In routine intensive care unit (ICU) practice, fluids are often administered without a safety limit, which may lead to fluid overload and decreased survival. Recently, B-lines score (BLS) has been ...validated as a lung ultrasound (LUS) quantification of pulmonary congestion. This suggests that LUS may provide a safety threshold to conduct fluid therapy and to avoid overhydration. However, there is no randomized study to test the utility of LUS in guiding fluid management in ICU patients by using a pre-specified BLS cut-off value as a threshold for fluid removal.
LUS Guided Fluid Management Protocol for the Critically Ill Patient is a prospective, multi-centre, randomized controlled trial. Five hundred ICU patients will be randomly assigned in a 1:1 ratio, to protocolized LUS-based fluid management or usual care. The trial intervention will start on ICU admission and will consist in daily assessment of BLS and triggered evacuation of excessive fluids with loop diuretics (Furosemide) when BLS ≥ 15. If rebalancing volume status with diuretics fails, forced evacuation by ultrafiltration will be used. The main endpoint is death from all causes at 28 days from randomization. The secondary outcomes are presence and time-course evolution of organ dysfunctions, ICU- and hospital length of stay, all-cause mortality at 90 days, and health economics data.
If study results will show that LUS guided fluid management protocol improves outcome in ICU patients, it will be the base for other studies to refine this protocol or track those categories of critically ill patients to whom it may bring maximum benefits.
ClinicalTrials.gov, NCT03393065 . Registered on 8 January 2018.
Modern antineoplastic therapy improves survival and quality of life in cancer patients, but its indisputable benefits are accompanied by multiple and major side effects, such as cardiovascular ones. ...Endothelial dysfunction, arterial spasm, intravascular thrombosis, and accelerated atherosclerosis affect the coronary arteries, leading to acute and chronic coronary syndromes that negatively interfere with the oncologic treatment. The cardiac toxicity of antineoplastic agents may be mitigated by using adequate prophylactic measures. In the absence of dedicated guidelines, our work provides the most comprehensive, systematized, structured, and up-to-date analyses of the available literature focusing on measures aiming to protect the coronary arteries from the toxicity of cancer therapy. Our work facilitates the implementation of these measures in daily practice. The ultimate goal is to offer clinicians the necessary data for a personalized therapeutic approach for cancer patients receiving evidence-based oncology treatments with potential cardiovascular toxicity.
Pylorus preserving (PP) pancreaticoduodenectomy (PD) has several advantages in terms of shorter operation time and improved nutritional status but with an increased risk for delayed gastric emptying.
...We performed a retrospective study on all patients in which PD was performed from May 2012 to May 2018. It was analyzed early postoperative outcomes and the incidence of delayed gastric emptying (DGE) syndrome for patients with pylorus PP PD technique and pancreaticogastrostomy (PG).
There were 47 PD, in which PP technique was performed in 42 cases. The tumour location was in the pancreatic head (n=21, 44.68%), periampullary (ampulla of Vater) (n=14,29.78%), distal bile duct (n=7,14.89%), duodenum (n=2, 4.25%) and advanced right colon cancer (n=3, 6.38%). There were 10 cases (21.2%) of grade III-V complications, grade A pancreatic fistula (PF)8 cases (17%), grade B in 3 cases (6.4%) and grade C in 1 case (2.12%). DGE was encountered in 17 cases (36.17%), grade A 2 cases (4.25%), grade B in 4 cases (8.5%) and grade C in 2 cases (4.25%). Biliary fistula occurred in 3 cases (6.4%) and in 4 cases relaparotomy was needed.
The results of our study are concluding with the previous studies, the addition of PG to PP PD does not increase the risk of DGE.
Metastatic breast cancer has a very poor prognosis, considering the lack of reliable curative medical or surgical approaches. Patients with stage IV breast cancer usually undergo palliative surgical ...procedures and symptomatic treatment. In a 5-year period, 1258 patients with breast cancer were treated in our surgical oncology unit. For the current study, we have selected 19 (1.43%) female patients with intraabdominal metastases (peritoneal, hepatic, ovarian etc.) derived from breast cancer, which received at least one surgical procedure in our unit. We compared our data with up-to-date reports and guidelines in order to establish the role and further directions of surgery, and (most importantly) the necessity of surgery itself in the management of this therapeutically disadvantaged patient-group. Even if current guidelines do not recommend surgical treatment of intraabdominal metastases derived from breast cancer, several oncology centers (including our unit) did not discard surgery, especially in patients with solitary metastasis.Keywords: metastatic breast cancer, peritoneal metastases, liver metastases, ovarian metastases, unusual origin metastases, cytoreductive surgery, HIPEC
Gastroenteropancreatic neuroendocrine carcinomas (GEP-NENs) represent a heterogeneous group of rare tumors. The incidence of GEP-NENs has increased worldwide over the past decades, with the small ...intestine, rectum, and pancreas as the most common tumor locations. The epidemiological characteristics, pathogenesis and treatment have raised many questions, and some of them are still being debated. Here, we report a case of gastric collision tumor with large-cell neuroendocrine carcinoma and adenocarcinoma. A 73-year-old male patient with a history of gastric resection performed 30 years ago, with no medical records revealing the type of resection or the reconstructive way, presented with epigastric pain. The endoscopy revealed a solid, ulcerated mass at the gastrojejunal anastomosis site from which a tissue biopsy was taken, which was reported as adenocarcinoma. For staging, the patient underwent an abdominal CT scan, which showed the thickening of the gastric wall adjacent to anastomosis and perilesional adenopathy. The patient underwent a subtotal gastrectomy and regional lymphadenectomy. A diagnosis of large-cell neuroendocrine carcinoma developed on the gastric stump associated with isolated foci of moderately differentiated tubular adenocarcinoma pT3N1G3 was made. Immunohistochemical analysis is essential for the diagnosis and classification of the lesion. To confirm the diagnosis, Chromogranin A and Synaptophysin are needed, and for prognostic evaluation the identification of Ki-67 and mitotic figure count are required.Keywords: neuroendocrine tumor; gastric carcinoma; adenoneuroendocrine carcinoma; G-NET; surgery.
Background/Objective
Although promising, data regarding the renal impact and safety of bariatric surgery (BS) are insufficient. We aimed at investigating the benefits and harms of BS for weight loss ...on kidney function.
Methods
A systematic review and meta-analysis of observational studies reporting data about the impact of BS (any techniques) on serum/plasma creatinine, creatinine clearance, glomerular filtration rate (GFR), proteinuria, nephrolithiasis, and need for renal replacement therapy (RRT)) was performed. Obese adults (non-chronic kidney disease (CKD), CKD or transplanted patients) that underwent BS for weight loss were included. After searching MEDLINE (inception to August 2017), the Cochrane Library (Issue 10–12, October 2017), and the
websiteclinicaltrials.gov
(August 2017), data were extracted and summarized using a random-effects model.
Results
The final analysis included 23 cohort studies, comprising 3015 participants. Compared with renal function before treatment, BS significantly decreased serum creatinine level (mean difference (MD), − 0.08 mg dl
−1
; 95% confidence interval (CI), − 0.10 to − 0.06);
p
< 0.001) and proteinuria (MD, − 0.04 g 24 h
−1
; 95% CI, − 0.06 to − 0.02;
p
< 0.001) in the overall group. GFR significantly improved 6 months or more after BS both in the hyperfiltration and CKD subgroups. Renal function also tended to improve in renal transplant patients. Data on nephrolithiasis and the need for RRT were scarce or not reported.
Conclusions
BS apparently has positive effects on kidney function and tends to normalize GFR across different categories of renal impairment (hyperfiltration and CKD patients).
Cholangiocarcinoma (CCA) is a rare and heterogeneous biliary cancer, whose incidence and related mortality is increasing. This study investigates the clinical course of CCA and subtypes (intrahepatic ...iCCA, perihilar pCCA, and distal dCCA) in a pan-European cohort.
The ENSCCA Registry is a multicenter observational study. Patients were included if they had a histologically proven diagnosis of CCA between 2010-2019. Demographic, histomorphological, biochemical, and clinical studies were performed.
Overall, 2,234 patients were enrolled (male/female=1.29). iCCA (n = 1,243) was associated with overweight/obesity and chronic liver diseases involving cirrhosis and/or viral hepatitis; pCCA (n = 592) with primary sclerosing cholangitis; and dCCA (n = 399) with choledocholithiasis. At diagnosis, 42.2% of patients had local disease, 29.4% locally advanced disease (LAD), and 28.4% metastatic disease (MD). Serum CEA and CA19-9 showed low diagnostic sensitivity, but their concomitant elevation was associated with increased risk of presenting with LAD (odds ratio 2.16; 95% CI 1.43-3.27) or MD (odds ratio 5.88; 95% CI 3.69-9.25). Patients undergoing resection (50.3%) had the best outcomes, particularly with negative-resection margin (R0) (median overall survival mOS = 45.1 months); however, margin involvement (R1) (hazard ratio 1.92; 95% CI 1.53-2.41; mOS = 24.7 months) and lymph node invasion (hazard ratio 2.13; 95% CI 1.55-2.94; mOS = 23.3 months) compromised prognosis. Among patients with unresectable disease (49.6%), the mOS was 10.6 months for those receiving active palliative therapies, mostly chemotherapy (26.2%), and 4.0 months for those receiving best supportive care (20.6%). iCCAs were associated with worse outcomes than p/dCCAs. ECOG performance status, MD and CA19-9 were independent prognostic factors.
CCA is frequently diagnosed at an advanced stage, a proportion of patients fail to receive cancer-specific therapies, and prognosis remains dismal. Identification of preventable risk factors and implementation of surveillance in high-risk populations are required to decrease cancer-related mortality.
This is, to date, the largest international (pan-European: 26 hospitals and 11 countries) observational study, in which the course of cholangiocarcinoma has been investigated, comparing the 3 subtypes based on the latest International Classification of Diseases 11th Edition (ICD-11) (i.e., intrahepatic 2C12, perihilar 2C18, or distal 2C15 affected bile ducts), which come into effect in 2022. General and tumor-type specific features at diagnosis, risk factors, biomarker accuracy, as well as patient management and outcomes, are presented and compared, outlining the current clinical state of cholangiocarcinoma in Europe.
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•CCA subtypes present different risk factors and tumor features.•CA19-9 shows low sensitivity in early stages but increased sensitivity in advanced disease.•Under surgery, positive margins and lymph node invasion compromise survival.•ECOG-PS, disease status and CA19-9 are independent prognostic factors.
Perineal eventration (PE) is a rare complication after the lower rectal cancer resection surgery, affecting the quality of life of the patient. In 5.5 years of evolution, out of 620 patients with ...rectal cancer treated by curative surgery, 176 patients with lower ampullary rectal cancer treated by abdominoperineal resection (APR) with the closure of the defect by direct suture of the perineal floor were selected. Ten (5.6%) of them were diagnosed with PE. This paper shows the results of a retrospective study, which compares the clinico-pathological and therapeutic aspects of a subgroup of 166 patients (subgroup I) with APR without PE and a subgroup of 10 patients (subgroup II) with PE. Starting from the question of whether aspects can influence the evolution of PE, we aimed to investigate the similarities and differences between these two groups, from the histological, clinical and therapeutic points of view. Regarding the tumor, node, metastasis (TNM) staging, we encountered the following aspects: for the subgroup II with PE, pT3 predominated, stages N0 and N1 were equal (50%) and the absence of metastases (M0) was found in all cases; in subgroup I, pT3 and N0 also predominated, followed by N1 and N2, and for stage M, M0 is predominant, followed by M1. For the clinical profile of the PE group, the symptoms were characteristic, with the presence of the usual triggering factors hysterectomy, radiochemotherapy and wide resection surgery – extralevatorial APR. The therapeutic approach revealed various aspects, including plastic surgery procedures (direct closure, meshes, flaps) used in pelvic reconstruction. The accurate surgical technique applied in order to achieve oncological safety allowed for a longer survival, which favored the appearance of PE in addition to the other favoring factors. Our results underlined the clinico-pathological profile of the two subgroups, without being able to establish a correlation with the appearance and evolution of PE. However, the clinico-pathological risk factors for this condition are not yet fully defined. Therefore, reports based on the experience in the diagnosis and treatment of PE should bring valuable data, aiming to create the knowledge framework for prevention.
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