https://www.zora.uzh.ch/id/eprint/159463/1/rindi_modern_pathology_2018.pdf

A common classification framework for neuroendocrine neoplasms: an International Agency for Research on Cancer (IARC) and World Health Organization (WHO) expert consensus proposal.

Several challenging clinical situations in patients with peritonitis can result in an open abdomen (OA) and subsequent temporary abdominal closure (TAC). Indications and treatment choices differ among surgeons. The risk of fistula development and the possibility to achieve delayed fascial closure differ between techniques. The aim of this study was to review the literature on the OA and TAC in peritonitis patients, to analyze indications and to assess delayed fascial closure, enteroatmospheric fistula and mortality rate, overall and per TAC technique. Electronic databases were searched for studies describing the OA in patients of whom 50 % or more had peritonitis of a non-traumatic origin. The search identified 74 studies describing 78 patient series, comprising 4,358 patients of which 3,461 (79 %) had peritonitis. The overall quality of the included studies was low and the indications for open abdominal management differed considerably. Negative pressure wound therapy (NPWT) was the most frequent described TAC technique (38 of 78 series). The highest weighted fascial closure rate was found in series describing NPWT with continuous mesh or suture mediated fascial traction (6 series, 463 patients: 73.1 %, 95 % confidence interval 63.3–81.0 %) and dynamic retention sutures (5 series, 77 patients: 73.6 %, 51.1–88.1 %). Weighted rates of fistula varied from 5.7 % after NPWT with fascial traction (2.2–14.1 %), 14.6 % (12.1–17.6 %) for NPWT only, and 17.2 % after mesh inlay (17.2–29.5 %). Although the best results in terms of achieving delayed fascial closure and risk of enteroatmospheric fistula were shown for NPWT with continuous fascial traction, the overall quality of the available evidence was poor, and uniform recommendations cannot be made.

Systematic review and meta-analysis of the open abdomen and temporary abdominal closure techniques in non-trauma patients.

Background
Reports of direct comparisons between operative techniques for anal fissure are variable in their results. These reports are either subject to selection bias (in non-randomized studies) or observer bias (in all studies) or have inadequate numbers of patients enrolled to answer the question of efficacy.

Objectives
To determine the best technique for fissure surgery.

Search methods
The Cochrane Central Register of Controlled Trials and MEDLINE (1965-2011), Medline (Pubmed) and Embase were searched March to 2011. The list of cited references in all included reports and several study authors also were helpful in finding additional comparative studies.

A total of four new trials were included in this update of the review.

Selection criteria
All reports in which there was a direct comparison between at least two operative techniques were reviewed and when more than one report existed for any given pair, that report was included. All studies must also be randomised. If crude data were not presented in the report, the authors were contacted and crude data obtained.

Data collection and analysis
The two most commonly used end points in all reported studies were treatment failure and post-operative incontinence both to flatus and faeces. These are the only two endpoints included in the meta-analysis.

Main results
Four trials, encompassing 406 patients were included in this update, with now a total of 2056 patients in the review from 27 studies that describe and analyze 13 different operative procedures. These operative techniques used by these studies include closed lateral sphincterotomy, open lateral internal sphincterotomy, anal stretch, balloon dilation, wound closure, perineoplasty, length of sphincterotomy and fissurectomy. Two new procedures in the update, similar to anal stretch were described- sphincterolysis and controlled intermittent anal dilatation. A new comparison was described, comparing the effects of unilateral internal sphincterotomy and bilateral internal sphincterotomy.

Manual Anal stretch has a higher risk of fissure persistence than internal sphincterotomy and also a significantly higher risk of minor incontinence than sphincterotomy. The combined analyses of open versus closed partial lateral internal sphincterotomy show little difference between the two procedures both in fissure persistence and risk of incontinence

Unilateral internal sphincterotomy was shown to be more likely to result in treatment failure compared to bilateral internal sphincterotomy, but there is no significant difference in the risk of incontinence.

Sphincterotomy was less likely to result in treatment failure when compared to fissurectomy, but there was no significant difference when considering post-operative incontinence.

When comparing sphincterotomy to sphincterolysis, there was no significant difference between the two procedures both in treatment failure and risk of incontinence; the same is the case when comparing sphincterotomy with controlled anal dilation.

Authors' conclusions
Manual anal stretch should probably be abandoned in the treatment of chronic anal fissure in adults. For those patients requiring surgery for anal fissure, open and closed partial lateral internal sphincterotomy appear to be equally efficacious. More data are needed to assess the effectiveness of posterior internal sphincterotomy, anterior levatorplasty, wound suture or papilla excision. Bilateral internal sphincterotomy shows promise, but needs further research into its efficacy.

/pdf/operative-procedures-for-fissure-in-ano-1v99qpnkw0.pdf

Operative procedures for fissure in ano

Aim Several techniques for temporary abdominal closurehave been developed. We systematically review theliterature on temporary abdominal closure to ascertainwhether the method can be tailored to the indication.Method Medline,Embase,theCochraneCentralRegisterof Controlled Trials and relevant meeting abstracts untilDecember 2009 were searched using the following head-ings: open abdomen, laparostomy, VAC (vacuum assistedclosure), TNP (topical negative pressure), fascial closure,temporary abdominal closure, fascial dehiscence and deepwound dehiscence. The data were analysed by closuretechniqueandaetiology.Theprimaryend-pointsincludeddelayed fascial closure and in-hospital mortality. The sec-ondary end-points were intra-abdominal complications.Results The search identiﬁed 106 papers for inclusion.The techniques described were VAC (38 series), mesh ⁄sheet (30 series), packing (15 series), Wittmann patch(eight series), Bogota´ bag (six series), dynamic retentionsutures (three series), zipper (15 series), skin only andlocking device (one series each). The highest facialclosure rates were seen with the Wittmann patch (78%),dynamic retention sutures (71%) and VAC (61%).Conclusion Temporary abdominal closure has evolvedfrom simple packing to VAC based systems. In theabsence of sepsis Wittmann patch and VAC offered thebest outcome. In its presence VAC had the highestdelayed primary closure and the lowest mortality rates.However, due to data heterogeneity only limited con-clusions can be drawn from this analysis.Keywords Open abdomen, laparostomy, historical evo-lution, systematic review

The open abdomen and temporary abdominal closure systems - historical evolution and systematic review

Gastroenteropancreatic (GEP) neuroendocrine neoplasms (NENs) are heterogeneous regarding site of origin, biological behavior, and malignant potential. There has been a rapid increase in data publication during the last 10 years, mainly driven by high-throughput studies on pancreatic and small intestinal neuroendocrine tumors (NETs). This review summarizes the present knowledge on genetic and epigenetic alterations. We integrated the available information from each compartment to give a pathway-based overview. This provided a summary of the critical alterations sustaining neoplastic cells. It also highlighted similarities and differences across anatomical locations and points that need further investigation. GEP-NENs include well-differentiated NETs and poorly differentiated neuroendocrine carcinomas (NECs). NENs are graded as G1, G2, or G3 based on mitotic count and/or Ki-67 labeling index, NECs are G3 by definition. The distinction between NETs and NECs is also linked to their genetic background, as TP53 and RB1 inactivation in NECs set them apart from NETs. A large number of genetic and epigenetic alterations have been reported. Recurrent changes have been traced back to a reduced number of core pathways, including DNA damage repair, cell cycle regulation, and phosphatidylinositol 3-kinase/mammalian target of rapamycin signaling. In pancreatic tumors, chromatin remodeling/histone methylation and telomere alteration are also affected. However, also owing to the paucity of disease models, further research is necessary to fully integrate and functionalize data on deregulated pathways to recapitulate the large heterogeneity of behaviors displayed by these tumors. This is expected to impact diagnostics, prognostic stratification, and planning of personalized therapy.

Genetics and Epigenetics of Gastroenteropancreatic Neuroendocrine Neoplasms

Comparison of controlled-intermittent anal dilatation and lateral internal sphincterotomy in the treatment of chronic anal fissures: a prospective, randomized study.

Introduction The present study was undertaken to define the prognostic factors for overall survival subsequent to definitive surgery, and for survival after the development of distant metastasis in breast cancer patients who developed distant metastasis subsequent to definitive surgery. Methods The records of 470 breast cancer patients with T1-3 tumours and distant metastasis following surgery were reviewed. Prognostic factors were compared to the first metastatic sites as solitary skeletal, multiple skeletal, and visceral metastases, and were analysed for overall survival following surgery and survival after metastasis. Survival curves were generated by the Kaplan-Meier method, and multivariate analysis was performed by the Cox proportional hazard model. Results 79 patients (17 percent) had a solitary skeletal metastasis, 105 (22 percent) had multiple skeletal metastases, and 286 (61 percent) had a visceral metastasis. The five-year overall survival was significantly better for patients with a solitary bone metastasis (73 percent) compared to patients who had multiple bone metastases (46 percent), or a visceral metastasis (22 percent) (p-value is less than 0.0001). Pathological lymph node status 3, stage IIIC, grade 3, oestrogen receptor negativity, and visceral metastases were found to have independent detrimental influence on overall survival following surgery and survival after metastasis. A long-term metastasis-free interval affected post-metastatic outcome favourably. Radiotherapy improved overall survival. Conclusion Pathological lymph node status, stage, grade, and oestrogen receptor status predicted survival after surgery as well as after the development of metastasis. Solitary bone metastasis has a more favourable prognosis than multiple bone metastases, and compared to visceral metastasis, skeletal metastasis has a more favourable prognosis.

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Prognostic factors for survival in breast cancer patients who developed distant metastasis subsequent to definitive surgery.

BACKGROUND: The aim of this study was to evaluate the effectiveness of laparostomy with the Bogota bag for the management of patients with severe secondary peritonitis and the risk factors for survival. METHODS: Thirty-seven patients (22 males, 15 females; mean age 63.5; range 44 to 83 years) with secondary peritonitis were treated by laparostomy and temporary closure with Bogota bag. APACHE II scores and Mannheim Peritonitis Index (MPI) were used to calculate the disease severity. The outcomes and effectiveness of APACHE II and MPI values were analyzed retrospectively. RESULTS: The mortality rate was 43.2%. Significant differences were noted between survivors and non-survivors according to initial APACHE II and MPI scores and the number of operations. The non-survivors had higher APACHE II (r=0.81, p=0.001) and MPI (r=0.39, p=0.02) scores. The patients who survived were re-operated 1.6 times and those who died were re-operated 4.7 times. In five patients, laparostomy was closed primarily, while in the others, the wound was left open to heal secondarily. CONCLUSION: Patients with higher APACHE II and MPI scores and number of operations had higher rates of mortality due to their major risk factors. Temporary abdominal closure using the Bogota bag in patients with secondary peritonitis is an inexpensive-simple method, permitting evaluation of underlying viscera and recognition of infection.

Laparostomy in patients with severe secondary peritonitis.

Background: Left thoracoabdominal stab wounds (LTSWs) leadingto diaphragmatic injuries can cause serious morbidity andmortality. The diagnosis and treatment of LTSWs are controver-sial. This study investigated the reliability of laparoscopy for thediagnosis and treatment of diaphragmatic lacerations in hemo-dynamically stable patients with an LTSW, hypothesizing thatlaparoscopy is suﬃcient for diagnosing and treating diaphragmaticinjury after an LTSW.Methods: This study included 36 cases of LTSWs with nohemodynamic instability or abdominal tenderness seen betweenJune 2002 and June 2007. After systemic examination andresuscitation of the patients, chest x-ray and focused assessmentwith sonography for trauma were carried out and then laparo-scopic exploration was performed in all cases.Results: Of the 36 cases, 36.1% (n=13) had injuries to thediaphragm and 53.8% (7/13) had associated intraabdominalinjuries. Nine (69.2%) of the patients with diaphragmatic injuries,but no hollow organ injuries, were repaired through laparoscopy.The hemopneumothorax was found in 33.3% (n=12) of thepatients. No relationship was seen between diaphragmatic injuriesand the location of the LTSW and existence of hemopneumothorax.Conclusions: Laparotomy was required in only 11.1% (4/36) ofthe cases with LTSWs and 30.8% (4/13) of the cases with dia-phragmatic injury. Diagnostic and therapeutic laparoscopy wasa suﬃcient and necessary surgical procedure in cases with ahemodynamically stable LTSW, when emergency surgery (laparo-tomy or thoracotomy) was not necessary.Key Words: thoracoabdominal trauma, zones, stab wounds,hemopneumothorax, laparoscopy, diaphragmatic injuries, diaphragmwound size, laparoscopic repair

Laparoscopic management of left thoracoabdominal stab wounds: a prospective study.

Background/Aims: Gastrointestinal and pancreatic neuroendocrine tumors (GEPNETs) originate from the cells of the endocrine system. Their molecular genetic mechanism of development and progression is complex and remains largely unknown. The purpose of this study was to review the gastrointestinal and pancreatic neuroendocrine tumors and to evaluate p53, Ki-67 and CD 117 expressions with their clinicopathological correlations. Materials and Methods: Twenty-one patients were reviewed and classified as having well-differentiated neuroendocrine neoplasm (WDET, Grade I), well-differentiated neuroendocrine carcinoma (WDEC, Grade II) and poorly differentiated neuroendocrine carcinoma (PDEC, Grade III). We performed immunohistochemical tests to characterize the expession of the immunoreactivity for synaptophysin, chromogranin, p53, Ki67 and CD 117. Results: Median age of 21 patients was 43 years. Thirteen (61.9%) patients were male and eight (38.1%) patients were female. Tumors were located in the stomach (38.1%), appendix (38.1%), duodenum (4.8%), ileum (4.8%), colon (9.5%), and pancreas (4.8%). Conclusion: There was a statistically significant difference between well-differentiated endocrine neoplasm (Grade I), and well-differentiated endocrine carcinoma (WDEC, Grade II) and PDEC for Ki-67 >20% (p<0.001) (Pearson chisquare test). There was a statistically significant difference between WDET (Grade I), WDEC (Grade II) and PDEC (Grade III) for p53 positivity (p<0.05) (Pearson chi-square test).

P53, KI-67, CD117 expression in gastrointestinal and pancreatic neuroendocrine tumours and evaluation of their correlation with clinicopathological and prognostic parameters

Dogan Gonullu

Papers

Comparison of controlled-intermittent anal dilatation and lateral internal sphincterotomy in the treatment of chronic anal fissures: a prospective, randomized study.

Prognostic factors for survival in breast cancer patients who developed distant metastasis subsequent to definitive surgery.

Laparostomy in patients with severe secondary peritonitis.

Laparoscopic management of left thoracoabdominal stab wounds: a prospective study.

P53, KI-67, CD117 expression in gastrointestinal and pancreatic neuroendocrine tumours and evaluation of their correlation with clinicopathological and prognostic parameters