Cristina Nistri’s research while affiliated with Chinook Regional Hospital and other places

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Publications (9)


The M-ANNHEIM scoring system for the grading of clinical features of chronic pancreatitis.
Management of Acute and Chronic Pancreatitis
  • Chapter
  • Full-text available

December 2022

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330 Reads

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Cristina Nistri

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[...]

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Pancreatitis is a major public health issue worldwide. There is geographical variation in the burden of acute and chronic pancreatitis (CP). Globally, the age-standardized prevalence rate increased from 1990 to 2017. Acute pancreatitis (AP) is now one of the most common reasons for hospitalization with a gastrointestinal condition. The essential requirements for the management of AP are accurate diagnosis, appropriate triage, high-quality supportive care, monitoring for and treatment of complications, and prevention of relapse. Clinicians should be aware of the time course and the best management of AP, identifying which patient will have a severe course allowing earlier triage to an intensive care unit and earlier initiation of effective therapy. CP is a pathologic fibroinflammatory syndrome of the pancreas in individuals with genetic, environmental, and other risk factors who develop persistent pathologic responses to parenchymal injury or stress. Diagnosing the underlying pathologic process early in the disease course and managing the syndrome to change the natural course of disease and minimize adverse disease effects are the managing paradigm. In this review, we consider recent changes in the management of acute and CP, as well as common misunderstandings and areas of ongoing controversy.

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A scoring system for predicting malignancy in intraductal papillary mucinous neoplasms of the pancreas: a multicenter EUROPEAN validation

October 2022

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186 Reads

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3 Citations

Langenbeck's Archives of Surgery

PurposeA preoperative estimate of the risk of malignancy for intraductal papillary mucinous neoplasms (IPMN) is important. The present study carries out an external validation of the Shin score in a European multicenter cohort.Methods An observational multicenter European study from 2010 to 2015. All consecutive patients undergoing surgery for IPMN at 35 hospitals with histological-confirmed IPMN were included.ResultsA total of 567 patients were included. The score was significantly associated with the presence of malignancy (p < 0.001). In all, 64% of the patients with benign IPMN had a Shin score < 3 and 57% of those with a diagnosis of malignancy had a score ≥ 3. The relative risk (RR) with a Shin score of 3 was 1.37 (95% CI: 1.07–1.77), with a sensitivity of 57.1% and specificity of 64.4%.Conclusion Patients with a Shin score ≤ 1 should undergo surveillance, while patients with a score ≥ 4 should undergo surgery. Treatment of patients with Shin scores of 2 or 3 should be individualized because these scores cannot accurately predict malignancy of IPMNs. This score should not be the only criterion and should be applied in accordance with agreed clinical guidelines.


Fig. 1. Axial images of Chest and Abdomen CT-scan showing the severe left lung hypoplasia (a), the size of the left diaphragmatic Larrey-type hernia (b-c) and the dislocation of the spleen (d).
Fig. 2. Coronal CT-scan images demonstrating the giant left-sided hernia defect.
Fig. 3. Four-trocar setup plus AIRSEAL during trans-abdominal robotic-assisted laparoscopic approach for hernia repair.
Fig. 4. Intraoperative photo of mesh placement over the diaphragmatic defect.
Fig. 5. Chest X-ray performed 1-month after surgery, showing no signs of recurrences.
Robotic repair of a giant Larrey-type congenital left-sided diaphragmatic hernia in a young woman. A case report and literature review

August 2022

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72 Reads

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1 Citation

International Journal of Surgery Case Reports

Congenital diaphragmatic hernia is a rare condition caused by a malformation in the diaphragm that is usually diagnosed in newborns, infants and children. Sometimes it can be incidentally identified in adults. Once the diagnosis is made, surgery is indicated to avoid the risk of life-threatening complications of herniated viscera. Traditional approaches include laparotomy or thoracotomy or both; in the last decades minimally invasive techniques have proved to be a safe alternative to the open approach but only few cases of robotic hernia repair have been described so far, the most with a combined thoracic-abdomen approach. We report a case of an 18-year-old female presenting with abdominal pain due to a giant left-sided anterior diaphragmatic hernia (Larrey-type) that was repaired using a robotic-assisted laparoscopic approach with mesh placement. The hernia contents included gastric body and fundus, duodenum, jejunum, ileus, cecum, right colon and mesentery; spleen and pancreas were rotated and dislocated anteriorly. The outcome was unremarkable, with no major post-operative complications and no signs of long-term recurrence. The robotic approach seems to be a valid option for the treatment of diaphragmatic hernias, improving post-operative outcome and providing surgeon better visualization, greater precision and enhanced dexterity in a confined space.


Bacteriobilia resistance to antibiotic prophylaxis increases morbidity after pancreaticoduodenectomy: a monocentric retrospective study of 128 patients

April 2020

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50 Reads

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14 Citations

Updates in Surgery

Several studies attempted to determine whether there is a relationship between the use of preoperative biliary drainage and morbidity after pancreaticoduodenectomy (PD). We retrospectively evaluated post-PD outcome in patients with and without preoperative biliary drainage and the role of bacteriobilia and antibiotic prophylaxis in post-operative complications. Data relating to the PDs performed at the Hepato-Bilio-Pancreatic Surgical Department of Treviso Hospital between 2010 and 2017 were retrospectively evaluated. Morbidity and intra-hospital mortality related to preoperative biliary stent were the primary outcomes. Between 2010 and 2017, 128 patients (mean age 68 years) underwent PD; 72 were treated with early surgery (ES) and 56 underwent preoperative biliary drainage (PBD). Overall morbidity was 50% in the ES cohort and 43% in the PBD (ns, p = 0.43). In the PBD group, bacteriobilia was found in the 100% of the bile cultures (48; 8 unavailable). The microbiota was represented by: Klebsiella spp (48%), Enterococcus spp (29%), E. coli (27%) and Candida spp (21%). In 52% of cases, at least one of the isolated bacteria was resistant to the perioperative antibiotic prophylaxis (69% of cases Amoxicillin–Clavulanic Ac.). The majority of postoperative surgical complications occurred in patients with prophylaxis-resistant bacteriobilia (68% vs 39%; p = 0.04). Antibiotic resistance is a determining factor in morbidity after PD. We therefore propose to pay particular attention to the preoperative prophylaxis, diversifying it between drained and non-drained patients. In fact, in the former, appropriate broad spectrum preoperative antibiotic coverage is strongly suggested.


Evaluation of appendicitis risk prediction models in adults with suspected appendicitis

December 2019

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1,936 Reads

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118 Citations

BJS (British Journal of Surgery)

Background: Appendicitis is the most common general surgical emergency worldwide, but its diagnosis remains challenging. The aim of this study was to determine whether existing risk prediction models can reliably identify patients presenting to hospital in the UK with acute right iliac fossa (RIF) pain who are at low risk of appendicitis. Methods: A systematic search was completed to identify all existing appendicitis risk prediction models. Models were validated using UK data from an international prospective cohort study that captured consecutive patients aged 16-45 years presenting to hospital with acute RIF in March to June 2017. The main outcome was best achievable model specificity (proportion of patients who did not have appendicitis correctly classified as low risk) whilst maintaining a failure rate below 5 per cent (proportion of patients identified as low risk who actually had appendicitis). Results: Some 5345 patients across 154 UK hospitals were identified, of which two-thirds (3613 of 5345, 67·6 per cent) were women. Women were more than twice as likely to undergo surgery with removal of a histologically normal appendix (272 of 964, 28·2 per cent) than men (120 of 993, 12·1 per cent) (relative risk 2·33, 95 per cent c.i. 1·92 to 2·84; P < 0·001). Of 15 validated risk prediction models, the Adult Appendicitis Score performed best (cut-off score 8 or less, specificity 63·1 per cent, failure rate 3·7 per cent). The Appendicitis Inflammatory Response Score performed best for men (cut-off score 2 or less, specificity 24·7 per cent, failure rate 2·4 per cent). Conclusion: Women in the UK had a disproportionate risk of admission without surgical intervention and had high rates of normal appendicectomy. Risk prediction models to support shared decision-making by identifying adults in the UK at low risk of appendicitis were identified.



Intrahepatic chemotherapy for unresectable cholangiocarcinoma: review of literature and personal experience

October 2015

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42 Reads

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31 Citations

Updates in Surgery

Most patients with intrahepatic cholangiocarcinoma (IH-CCA) are unresectable and treatment options are limited. This study evaluates the efficacy of hepatic artery infusion (HAI) chemotherapy in patients whose disease is not initially treatable with resection. We selected patients with unresectable IH-CCA treated only with HAI chemotherapy at our centre between January 2008 and December 2012. We compared our outcome, using mRECIST, with published results of patients treated with systemic chemotherapy during the same period. Eleven patients underwent HAI chemotherapy with fluorouracil and oxaliplatin after placement of an HAI pump. A CT scan performed after the sixth cycle of therapy revealed that 5 of them had partial hepatic response (more than 45 %), 2 stable disease and 4 showed clear signs of disease progression. The average survival of the entire group was 17.6 months. Three of the patients with partial hepatic response underwent resection and 2 had more than 70 % tumour necrosis, both of whom are still alive and disease-free. The median survival of patients with liver-only disease treated with systemic chemotherapy, who were not submitted for resection, was 15.3 months. HAI chemotherapy enables this small group of patients to have their unresectable IH-CCA disease converted into a resectable one, thus confirming its role in treatment of this disease.


Benign Tumors of Bile Ducts and Gallbladder

January 2015

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33 Reads

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2 Citations

The aim of this chapter is to define diagnosis and treatment of benign lesions of the bile ducts and the gallbladder. Benign tumors of the bile ducts are uncommon clinical entities, and therefore, most published papers describe only case reports. Nevertheless, these entities, together with pseudotumors, should be considered in the differential diagnosis of painless jaundice patients. In recent years, particular attention has been paid in the study of two bile duct lesions: intraductal papillary neoplasm and mucinous cystic neoplasms. Gallbladder (GB) tumors are a rare pathology that occurs in 3–7 % of adult population, but with the frequent use of abdominal US, detection of small polypoid lesion of the gallbladder has been increasing considerably in the last years. Most lesions of the GB are benign and are divided into polypoid lesions and atypical thickening of the gallbladder wall with an uncertain diagnosis, which can mimic malignant lesions. Polyps of the GB include neoplastic and non-neoplastic lesions, and the majority of them are represented by cholesterol polyps (CPs) that have a prevalence of 60–90 %. CPs are composed by accumulation of triglycerides and cholesterol esters within macrophages in the GB wall (without a real cellular proliferation) forming a polypoid proliferation usually very small (1–2 mm) and that however do not exceed 10 mm. Clinically asymptomatic in most of cases, this lesion is usually an occasional detection at US analysis.

Citations (5)


... [6][7][8] Despite the success of LAE, complications attributed to this procedure are well described and not uncommon. [9][10][11][12][13] The existing literature supports a post-LAE complication rate between 27% and 50%. [9][10][11][12][13] Although liver abscess is the complication most frequently encountered, 10 cases of hepatic necrosis, gallbladder infarction, bile peritonitis, bile leak, and biloma have also been described. ...

Reference:

Outcomes following hepatic angioembolization for patients with traumatic liver injury
Angioembolization in Non-operative Management of Grade III to V Blunt Liver Trauma Increases Incidence of Biliary Complications
  • Citing Article
  • October 2022

HPB

... The 5-year survival was also different based on the Shin scoring system ranging from 94.4 % in score 0-1 group, to 71.8 % in score 4-5 group. The Shin scoring system was later validated in a European cohort involving 11 countries and 567 patients overall: sensitivity and specificities for predicting malignancy were respectively 57.3 % and 64.4 % for a Shin score of 3, 21.7 % and 90.4 % for a Shin score of 4 %, and 4.2 % and 98.6 % for a Shin score of 5 [33]. Authors conclude that a Shin score of 1 or less should be monitored, while those with scores of 4 or more should undergo surgery [33]. ...

A scoring system for predicting malignancy in intraductal papillary mucinous neoplasms of the pancreas: a multicenter EUROPEAN validation

Langenbeck's Archives of Surgery

... Multiple studies [6,[11][12][13][14][15][16][17][18][19] and a recent meta-analysis [20] investigated the association between bacterobilia and postoperative complications. An increase in postoperative morbidity is frequently described, and some studies also show an association of bacterobilia with CR-POPF [13,18,19], although the latter is not a consistent finding [20]. ...

Bacteriobilia resistance to antibiotic prophylaxis increases morbidity after pancreaticoduodenectomy: a monocentric retrospective study of 128 patients
  • Citing Article
  • April 2020

Updates in Surgery

... Three studies reported results for both > 3 and > 4 points as the low cut-off points [18,25,28,29]. One study reported results for men and women separately, using two different cut-off points [20]. ...

Evaluation of appendicitis risk prediction models in adults with suspected appendicitis

BJS (British Journal of Surgery)

... For those with disease that is deemed unresectable, systemic therapy has been considered the cornerstone of treatment. Historical data suggest that median survival in this setting without systemic therapy is around 4-5 months [23,24]. Overall outcomes with systemic therapy still remain poor. ...

Intrahepatic chemotherapy for unresectable cholangiocarcinoma: review of literature and personal experience
  • Citing Article
  • October 2015

Updates in Surgery