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Background: Robot-assisted distal pancreatectomy (RDP) is increasingly used as an alternative to laparoscopic distal pancreatectomy (LDP) in patients with resectable pancreatic cancer but comparative multicenter studies confirming the safety and efficacy of RDP are lacking., Methods: An international, multicenter, retrospective, cohort study, including consecutive patients undergoing RDP and LDP for resectable pancreatic cancer in 33 experienced centers from 11 countries (2010-2019). The primary outcome was R0-resection. Secondary outcomes included lymph node yield, major complications, conversion rate, and overall survival., Results: In total, 542 patients after minimally invasive distal pancreatectomy were included: 103 RDP (19%) and 439 LDP (81%). The R0-resection rate was comparable (75.7% RDP vs. 69.3% LDP, p = 0.404). RDP was associated with longer operative time (290 vs. 240 min, p < 0.001), more vascular resections (7.6% vs. 2.7%, p = 0.030), lower conversion rate (4.9% vs. 17.3%, p = 0.001), more major complications (26.2% vs. 16.3%, p = 0.019), improved lymph node yield (18 vs. 16, p = 0.021), and longer hospital stay (10 vs. 8 days, p = 0.001). The 90-day mortality (1.9% vs. 0.7%, p = 0.268) and overall survival (median 28 vs. 31 months, p = 0.599) did not differ significantly between RDP and LDP, respectively., Conclusions: In selected patients with resectable pancreatic cancer, RDP and LDP provide a comparable R0-resection rate and overall survival in experienced centers. Although the lymph node yield and conversion rate appeared favorable after RDP, LDP was associated with shorter operating time, less major complications, and shorter hospital stay. The specific benefits associated with each approach should be confirmed by multicenter, randomized trials., (© 2023. The Author(s).)

Background: The European registry for minimally invasive pancreatic surgery (E-MIPS) collects data on laparoscopic and robotic MIPS in low- and high-volume centers across Europe., Methods: Analysis of the first year (2019) of the E-MIPS registry, including minimally invasive distal pancreatectomy (MIDP) and minimally invasive pancreatoduodenectomy (MIPD). Primary outcome was 90-day mortality., Results: Overall, 959 patients from 54 centers in 15 countries were included, 558 patients underwent MIDP and 401 patients MIPD. Median volume of MIDP was 10 (7-20) and 9 (2-20) for MIPD. Median use of MIDP was 56.0% (IQR 39.0-77.3%) and median use of MIPD 27.7% (IQR 9.7-45.3%). MIDP was mostly performed laparoscopic (401/558, 71.9%) and MIPD mostly robotic (234/401, 58.3%). MIPD was performed in 50/54 (89.3%) centers, of which 15/50 (30.0%) performed ≥20 MIPD annually. This was 30/54 (55.6%) centers and 13/30 (43%) centers for MIPD respectively. Conversion rate was 10.9% for MIDP and 8.4% for MIPD. Overall 90 day mortality was 1.1% (n = 6) for MIDP and 3.7% (n = 15) for MIPD., Conclusion: Within the E-MIPS registry, MIDP is performed in about half of all patients, mostly using laparoscopy. MIPD is performed in about a quarter of patients, slightly more often using the robotic approach. A minority of centers met the Miami guideline volume criteria for MIPD., (Copyright © 2022. Published by Elsevier Ltd.)

Cancer-related mortality is primarily a consequence of metastatic dissemination and associated complications. Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignancies and tends to metastasize early, especially in the liver. Emerging evidence suggests that organs that develop metastases exhibit microscopic changes that favor metastatic growth, collectively known as "pre-metastatic niches". By definition, a pre-metastatic niche is chronologically established before overt metastatic outgrowth, and its generation involves the release of tumor-derived secreted factors that modulate cells intrinsic to the recipient organ, as well as recruitment of additional cells from tertiary sites, such as bone marrow-all orchestrated by the primary tumor. The pre-metastatic niche is characterized by tumor-promoting inflammation with tumor-supportive and immune-suppressive features, remodeling of the extracellular matrix, angiogenic modulation and metabolic alterations that support growth of disseminated tumor cells. In this paper, we review the current state of knowledge of the hepatic pre-metastatic niche in PDAC and attempt to create a framework to guide future diagnostic and therapeutic studies.

Background: Preoperative patient selection in Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is not always reliable with currently available scores, particularly in patients with primary liver tumor. This study aims to (I) to determine whether comorbidities and patients characteristics are a risk factor in ALPPS and (II) to create a score predicting 90-day mortality preoperatively., Methods: Thirteen high-volume centers participated in this retrospective multicentric study. A risk analysis based on patient characteristics, underlying disease and procedure type was performed to identify risk factors and model the Comprehensive ALPPS Preoperative Risk Assessment (CAPRA) score. A nonparametric receiver operating characteristic analysis was performed to estimate the predictive ability of our score against the Charlson Comorbidity Index (CCI), the age-adjusted CCI (aCCI), the ALPPS risk score before Stage 1 (ALPPS-RS1) and Stage 2 (ALPPS-RS2). The model was internally validated applying bootstrapping., Results: A total of 451 patients were included. Mortality was 14.4%. The CAPRA score is calculated based on the following formula: (0.1 × age) - (2 × BSA) + 1 (in the presence of primary liver tumor) + 1 (in the presence of severe cardiovascular disease) + 2 (in the presence of moderate or severe diabetes) + 2 (in the presence of renal disease) + 2 (if classic ALPPS is planned). The predictive ability was 0.837 for the CAPRA score, 0.443 for CCI, 0.519 for aCCI, 0.693 for ALPPS-RS1 and 0.807 for ALPPS-RS2. After 1,000 cycles of bootstrapping the C statistic was 0.793. The accuracy plot revealed a cut-off for optimal prediction of postoperative mortality of 4.70., Conclusions: Comorbidities play an important role in ALPPS and should be carefully considered when planning the procedure. By assessing the patient's preoperative condition in relation to ALPPS, the CAPRA score has a very good ability to predict postoperative mortality., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-21-396/coif). HP and TMvG serve as unpaid editorial board members of Hepatobiliary Surgery and Nutrition. The other authors have no conflicts of interest to declare., (2022 Hepatobiliary Surgery and Nutrition. All rights reserved.)

Background: ALPPS is found to increase the resectability of primary and secondary liver malignancy at the advanced stage. The aim of the study was to verify the surgical and oncological outcome of ALPPS for intrahepatic cholangiocarcinoma (ICC)., Methods: The study cohort was based on the ALPPS registry with patients from 31 international centers between August 2009 and January 2018. Propensity score matched patients receiving chemotherapy only were selected from the SEER database as controls for the survival analysis., Results: One hundred and two patients undergoing ALPPS were recruited, 99 completed the second stage with median inter-stage duration of 11 days. The median kinetic growth rate was 23 ml/day. R0 resection was achieved in 87 (85%). Initially high rates of morbidity and mortality decreased steadily to a 29% severe complication rate and 7% 90-day morbidity in the last 2 years. Post-hepatectomy liver failure remained the main cause of 90-day mortality. Multivariate analysis revealed insufficient future liver remnant at the stage-2 operation (FLR2) to be the only risk factor for severe complications (OR 2.91, p = 0.02). The propensity score matching analysis showed a superior overall survival in the ALPPS group compared to palliative chemotherapy (median overall survival: 26.4 months vs 14 months; 1-, 2-, and 3-year survival rates: 82.4%, 70.5% and 39.6% vs 51.2%, 21.4% and 11.3%, respectively, p < 0.01). The survival benefit, however, was not confirmed in the subgroup analysis for patients with insufficient FLR2 or multifocal ICC., Conclusion: ALPPS showed high efficacy in achieving R0 resections in locally advanced ICC. To get the most oncological benefit from this aggressive surgery, ALPPS would be restricted to patients with single lesions and sufficient FLR2.

Short-duration precipitation bursts can cause substantial property damage and pose operational risks for wastewater managers. The objective of this study was to assess the present and possible future flood hazard in the combined sewer system in Reykjavik city centre. The catchment is characterised by two hills separated by a plain. A large portion of the pipes in the aging network are smaller than the current minimum diameter of 250 mm. Runoff and sewer flows were modelled using the MIKE URBAN software package incorporating both historical precipitation and synthetic storms derived from annual maximum rainfall data. Results suggest that 3% of public network manholes were vulnerable to flooding during an 11-year long rainfall sequence. A Chicago Design Storm (CDS) incorporating a 10-minute rainfall burst with a 5-year return period predicted twice as many flooded manholes at similar locations. A 20% increase in CDS intensity increased the number of flooded manholes and surface flood volume by 70% and 80%, respectively. The flood volume tripled if rainfall increase were combined with urban re-development, leading to a 20% increase in the runoff coefficient. Results highlight the need for reducing network vulnerabilities, which include decreased pipe diameters and low or drastically varying pipe grades.

Objective: To evaluate the long-term outcome of elective splenectomy, with emphasis on the incidence of complications, vaccine immunization and patient´s knowledge about asplenia., Material and Methods: Medical reports of all patients, who underwent elective splenectomy during the time period of 1993-2004, were reviewed. Questionnaire was sent to 96% (44/46) patients alive., Results: The average age was 50 (8-83) years. Thirty-five patients were male and 32 were female. Eighty percent responded to the questionnaire. Most of the patients (31) had idiopathic thrombocytopenic purpura (ITP). Complete response was obtained in 60% (18/30) and partial response in 23% (7/30). Five patients had spherocytosis and all of them had complete response. None of the three patients with autoimmune hemolytic anemia had any response to the splenectomy. Patients were vaccinated against pneumococci in 92% of the cases. In 44% of the cases revaccination was done. Only 41% of those who answered experienced that they had got a good education about the consequences of asplenia. Sixteen percent of the patients (10/64) had major postoperative complications. One patient with metastatic cancer and thrombocytopenia died within 30 days of surgery. Five patients had long-term complications. Two had pneumococcal sepsis, one of them was unvaccinated and the other had not been revaccinated., Conclusion: Splenectomy has a good long-term outcome for spherocytosis and ITP patients. The incidence of complications is high. It is possible that better guidelines and better patient´s education can lower the complication rate and improve the outcome.

Background: Laparoscopic adrenalectomy (LA) was first performed in Iceland in 1997. Since then, all procedures for presumed benign lesions of the adrenals have been performed laparoscopically in a single center. Compared with conventional adrenalectomy, LA appears to achieve superior results in terms of recovery, hospital stay, and morbidity. This study aimed to evaluate the results of LA in Iceland., Methods: The hospital records of all patients who underwent LA in Iceland from 1997 through 2005 were reviewed. The preoperative diagnosis was documented, as well as the pathologic diagnosis, operative details, complications, and length of hospital stay., Results: In 49 operations, 53 adrenal glands were removed from 48 patients (37 women and 11 men). The mean patient age was 53.6 years (range, 24.4-78.8 years). The left adrenal was removed from 29 patients, the right adrenal from 14 patients, and both adrenals from 5 patients. The most common indications and diagnoses included 17 nonsecreting tumors (12 adenomas, 3 hyperplasias, 1 complex adrenal cyst, and 1 hemangioma), 12 aldosteronomas (10 aldosteronomas and 2 nodular hyperplasias), and 10 pheochromocytomas (9 confirmed, 1 adrenal hyperplasia). Other indications and diagnoses were less common. The mean operative time was 168 min (range, 87-370 min) for unilateral operations and 412 min (range, 345-480 min) for bilateral operations. The mean blood loss was 117 ml (range, 0-650 ml) for unilateral operations and 200 ml (range, 0-350 ml) for bilateral operations. The complications were mild pancreatitis (n = 1), urinary tract infection (n = 1), atelectasis (n = 1), mild congestive heart failure (n = 2), and transient corneal abrasion (n = 1). No conversion to open procedure was needed. The mean tumor size was 3.5 cm (range, 1.5-6.2 cm), and the mean postoperative hospital stay was 2.6 days (range, 1-6 days)., Conclusion: The results of laparoscopic adrenalectomies in Iceland for benign lesions of the adrenals are comparable with published results from large referral centers.

Purpose: Histological changes in lymph nodes simulating metastatic prostatic adenocarcinoma are reported., Materials and Methods: Lymph node frozen sections from 3 patients with prostatic cancer displayed marked histiocytosis. This tissue was subjected to histochemical, immunohistochemical and electron microscopic studies., Results: Only 1 erroneous diagnosis of metastasis was made. All patients had hip prostheses for at least 6 years. Tissue replacing up to 80% of lymph nodes consisted of histiocytes containing large amounts of polyethylene., Conclusions: Hip replacement predisposes the patient to have pelvic lymph node histiocytosis mimicking metastatic adenocarcinoma. This history should be communicated to the pathologist. Polyethylene is the most important factor in the cause of post-prosthesis lymph node histiocytosis.

We present 10 cases of mixed cryoglobulinemia in patients infected with hepatitis C, including pertinent clinical, serologic, and pathological data. The findings attributable to MC appear to be similar in patients who are HCV-infected as in those with unknown HCV status. The prevalence of MC in HCV-infected patients appears to be lower in our region (13%) than in southern Europe (50-90%) although some of this difference is due to our requirement that patients included in our study have a cryocrit of at least 5%. In our patients, cryoglobulins were shown to be deposited in skin and kidney, but not in liver. The mechanisms by which HCV and MC are related remain uncertain. Although we and others have evidence for enrichment of HCV RNA in the cryoprecipitates of some patients, this was not always the case, and it is not yet clear that this finding is of fundamental pathogenic importance. Finally, it appears that some patients with HCV and MC may have a beneficial clinical response of vasculitic symptoms to therapy with alpha-interferon, as well as to glucocorticoids or other immunosuppressants. In our group, no predictors were apparent to distinguish responders from nonresponders before treatment. Similarly, the duration of response remains to be determined.

The efficacy of frozen section in detecting metastases in pelvic and or periaortic lymph nodes during radical hysterectomy is unknown. The finding of positive nodes may result in termination of the operative procedure. In this study, we attempted to determine the accuracy of frozen sections in this situation. Intraoperative pathology consultation records were examined for 127 patients undergoing surgical exploration for radical hysterectomy between 1977 and 1992. Microscopic slides of lymph nodes were reviewed for accuracy. Metastasis diameters were measured and blocks cut five close microtome levels deeper. In 19 cases (15%) positive nodes were documented on permanent section, with metastases ranging in size from less than 1 to 19 mm. Thirteen cases of node metastasis were diagnosed at frozen section. All were suspicious to the pathologist on palpation and gross inspection after bisection. Six cases were missed by sampling error on frozen section; in 4, metastases were smaller than 1 mm; in 1, between 2 and 3 mm; and in 1, 19 mm. The sensitivity was 68%, the false-negative rate was 32%, and the specificity was 100%. No cases were false positive at frozen section. The frequency of nodal metastasis and detection rate by frozen section did not differ significantly between carcinoma types. No micrometastases (< 2 mm) were detected by frozen section. All micrometastases were no longer present within five microtome levels. Frozen section diagnosis of pelvic node metastasis is a highly specific procedure which should alter intraoperative management of early-stage cervical cancer.

The effects of estradiol-17 beta (E2) implants on plasma prolactin (PRL) concentrations, pituitary PRL content and pituitary PRL mRNA levels were examined in rainbow trout (Oncorhynchus mykiss). Intact immature fish treated with 1 mg estradiol-17 beta did not show significant changes in both PRL mRNA levels and pituitary PRL content after 3 days of treatment. In a similar experiment, no changes were observed in plasma PRL levels followed during 7 days. Similarly, lack of estradiol-17 beta effect on plasma PRL levels and on final PRL pituitary content was observed in ovariectomized female rainbow trout treated during 48 days with 25 mg estradiol-17 beta and in mature male fish over a 3-week treatment period. Localization of estradiol receptor (ER) mRNAs in the pituitary was carried out by Northern blot analysis using a full-length rainbow trout estrogen receptor (rtER) cDNA as a probe. The rostral pars distalis of the pituitary which contained mostly PRL cells showed the lower amount of rtER mRNA when compared to other parts of the pituitary. Moreover, two mRNAs of different size (3.5 and 1.4 kb) were detected in different parts of the pituitary. Further hybridization experiments using probes containing part of the rtER cDNA (E domain or C and D domains) indicated that the small-sized mRNA (1.4 kb) probably encodes a truncated ER protein lacking hormone binding domain or an ER-related protein. Thus, only the 3.56 kb mRNA appeared to be involved in the regulation of pituitary function by estradiol. In situ hybridization analysis allowed a more precise localization of this rtER mRNA in the pituitary.(ABSTRACT TRUNCATED AT 250 WORDS)