To the Editor We read with great interest the article by Wellner and colleagues about the comparison between pancreaticogastrostomy (PG) and Roux-en-Y pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD) with regard to postoperative pancreatic fistula (POPF) and other complications. 1 The authors concluded that PG was superior to PJ in terms of clinically relevant POPF; although this study is retrospective, the use of a large case number and standardized measures in evaluation of the surgical outcome makes the results not negligible. Instead, the results of our previously described technique of Roux-en-Y reconstruction show that PJ may have a lower prevalence of POPF than that reported by Wellner and colleagues and suggest that outcome after Roux-en-Y reconstruction with regard to POPF can be further improved using fibrinogen/thrombincoated collagen patch (TachoSil®, Nycomed, UK Ltd.) in carrying out PJ.Briefly, we reviewed the clinical records of 54 consecutive patients who underwent PD by one surgeon (P.C.) at "La Sapienza" University (Rome, Italy) from January 1995 to December 2008. The underlying diseases were: pancreatic carcinoma in 31 cases; pancreatic serous cystadenoma in six cases; mucinous cystadenoma in one case; pancreatic endocrine tumor in two cases; ampullar carcinoma in seven cases; distal bile duct carcinoma in six cases; and chronic pancreatitis in one case. In all patients, the surgical procedure comprised PD with suprapyloric gastric resection and Roux -en-Y reconstruction with anastomosis of the isolated Roux limb to the stomach and single Roux limb to both the pancreatic stump and hepatic duct. 2

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The authors reviewed the original reports of the association of malignant ovarian tumors with cytologically negative pleural and peritoneal effusions, commonly known as Meigs' pseudo-syndrome and challenged the recent attribution of this disease to Demons. They underlined the historical and clinical interest of the reports of Demons and Meigs and concluded that the term pseudo-Meigs' syndrome, and not pseudo-Demons' syndrome, must be used for malignant ovarian lesions with effusions with negative cytology because Demons did not describe a similar syndrome caused by malignant tumors.

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Anal sphincteric continence was better after surgery with a high or low colorectal anastomosis than after coloanal anastomosis.

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This review highlights the rationale for dissection of the 16a2 and 16b1 paraaortic area during pancreaticoduodenectomy (PD) for carcinoma of the head of the pancreas. Recent advances in surgical anatomy of the mesopancreas indicate that the retropancreatic area is not a single entity with well defined boundaries but an anatomical site of embryological fusion of peritoneal layers, and that continuity exists between the neuro lymphovascular adipose tissues of the retropancreatic and paraaortic areas. Recent advances in surgical pathology and oncology indicate that, in pancreatic head carcinoma, the mesopancreatic resection margin is the primary site for R1 resection, and that epithelial-mesenchymal transition-related processes involved in tumor progression may impact on the prevalence of R1 resection or local recurrence rates after R0 surgery. These concepts imply that mesopancreas resection during PD for pancreatic head carcinoma should be extended to the paraaortic area in order to maximize retropancreatic clearance and minimize the likelihood of an R1 resection or the persistence of residual tumor cells after R0 resection. In PD for pancreatic head carcinoma, the rationale for dissection of the paraaortic area is to control the spread of the tumor cells along the mesopancreatic resection margin, rather than to control or stage the nodal spread. Although mesopancreatic resection cannot be considered "complete" or "en bloc", it should be "extended as far as possible" or be "maximal", including dissection of 16a2 and 16b1 paraaortic areas.

ObjectivesTumor burden and invasiveness establish a microenvironment that surgery could alter. This study shows a comprehensive analysis of size, dynamics, and function of peripheral lymphocyte subsets in pancreatic cancer patients before and at different times after duodenopancreatectomy.MethodsLymphocyte frequency and natural cytotoxicity were evaluated by flow cytometry and in vitro assay on peripheral blood from initial and advanced-stage pancreatic cancer patients before (BS), at day 7 (PS7), and at day 30 (PS30) after surgery.ResultsAn increase in natural killer (NK) cells and the diminution of B-cells occurred at PS30, whereas cytotoxicity decreased at PS7. The positive correlation between NK frequency and cytotoxicity at BS and PS7 revealed an altered NK behavior. The elevation of NK cell frequency at PS30, an initial defect in CD56bright NK, and the aberrant correlation between NK frequency and cytotoxicity remained significant in advanced-stage patients, whereas the diminution of NK cytotoxicity only affected initial stage patients.ConclusionsThe NK cell functional ability is altered in presurgery patients; duodenopancreatectomy is associated with short-term impairment of NK function and with a long-term NK cell augmentation and reversion of the aberrant NK behavior, which may impact on immunosurveillance against residual cancer.