Purpose
A preoperative estimate of the risk of malignancy for intraductal papillary mucinous neoplasms (IPMN) is important. The present study carries out an external validation of the Shin score in a ...European multicenter cohort.
Methods
An observational multicenter European study from 2010 to 2015. All consecutive patients undergoing surgery for IPMN at 35 hospitals with histological-confirmed IPMN were included.
Results
A total of 567 patients were included. The score was significantly associated with the presence of malignancy (
p
< 0.001). In all, 64% of the patients with benign IPMN had a Shin score < 3 and 57% of those with a diagnosis of malignancy had a score ≥ 3. The relative risk (
RR
) with a Shin score of 3 was 1.37 (95%
CI
: 1.07–1.77), with a sensitivity of 57.1% and specificity of 64.4%.
Conclusion
Patients with a Shin score ≤ 1 should undergo surveillance, while patients with a score ≥ 4 should undergo surgery. Treatment of patients with Shin scores of 2 or 3 should be individualized because these scores cannot accurately predict malignancy of IPMNs. This score should not be the only criterion and should be applied in accordance with agreed clinical guidelines.
Being able to predict preoperatively the difficulty of a cholecystectomy can increase safety and improve results. However, there is a need to reach a consensus on the definition of a cholecystectomy ...as “difficult”. The aim of this study is to achieve a national expert consensus on this issue.
A two-round Delphi study was performed. Based on the previous literature, history of biliary pathology, preoperative clinical, analytical, and radiological data, and intraoperative findings were selected as variables of interest and rated on a Likert scale.
Inter-rater agreement was defined as “unanimous” when 100% of the participants gave an item the same rating on the Likert scale; as “consensus” when ≥80% agreed; as “majority” when the agreement was ≥70%. The delta of change between the two rounds was calculated.
After the two rounds, the criteria that reached “consensus” were bile duct injury (96.77%), non-evident anatomy (93.55%), Mirizzi syndrome (93.55%), severe inflammation of Calot's triangle (90.32%), conversion to laparotomy (87.10%), time since last acute cholecystitis (83.87%), scleroatrophic gallbladder (80.65%) and pericholecystic abscess (80.65%).
The ability to predict difficulty in cholecystectomy offers important advantages in terms of surgical safety. As a preliminary step, the items that define a surgical procedure as difficult should be established. Standardization of the criteria can provide scores to predict difficulty both preoperatively and intraoperatively, and thus allow the comparison of groups of similar difficulty.
•There is not a clear definition of “difficult” cholecystectomy.•National survey to reach consensus on the definition of difficult cholecystectomy.•Predicting the difficulty offers major advantages in terms of surgical safety.
A clinical case is presented about a rare presentation of pancreatic cancer. Firstly, pancreatic cancer rarely metastasizes to the ovary, and when it does, it usually presents in the form of ...peritoneal carcinomatosis and bilateral involvement. However, the initial radiological diagnosis was primary pancreatic carcinoma with a synchronous primary ovarian carcinoma. Once analyzed pathologically, it was concluded that it was ovarian metastasis from pancreatic cancer. Given the diagnostic difficulty along with the patient's long survival, an exceptional case is presented.A clinical case is presented about a rare presentation of pancreatic cancer. Firstly, pancreatic cancer rarely metastasizes to the ovary, and when it does, it usually presents in the form of peritoneal carcinomatosis and bilateral involvement. However, the initial radiological diagnosis was primary pancreatic carcinoma with a synchronous primary ovarian carcinoma. Once analyzed pathologically, it was concluded that it was ovarian metastasis from pancreatic cancer. Given the diagnostic difficulty along with the patient's long survival, an exceptional case is presented.
Introduction
Enhanced recovery after surgery (ERAS) has been shown to facilitate discharge, decrease length of stay, improve outcomes and reduce costs. We used this concept to design a comprehensive ...fast-track pathway (OR-to-discharge) before starting our liver transplant activity and then applied this protocol prospectively to every patient undergoing liver transplantation at our institution, monitoring the results periodically. We now report our first six years results.
Patients and methods
Prospective cohort study of all the liver transplants performed at our institution for the first six years. Balanced general anesthesia, fluid restriction, thromboelastometry, inferior vena cava preservation and temporary portocaval shunt were strategies common to all cases. Standard immunosuppression administered included steroids, tacrolimus (delayed in the setting of renal impairment, with basiliximab induction added) and mycophenolate mofetil. Tacrolimus dosing was adjusted using a Bayesian estimation methodology. Oral intake and ambulation were started early.
Results
A total of 240 transplants were performed in 236 patients (191♂/45♀) over 74 months, mean age 56.3±9.6 years, raw MELD score 15.5±7.7. Predominant etiologies were alcohol (
n
= 136) and HCV (
n
= 82), with hepatocellular carcinoma present in 129 (54.7%). Nine patients received combined liver and kidney transplants. The mean operating time was 315±64 min with cold ischemia times of 279±88 min. Thirty-one patients (13.1%) were transfused in the OR (2.4±1.2 units of PRBC). Extubation was immediate (< 30 min) in all but four patients. Median ICU length of stay was 12.7 hours, and median post-transplant hospital stay was 4 days (2-76) with 30 patients (13.8%) going home by day 2, 87 (39.9%) by day 3, and 133 (61%) by day 4, defining our fast-track group. Thirty-day-readmission rate (34.9%) was significantly lower (28.6% vs. 44.7%
p
=0.015) in the fast-track group. Patient survival was 86.8% at 1 year and 78.6% at five years.
Conclusion
Fast-Tracking of Liver Transplant patients is feasible and can be applied as the standard of care
Hepatic epithelioid hemangioendothelioma (HEHE) is an extremely rare vascular tumor of unclear etiology. The diagnosis is difficult due to the absence of specific clinical characteristics, laboratory ...tests results and radiological findings. The management of HEHE depends on tumor size, location, extrahepatic extension, and patients’ medical status. Liver transplantation is one of the possible options with good clinical results, although the risk of recurrence is not negligible. We present a new case of HEHE managed with liver transplantation.
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