlusion by internal hernia is not a rare complication(0.2%-5%)after Laparoscopic Roux-en-Y-GBP(LGBP)with higher morbidity and mortality related to mesenteric vessels involvement.In our Center,from October 2009 to April 2013 we have had 17 pts treated for internal hernia on 412 LGBP(4.12%).Clinical case:28-year-old woman,operated of LGBP(BMI=49;comorbidity:diabetes mellitus and arthropathy)about 10mo before,was affected by recurrent abdominal pain with alvus alteration lasting for a week.After vomiting,she went to first aid Unit of a peripheric hospital where she made blood tests,RX and US of abdomen that resulted normal so she was discharged with flu like syndrome diagnosis.After 3 d the patient contacted our Center since her symptoms got worse and was hospitalized.Blood tests showed an alteration of hepatic enzymes and amylases.The abdominal computed tomography(CT)showed the presence of fluid in perisplenic,peri-hepatic areas and in pelvis and a"target like imagine"of"clustered ileal loops"with a superior mesenteric vein(SMV)thrombosis involving the Portal Vein.During the operation,we found a necrosis of80 cm of ileus(about 50 cm downstream the jejuno-jejunal anastomosis)due to an internal hernia through Petersen’s space causing a SMV thrombosis.The necrotic bowel was removed,the internal hernia was reduced and Petersen’space was sutured by not-absorbable running suture.An anticoagulant therapy was begun in the post-operative time and the patient was discharged after 28 d.Conclusions:The internal hernia diagnosis is rarely confirmed by preoperative exams and it is obtained in most cases by laparoscopy but the improvement of technologies and the discover of"new"CT signs interpretation can address to an early laparoscopic treatment for high suspicion cases.展开更多
基金Supported by National Natural Science Foundation of China,No.82373012.
文摘BACKGROUND Pancreatectomy with concomitant portomesenteric vein resection(PVR)enables patients with portomesenteric vein(PV)involvement to achieve radical resection of pancreatic ductal adenocarcinoma,however,early recurrence(ER)is frequently observed.AIM To predict ER and identify patients at high risk of ER for individualized therapy.METHODS Totally 238 patients undergoing pancreatectomy and PVR were retrospectively enrolled and were allocated to the training or validating cohort.Univariate Cox and LASSO regression analyses were performed to construct serum recurrence score(SRS)based on 26 serum-derived parameters.Uni-and multivariate Cox regression analyses of SRS and 18 clinicopathological variables were performed to establish a Nomogram.Receiver operating characteristic curve analysis was used to evaluate the predictive accuracy.Survival analysis was performed using Kaplan-Meier method and log-rank test.RESULTS Independent serum-derived recurrence-relevant factors of LASSO regression model,including postoperative carbohydrate antigen 19-9,postoperative carcinoembryonic antigen,postoperative carbohydrate antigen 125,preoperative albumin(ALB),preoperative platelet to ALB ratio,and postoperative platelets to lymphocytes ratio,were used to construct SRS[area under the curve(AUC):0.855,95%CI:0.786–0.924].Independent risk factors of recurrence,including SRS[hazard ratio(HR):1.688,95%CI:1.075-2.652],pain(HR:1.653,95%CI:1.052-2.598),perineural invasion(HR:2.070,95%CI:0.827-5.182),and PV invasion(HR:1.603,95%CI:1.063-2.417),were used to establish the recurrence nomogram(AUC:0.869,95%CI:0.803-0.934).Patients with either SRS>0.53 or recurrence nomogram score>4.23 were considered at high risk for ER,and had poor long-term outcomes.CONCLUSION The recurrence scoring system unique for pancreatectomy and PVR,will help clinicians in predicting recurrence efficiently and identifying patients at high risk of ER for individualized therapy.
文摘Pneumatosis intestinalis and portomesenteric vein gas are rare and potentially severe radiological findings that occur both in pediatric and adult populations.They actually are radiographic signs of underlying intra-abdominal pathology,abnormality or diagnostic medical interference.If combined with other radiological or clinical signs of intestinal ischemia or sepsis,the prognosis is dismal and urgent laparotomy is mandatory.We report two cases of surgical treatment with ominous outcome in an effort to characterize this finding correctly as an absolute surgical indication or as an additional diagnostic criterion that simply marks a further breakdown of the systems in patients with a long list of severe medical conditions.
文摘BACKGROUND Mesenteric ischemia represents an uncommon complication of splanchnic vein thrombosis,and it is less infrequently seen in young women using oral contraceptives.Diagnosis is often delayed in the emergency room;thus,surgical intervention may be inevitable and the absence of thrombus regression or collateral circulation may lead to further postoperative ischemia and a fatal outcome.CASE SUMMARY We report a 28-year-old female patient on oral contraceptives who presented with acute abdominal pain.Her physical examination findings were not consistent with her symptoms of severe pain and abdominal distention.These findings and her abnormal blood tests raised suspicion of acute mesenteric ischemia(AMI)induced by splanchnic vein thrombosis.Contrast-enhanced abdominal computed tomography revealed ischemia of the small intestine with portomesenteric and splenic vein thrombosis(PMSVT).We treated the case promptly by anticoagulation after diagnosis.We then performed delayed segmental bowel resection after thrombus regression and established collateral circulation guided by collaboration with a multidisciplinary team.The patient had an uneventful postoperative course and was discharged 14 d after surgery and took rivaroxaban orally for 6 mo.In subsequent follow-up to date,the patient has not complained of any other discomfort.CONCLUSION AMI induced by PMSVT should be considered in young women who are taking oral contraceptives and have acute abdominal pain.Prompt anticoagulation followed by surgery is an effective treatment strategy.
文摘Objective: Obesity has become a worldwide epidemic that is directly related to chronic tissue inflammation and impaired fibrinolysis, both of which lead to an increased risk of thrombosis. The management of complications after bariatric surgery is still a challenge. The study aims to report the incidence of portomesenteric venous thrombosis (PMVT) in patients undergoing bariatric surgery. Introduction: Bariatric surgery is the procedure of choice for the treatment of obesity type III. Despite the safe technique, the surgeon must be aware of the risks linked to laparoscopy such as the PMVT. Computed tomography (CT) with intravenous contrast was the imaging method of choice for diagnosis. Materials and Methods: We performed a retrospective analysis of 4790 patients from August 1999 to June 2020 was observed the incidence of PMVT in this group. Of all patients, 72.8% were female and 27.2% male. The mean age was 46.3 years (34 - 72) and the mean BMI before bariatric surgery was 41.4 kg/m<sup>2</sup>. Results: The study showed an incidence of PMVT of 0.12% (N = 6), portal vein thrombosis was of 0.10% (n = 5) and 0.03% of MVT (n = 1). Of these, 72.5% (n = 3473 patients) underwent laparoscopic gastric bypass, 23.6% (n = 1131 patients) were submitted to the laparoscopic sleeve gastrectomy and 3.8% (n = 186 patients) to other procedures. The mean postoperative hospital stay for bariatric surgery was 3.3 days. The average time of hospital stay of patients complicated with PMVT range from 5 to 14 days. No patient died of complications related to PMVT. Conclusion: Portomesenteric vein thrombosis is a rare presentation after laparoscopic bariatric surgery. However, it is a serious complication that has a high index of suspicion for making its diagnosis. Conservative treatment using anticoagulants and thrombolytics is effective, it should always be considered the main treatment option. However, these patients must be followed up in the long term, as late complications can occur in high numbers of patients.
文摘Pneumatosis intestinalis(PI) is a striking radiological diagnosis. Formerly a rare diagnostic finding, it is becoming more frequently diagnosed due to the wider availability and improvement of computed tomography scan imaging. Once associated only with poor outcome, its clinical and prognostic significance nowadays has to be cross-referenced to the nature of the underlying condition.Multiple mechanisms of pathogenesis have been debated and multiple causes have been detected during the years. All this contributes to creating a broad range of clinical and radiological presentations. The management of patients presenting PI is related to the determining cause if it is identified. Otherwise, in particular if an association with portal venous gas and/or pneumoperitoneum is present, the eventual decision between surgery and non-operative management is challenging,even for stable patients, since this clinical condition is traditionally associated to intestinal ischemia and consequently to pending clinical collapse if not treated.Considering the wide variety of origin and outcomes, PI still remains for surgeons a demanding clinical entity. The manuscript is an updated narrative review and gives some suggestions that may help make the decisional process easier,identifying patients who can benefit from surgical intervention and those who can benefit from non-operative management avoiding unnecessary procedures.
文摘Intestinal occlusion by internal hernia is not a rare complication(0.2%-5%)after Laparoscopic Roux-en-Y-GBP(LGBP)with higher morbidity and mortality related to mesenteric vessels involvement.In our Center,from October 2009 to April 2013 we have had 17 pts treated for internal hernia on 412 LGBP(4.12%).Clinical case:28-year-old woman,operated of LGBP(BMI=49;comorbidity:diabetes mellitus and arthropathy)about 10mo before,was affected by recurrent abdominal pain with alvus alteration lasting for a week.After vomiting,she went to first aid Unit of a peripheric hospital where she made blood tests,RX and US of abdomen that resulted normal so she was discharged with flu like syndrome diagnosis.After 3 d the patient contacted our Center since her symptoms got worse and was hospitalized.Blood tests showed an alteration of hepatic enzymes and amylases.The abdominal computed tomography(CT)showed the presence of fluid in perisplenic,peri-hepatic areas and in pelvis and a"target like imagine"of"clustered ileal loops"with a superior mesenteric vein(SMV)thrombosis involving the Portal Vein.During the operation,we found a necrosis of80 cm of ileus(about 50 cm downstream the jejuno-jejunal anastomosis)due to an internal hernia through Petersen’s space causing a SMV thrombosis.The necrotic bowel was removed,the internal hernia was reduced and Petersen’space was sutured by not-absorbable running suture.An anticoagulant therapy was begun in the post-operative time and the patient was discharged after 28 d.Conclusions:The internal hernia diagnosis is rarely confirmed by preoperative exams and it is obtained in most cases by laparoscopy but the improvement of technologies and the discover of"new"CT signs interpretation can address to an early laparoscopic treatment for high suspicion cases.
