No abstract

IgG4-RD is an elusive inflammatory disease to be considered in the differential diagnosis of isolated or multiple tumefactive lesions. Long-term disease control can be achieved with corticosteroids and immunosuppressive drugs in the majority of cases.

The ERAS pathway was feasible and safe, yielding an earlier postoperative recovery. An ERAS protocol should be implemented in patients undergoing PD; however, patients with early postoperative low compliance should be carefully managed.

Summary.To evaluate the effect of combined kidney and pancreas transplantation on insulin action and glucose metabolism, 15 Type 1 (insulin-dependent) diabetic patients who were undergoing combined kidney-pancreas transplantation were studied before transplantation by means of the euglycaemic hyperinsulinaemic clamp technique combined with 3-3H-glucose infusion and indirect calorimetry. Nine of the original 15 patients were studied again after four months and six after 12 months, successful combined kidney-pancreas transplantation with the same experimental protocol. Nine volunteers formed the group of normal subjects. Combined kidney-pancreas transplantation normalised hepatic glucose production and reduced peripheral insulin resistance in Type 1 diabetic uraemic patients, despite chronic immunosuppressive therapy. To further evaluate the hypothesis that residual insulin resistance was due to chronic steroid therapy, 11 additional subjects with chronic uveitis (six of whom were treated with only prednisone, and five treated only with cyclosporin) underwent the same protocol demonstrating a normal hepatic glucose production. The insulin-stimulated peripheral glucose uptake was reduced in the prednisonetreated group, but normal in cyclosporin-treated subjects. Four additional diabetic patients with a kidney transplant were also studied. They showed a peripheral insulin sensitivity intermediate between diabetic uraemic patients and patients after combined transplant. We conclude that shortterm (one year) combined kidney-pancreas transplantation improves glucose metabolism by restoring normal rates of hepatic glucose production and reducing peripheral insulin resistance; chronic steroid therapy is the major determinant of residual reduced insulin action. Both kidney and pancreas substitution play a role in reducing peripheral insulin resistance.

No single prognostic factor proved to be associated with a sufficiently disappointing outcome to exclude patients from liver resection. However, in the presence of some prognostic factors (G3-G4 differentiation, preoperative CEA >5 ng/ml, high MSKCC-CRS), enrollment of patients in trials exploring new adjuvant treatments is suggested to improve the outcome after surgery.

Laparoscopic distal pancreatectomy (LDP) for benign and borderline pancreatic lesions is recently becoming the treatment of choice in experienced centres. No data have been published on learning curve so far. The purpose of this study was to identify the learning curve period for performing LDP. Between March 2009 and August 2010 all patients with lesions of pancreatic body or tail were assessed for eligibility for LDP. Exclusion criteria were: major vessels contact in cancer patients, severe organ dysfunction, BMI > 35, and refusing laparoscopic approach. All laparoscopic procedures were carried out by the same surgical team with large experience in open pancreatic surgery. All patients were treated according to an early recovery after surgery protocol. Primary endpoint was conversion rate. Secondary endpoints were operative time, operative blood loss, postoperative morbidity, and length of stay (LOS). Sixty patients were assessed for eligibility. Thirty (50.0 %) patients met the exclusion criteria, while the other 30 patients underwent LDP. Spleen-preserving procedure was planned in the 17 patients with benign lesion and successfully performed in 15 (82.3 %). Overall conversion rate was 23.3 %, but it dropped significantly after the first ten patients (p = 0.01). Mean operative time progressively declined from 254 min in the first subgroup of ten patients to 206 min in the second (p = 0.09 vs. first), and 183 min in the third subgroup (p = 0.006 vs. first). No significant difference was found for operative blood loss, postoperative morbidity rate, and LOS in the different subgroups. Both conversion rate and operative time dropped after the first ten patients who underwent LDP. Strict selection criteria, high-volume hospital, and experienced team in open pancreatic surgery may have played a role in shortening the learning curve.

Although larger data are needed to definitely exclude the risk of disease dissemination, the present study suggests that IAT indications can be extended to selected patients with neoplasm.

The combination of CRP and AVD was effective in the early prediction of clinically relevant POPF after PD.