Oncological feasibility of laparoscopic distal pancreatectomy for adenocarcinoma: a single-institution comparative study.

BACKGROUND: Laparoscopic distal pancreatectomy (LDP) is performed increasingly for pancreatic pathology in the body and tail of the pancreas. However, only few reports have compared its oncological efficacy with open distal pancreatectomy (ODP). We compared these two techniques in patients with pancreatic ductal adenocarcinoma. METHODS: From a prospectively maintained database, all patients who underwent either LDP or ODP for adenocarcinoma in the body and tail of the pancreas between January 2008 and December 2011 were compared. Data were analysed using SPSS(®) v19 utilising standard tests. A p value <0.05 was considered significant. RESULTS: Of 101 patients who underwent distal pancreatectomy, 22 had histologically confirmed adenocarcinoma (LDP n = 8, ODP n = 14). Both groups were well matched for age and the size of tumour (22 vs. 32 mm, p = 0.22). Intraoperative blood loss was 306 ml compared with 650 ml for ODP (p = 0.152). A longer operative time was noted for LDP (376 vs. 274 min, p < 0.05). Total length of stay was shorter for LDP compared with ODP (8 vs. 12 days, p = 0.05). The number of postoperative pancreatic fistulas were similar (LDP n = 2 vs. ODP n = 3, p = 0.5). Complete resection (R0) was achieved in 88 % of LDP (n = 7) compared with 86 % of ODP (n = 12). The median number of lymph nodes harvested was 16 for LDP versus 14 for ODP. Overall 3-year survival also was similar: LDP = 82 %, ODP = 74 % (p = 0.89). CONCLUSIONS: From an oncological perspective, LDP is a viable procedure and its results are comparable to ODP for ductal adenocarcinomas arising in the body and tail of the pancreas.

Methods of haemostasis during liver resection--a UK national survey.

BACKGROUND: Although haemorrhage is a major cause of morbidity and mortality in liver surgery, there is very little available guidance on its management. METHODS: The aim of this study was to identify current practice in the UK in this regard. An online survey was created and hepatobiliary (HPB) specialists who were members of a specialist society and others who were known practitioners were invited by e-mail to complete the survey anonymously. RESULTS: Fifty-one percent responded (n = 36/70), and most of these respondents worked at large HPB centres (>100 liver resections/year; n = 24, 66%). Not all questionnaires were fully completed by the individual surgeons. Thirty-eight percent of the surgeons routinely used Pringle's manoeuvre. Most surgeons used ligation of the inflow vessels (n = 16, 44%) and stapled the outflow vessels (n = 15, 42%). The Cavitron ultrasonic surgical aspirator (CUSA; 54%, 13/24) was preferred for parenchymal transection. The majority routinely used haemostatic adjuncts (n = 22, 62%), whilst 33% (n = 12) used them occasionally. Twenty-three (64%) felt manufactured haemostatic adjuncts played a major role in maintaining haemostasis and 19 preferred fibrin-based products. CONCLUSION: The Pringle manoeuvre is a popular technique amongst specialist UK liver surgeons and the CUSA is used by nearly half of the surgeons. Despite the absence of definitive evidence for their benefit, manufactured haemostatic adjuncts are still widely used, especially the fibrin-based adjuncts.

Family history of cancer and tobacco exposure in index cases of pancreatic ductal adenocarcinoma.

Aim. To examine interaction between history of cancer in first-degree relatives and tobacco smoking in index patients of pancreatic adenocarcinoma. Methods. We carried out a case-control involving 113 patients with pancreatic adenocarcinoma and 110 controls over a 12-month period at the Freeman Hospital, Newcastle upon Tyne, UK. They were all administered a detailed tobacco exposure questionnaire and a family history questionnaire. We calculated cumulative tobacco exposure and risk for pancreas cancer. Results. Both smokers (OR 3.01 (95% CI: 1.73 to 5.24)) and those with a family history of malignancy (OR 1.98 (95% CI: 1.15-3.38)) were more likely to develop pancreatic cancer. Having more than one first-degree relative with cancer did not significantly further increase the risk of pancreatic cancer. Amongst pancreatic cancer cases, cumulative tobacco exposure was significantly decreased (P = .032) in the group of smokers (current and ex-smokers) who had a family history of malignancy [mean (SD): 30.00 (24.77) pack-years versus 44.69 (28.47) pack-years with no such history]. Conclusions. Individuals with a family history of malignancy are at an increased risk of pancreatic cancer. Furthermore, individuals with a family history of malignancy and who smoke appear to require a lesser degree of tobacco exposure for the development of pancreatic cancer.

Surgery for retroperitoneal soft tissue sarcomas: aggressive re-resection of recurrent disease is possible.

INTRODUCTION: Retroperitoneal soft tissue sarcomas represent a relatively rare and complex therapeutic problem where surgery forms the mainstay of treatment and is technically demanding. In this study, we review a single UK centre's experience with the surgical management of retro-peritoneal soft tissue sarcoma. PATIENTS AND METHODS: We present analysis of data on patients treated between 1997 and 2006, our first 75 patients. Data collected from the Access database, included patient demographics, staging modalities, peri-operative details, treatment, outcome, pathological diagnosis and subsequent complications. RESULTS: A total of 75 patients (M:F, 44:31) underwent 115 resectional procedures as part of the management of retroperitoneal soft-tissue sarcoma. There were 12 major complications for the 115 procedures (morbidity of 8.69%). The 30-day operative mortality was zero and the 90-day mortality rate was 1.33% (1/75). Follow-up ranged from 16-131 months. The median disease-free survival was 69 months (range, 59-78 months). Recurrences developed in 46 patients; median time to overall recurrence was 13 months (range, 3-71 months). Of these 46, 22 developed localised recurrence, which was amenable to further resection. In the cohort of patients with recurrent disease, median survival in those who underwent surgery was 53 months (range, 30-76 months) and median survival in those who did not undergo surgery was 30 months (range, 18-41 months) and this difference was statistically significant (log rank, P = 0.01). CONCLUSIONS: Extensive resectional surgery with minimal morbidity, devoid of mortality is feasible in the treatment of retroperitoneal sarcoma. Development of recurrent disease is a significant factor influencing survival; however, localised recurrences are amenable to surgery and this can lead to improved survival.

Management strategies in isolated pancreatic trauma.

AIM: In the absence of damage to other organs, pancreatic injury is rare. We have reviewed our experience with isolated pancreatic injury. METHODS: Patients treated for isolated pancreatic trauma at our unit were identified prospectively and then retrospectively entered onto a database. The mode of presentation, mechanism of injury and management strategies were reviewed. RESULTS: Seven male and four female patients, median age 30 years (range 13-51 years) were treated. All suffered blunt abdominal trauma with different mechanisms of injury, each being characterised by a direct blow to the central abdomen. In two patients, somatostatin analogue treatment used as primary treatment resulted in early resolution of symptoms and signs. Six patients underwent surgery at various stages post-injury. At a median follow-up of 58 months (range 22-106 months), eight patients are asymptomatic, two patients have chronic pain following distal pancreatectomy and one patient has occasional discomfort. CONCLUSION: Confirmation of the mechanism of trauma and suspicion of pancreatic injury are essential for early diagnosis and appropriate management. Early contrast computed tomography examination is vital in the recognition of these injuries. Somatostatin analogue therapy may have an important role in the treatment regimen, especially when patients present early after sustaining a pancreatic injury. Only selected patients require open surgery.

Genetic susceptibility in pancreatic ductal adenocarcinoma.

BACKGROUND: The strongest risk factors for pancreatic adenocarcinoma are tobacco smoking and increasing age. However, only a few smokers or elderly individuals develop the disease and genetic factors are also likely to be important. METHODS: The literature on genetic factors modifying susceptibility to cancer was reviewed, with particular regard to the interindividual variation that exists in the development of pancreatic adenocarcinoma. RESULTS: Tobacco-derived carcinogen-metabolizing enzyme gene variants have been the main area of study in stratifying the risk of sporadic pancreatic cancer. Inconsistent results have emerged from the few molecular epidemiological studies performed. CONCLUSION: There is great scope for further investigation of critical pathways and unidentified genetic influences may be revealed. This may eventually allow the identification of individuals at high risk who might be targeted for screening.

Liver resection for colorectal liver metastasis.

At some point in the natural course of colorectal cancer up to 50% of patients will develop metastasis to the liver. Historically only 20% of these patients would have to be deemed resectable, with an intent to cure, at the time of presentation. But with recent improvements in cross-sectional imaging, chemotherapeutic agents and advances in the techniques of surgical resection the emphasis of resection has now changed to 'who is not resectable' as opposed to 'who is resectable'. There are few contraindications to liver resection on the proviso that the patient is fit enough. As a result of this paradigm shift, 5 year survival rates are approaching 60%. Historically liver resection was perceived as a formidable operation but now liver resection for CRLM is safe and specialist centres are reporting mortality rates of less than 1%. This review briefly covers the standard techniques currently employed and some of the recent innovations being developed to improve resectability.

Endoscopic necrosectomy as primary therapy in the management of infected pancreatic necrosis.

BACKGROUND AND STUDY AIMS: Open pancreatic necrosectomy is the standard treatment for infected pancreatic necrosis but is associated with significant morbidity, mortality, and prolonged hospital stay. Percutaneous or endoscopic necrosectomy are alternative techniques. We evaluated the use of endoscopic necrosectomy for treatment of patients with necrosis that could be accessed through the posterior wall of the stomach. PATIENTS AND METHODS: We retrospectively analyzed the indication, patient status according to acute physiology and chronic health evaluation (APACHE) 2 severity score, and success of endoscopic necrosectomy as primary treatment, in selected patients with localized infected pancreatic necrosis, who presented between May 2002 and October 2004. After the necrosis cavity had been accessed, with the assistance of endoscopic ultrasound, a large orifice was created and necrotic debris was removed using endoscopic accessories under radiological control. Follow-up was clinical and radiological. RESULTS: 13 patients (nine men, four women, mean age 53 years), 11 with positive bacteriology, underwent attempted endoscopic necrosectomy. Median APACHE 2 score on presentation was 8 (range 1-18). Four patients needed intensive therapy unit care and one other patient required (nonventilatory) high-dependency unit care only. Necrosis was successfully treated endoscopically in 12 patients, requiring a mean of 4 endoscopic interventions (range 1-10); one patient required open surgery; two underwent additional percutaneous necrosectomy and one required laparoscopic drainage. Two patients died of complications unrelated to the procedure. The 11 survivors have a median (range) follow-up of 16 (6-38) months. CONCLUSION: Endoscopic necrosectomy is a safe method for treatment of infected pancreatic necrosis. Multiple procedures are usually needed. It may be combined with other methods of surgical intervention. Larger prospective studies will more precisely define its role.

Herniography (peritoneography) for diagnosis of Spigelian hernia.

BACKGROUND: Spigelian hernia is a rare clinical condition. It is difficult to diagnose in absence of obvious clinical signs. Ultrasound scan, cross-sectional imaging and contrast studies like herniography have been widely used for detecting occult abdominal wall hernias in symptomatic patients. AIM AND METHODS: We present our experience of detecting a clinically occult Spigelian hernia in a 56-year-old symptomatic male patient, who had concomitant left sided inguinal and Spigelian hernias. In this patient, the Spigelian hernia was not detected on ultrasound scan. We also present a review of literature on the role of herniography in the diagnosis of this rare condition. RESULTS AND CONCLUSION: Herniography is a sensitive investigation for evaluation of occult hernias. However, it is an invasive contrast study and therefore must be used selectively. Non-invasive real-time imaging like ultrasonography remains the first line of investigation for detecting occult hernias.

Outcome of gall bladder polypoidal lesions detected by transabdominal ultrasound scanning: a nine year experience.

AIM: To determine the outcome of polypoidal lesions within the gall bladder (PLG) diagnosed by trans-abdominal scanning. METHODS: A nine-year (1993-2002) retrospective case-note review of all patients who underwent ultrasound scanning after referral to a single Upper GI Surgeon at a District General Hospital was conducted. Patients who were diagnosed with a PLG were included in our study. A database was constructed and patient details, investigations including ultrasound scan (USS) findings, treatment and histology and final diagnosis were recorded. RESULTS: Twenty-three (out of 651) patients were diagnosed pre-operatively by USS to have a polyp-like gall bladder lesion (PLG). Post cholecystectomy histological examination revealed 12 gallstones, 7 cholesterol polyps, 3 adenocarcinomas within polyps and 1 normal gall bladder. The specificity of USS in the diagnosis of PLG was 92.3%. All the true polyps were malignant. Overall USS had 66.66% sensitivity and 100% specificity in the pre-operative suspicion of malignancy. Using size greater than 10 mm as measured on USS as a cut-off, we find 100% sensitivity and 86.95% specificity with a positive predictive value of 50% in the diagnosis of malignancy in PLG. CONCLUSION: A large number of PLG are in fact calculi within diseased gall bladder. In cases of gall bladder polyps more then 10 mm in size on USS further imaging (cross-sectional and/or EUS) is indicated prior to surgery. This will help in the optimal management of patients and avoid histological surprises.

Bile peritonitis due to intra-hepatic bile duct rupture.

Generalized biliary peritonitis is a serious intra-abdominal emergency. Most of them occur due to duodenal ulcer perforation and rapidly evolve into bacterial peritonitis due to contamination by gut organisms and food. In this situation, recognition of the pathology and its treatment is straightforward and is usually associated with a good outcome. There are a few unusual causes of biliary peritonitis, of which rupture of the biliary tree is one. We describe a rare case of biliary peritonitis due to rupture of an intra-hepatic biliary radical. Unusual causes of peritonitis do interrupt our daily routine emergency surgical experience. Rapid recognition of the presence of peritonitis, adequate resuscitation, recognition of operative findings, establishment of biliary anatomy, and performance of a meticulous surgical procedure resulted in a good outcome.

Electromagnetic field in and around the campus of Jawaharlal Nehru University, New Delhi.

We have surveyed the levels of magnetic field in the open environment around the high-tension lines as well as in the domestic and laboratory environment in the JNU campus. Measurements were made in the direction of most likely access, and from the surface of the appliances. The data so obtained are analyzed and compared with some quoted in the literature. It is hoped that the results will be useful for epidemiological studies in determining the criteria for safe human exposure.

Occlusion of large atrial septal defects with a centering buttoned device: early clinical experience.

A feasibility clinical study was conducted for the transcatheter occlusion of large ostium secundum atrial septal defects with the centering buttoned device. The centering buttoned device is a modification of the regular buttoned device in which a centering counter-occluder is sutured at the central 40% portion of the occluder. During centering it is stretched, forming a parachute-shaped structure and pulling the occluder over the center of the defect. During buttoning, the counter-occluder forms a double figure eight, opposing the right atrial side of the atrial septum. Occlusion was performed in 12 patients aged 6 to 56 years. All had been rejected for transcatheter occlusion by the regular buttoned device, because of either their defect size or the lack of adequate septal rim. The defect size varied between 23 and 31 mm, and the device size varied between 45 and 60 mm. Nine had immediate effective occlusions of their defects and three residual shunts. One patient with unbuttoning had hemolysis at 2 weeks and underwent surgery. Early results of the transcatheter occlusion of large atrial septal defects are promising, and larger clinical trials are justified.

Intra pulmonary thrombolytic therapy with balloon dilatation in recurrent acute pulmonary embolism.

A 52-year-old man had recurrent pulmonary thrombo embolism following fracture in tibia and subsequent deep vein thrombosis. One episode of massive pulmonary embolism with haemodynamic compromise was managed successfully by balloon compression of the thrombus and thrombolysis with urokinase. Patient was rehabilitated in his previous profession.

Renal dysfunction in enteric fever.

Twenty-five culture positive cases of enteric fever were studied to see the effect of the disease on various kidney functions. The parameters studied were urine examination, blood urea, serum creatinine, serum electrolytes, 24 hours urinary examination (proteins, creatinine, electrolytes), creatinine clearance rate, plain X-ray abdomen, intravenous urogram and circulating immune complexes. Fifteen patients with fever of non-specific origin served as controls. Renal dysfunction was observed in four patients (16%). Repeat tests showed that abnormalities of renal functions, though significant, were short lasting and reversible. Renal biopsy done in three of these cases did not reveal any abnormality.