Palliative bypass surgery for patients with advanced pancreatic adenocarcinoma: experience from a tertiary center.

BACKGROUND: As advances in oncological treatment continue to prolong the survival of patients with non-resectable pancreatic ductal adenocarcinoma (PDAC), decision-making regarding palliative surgical bypass in patients with a heavy disease burden turns challenging. Here we present the results of a pancreatic surgery referral center. METHODS: Patients that underwent palliative gastrojejunostomy and/or hepaticojejunostomy for advanced, non-resectable PDAC between January 2010 and November 2018 were retrospectively assessed. All patients were taken to a purely palliative surgery with no curative intent. The postoperative course as well as short and long-term outcomes was evaluated in relation to preoperative parameters. RESULTS: Forty-two patients (19 females) underwent palliative bypass. Thirty-one underwent only gastrojejunostomy (22 laparoscopic) and 11 underwent both gastrojejunostomy and hepaticojejunostomy (all by an open approach). Although 34 patients (80.9%) were able to return temporarily to oral intake during the index admission, 15 (35.7%) suffered from a major postoperative complication. Seven patients (16.6%) died from surgery and another seven within the following month. Nine patients (21.4%) never left the hospital following the surgery. Mean length of hospital stay was 18 ± 17 days (range 3-88 days). Mean overall survival was 172.8 ± 179.2 and median survival was 94.5 days. Age, preoperative hypoalbuminemia, sarcopenia, and disseminated disease were associated with palliation failure, defined as inability to regain oral intake, leave the hospital, or early mortality. CONCLUSIONS: Although palliative gastrojejunostomy and hepaticojejunostomy may be beneficial for specific patients, severe postoperative morbidity and high mortality rates are still common. Patient selection remains crucial for achieving acceptable outcomes.

Rare Primary Retroperitoneal Neoplasms.

BACKGROUND: Primary retroperitoneal neoplasms (PRN) arise from diverse retroperitoneal tissues. Soft tissue sarcomas (STS) comprise the majority and are well studied. Other non-sarcomatous PRN are very rare and less familiar. OBJECTIVES: To evaluate the clinicopathologic and radiologic features of non-sarcomatous PRN, as well as the outcome of complete tumor resection (TR). METHODS: Retrospective data were collected on consecutive patients (June 2006 to January 2015) who underwent resection of retroperitoneal lesions at our department. Final pathology of non-sarcomatous PRN was included. RESULTS: The study population included 36 patients (26% with PRN). PRN were neurogenic (17%), fat-containing (3%), and cystic (6%). The preoperative diagnosis was correct in only 28%. All patients underwent TR via laparotomy (72%) or laparoscopy (28%), for mean operative time of 120 ± 46 minutes. En bloc organ resection was performed in 11%. Complete TR was achieved in 97%. Intra-operative spillage occurred in 8%. Intra-operative, 90-day postoperative complications, and mortality rates were 11%, 36%, and 0%, respectively. The mean length of stay was 6.5 ± 5.5 days. The median overall survival was 53 ± 4.9 months. CONCLUSIONS: Familiarity with radiologic characteristics of PRN is important for appropriate management. Counter to STS, other PRN are mostly benign and have an indolent course. Radical surgery is not required, as complete TR confers good prognosis. Expectant management is reserved for small, asymptomatic, benign neoplasms.

Primary Retroperitoneal Mucinous Cystic Neoplasm: Authors' Experience and Review of the Literature.

INTRODUCTION: Primary retroperitoneal mucinous cystic neoplasm (PRMCN) is a rare retroperitoneal tumor with female predilection. It is classified into 3 types: benign mucinous cystadenoma (MCA), borderline mucinous cystadenoma (MCAb), malignant mucinous cystadenocarcinoma (MCAc). This study retrospectively evaluates the prevalence of PRMCN among retroperitoneal neoplasms resected between June 2006 and January 2015 at a referral center. Authors' experience with PRMCN is reviewed, and a new case of PRMCN, incidentally diagnosed during pregnancy is reported. A literature review using PubMed is also presented, discussing several issues concerning clinicopathologic features, treatment options, and long-term outcome of PRMCN. CASE REPORT: A 36-year-old woman was incidentally diagnosed with a 12-cm retroperitoneal cyst discovered by ultrasound at 36 weeks of gestation. Eight months later the patient was referred to the department of surgery, the Tel Aviv Sourasky Medical Center. By that time, the patient has sensed local discomfort. Physical examination revealed a right abdomen mass with mild tenderness. Computed tomographic scan depicted the cyst, located along the right paracolic gutter, displacing the right colon medially. The patient underwent complete laparoscopic resection of a 15-cm cyst, without its disruption. The cyst was drained inside an endobag and retrieved. The patient was discharged home on postoperative day 1. The pathology was MCA. Long-term result was no evidence of disease for 9 months. DISCUSSION: The prevalence of PRMCN among resected retroperitoneal neoplasms was 1.95% (3/154 neoplasms). The treatment of choice is complete tumor resection. Surgical technique should be chosen depending on the surgeon's expertise and tumor factors affecting safe resection. Surgery timing during pregnancy should be dictated by both risk of malignancy and obstetric considerations. As for malignant PRMCN, radical surgery does not seem justified, especially in reproductive females. Adjuvant chemotherapy should probably be reserved for metastatic disease, recurrence, and tumor rupture. Long-term follow-up is lacking, although it is important to better define the prognosis of PRMCN.

Late Intragastric Balloon Induced Gastric Perforation.

Intragastric balloon (IGB) has been introduced in the 1980's for weight reduction. It can be classified into nonadjustable IGB, such as the BioEnterics Intragastric Balloon (BIB), or newer generation Spatz adjustable balloon system. Late IGB-induced gastric perforation is a rare major complication, presenting as acute abdominal pain weeks to months after its insertion. We herein present a 20-year-old patient, with gastric perforation occurring 10 months after Spatz IGB deployment. The patient underwent a successful endoscopic IGB retrieval and laparoscopic exploration with abdominal lavage. We also review the literature of late IGB-induced gastric perforation.

Laparoscopic splenectomy for solitary splenic tumors.

BACKGROUND: Solitary splenic masses are a rare entity. There is a paucity of data in the literature on the evaluation and laparoscopic treatment for splenic masses. To further elucidate the evaluation and laparoscopic management of splenic masses we evaluated our own data. MATERIALS AND METHODS: Data was collected retrospectively for all patients who underwent laparoscopic splenectomy (LS) in our institution for the diagnosis of a solid mass. Patients' charts were reviewed. Complementary data was completed when needed by telephone interviews. RESULTS: 28 patients underwent LS for solid splenic masses between 1997 and 2006. Mean age was 54.3 years and 68% were women. Patients' symptoms included abdominal pain (46.5%), anemia (32%), weight loss (21%), and palpable abdominal mass (21%). Fifty-three percent were asymptomatic at diagnosis. Preoperative patients' imaging included computed tomography (92.8%), abdominal ultrasound (71.4%), and positron emission tomography (PET, 32%). Seven patients (25%) had a history of lymphoproliferative disease. The mass size as measured by computed tomography (CT) scan ranged from 4 to 11 cm. Three patients (10.7%) had multiple splenic lesions. Mean operative time was 125 min. Mean estimated blood loss was 200 ml. Five patients (17.9%) had massive splenomegaly. Conversion rate was 14.3%. In three patients (10.7%) the spleen was removed with additional organs' tissue (stomach and pancreas). Two patients (7.1%) were reoperated. There was no postoperative mortality. Mean hospital stay was 4.7 days. Four patients (14.3%) were readmitted due to complications. Pathology revealed eight patients (28%) with benign tumors and the rest (71.4%) with malignant lymphoma. CONCLUSIONS: Splenic solid tumor is a rare entity. Most of the cases were eventually diagnosed as malignant tumors. In our series, all malignant tumors were non-Hodgkin lymphoma. The most common benign lesion was inflammatory pseudotumor. This study has demonstrated the feasibility and safety of LS for diagnosis and treatment of both benign and malignant tumors of the spleen.

Laparoscopic versus non-laparoscopic-assisted ventriculoperitoneal shunt placement in adults. A retrospective analysis.

BACKGROUND: Ventriculoperitoneal shunts and distal shunt revisions bear a high risk of distal malfunction, especially in patients with previous abdominal pathologies as well as in obese patients. We performed laparoscopy-guided distal shunt placement or revision for patients with and without a positive abdominal history. We review the indications, techniques, complications, and long-term outcomes of these cases and compare the results to those of patients operated without laparoscopic guidance. METHODS: A total of 211 distal shunt procedures were performed in our institute between January 2001 and December 2005, 59 of which were laparoscopically guided, and 152 were not. Of the 211 procedures, 177 were placement of new shunt systems, and 34 were distal revisions. A total of 33 procedures were performed in 25 patients with a history of abdominal surgery or inflammatory bowel disease; 15 procedures were operated with laparoscopic guidance. RESULTS: The short-term complication and outcome rates were similar between the laparoscopy group and the other patients. Among the patients with new shunts, the long-term distal malfunction rate was lower in the laparoscopy group compared with the nonlaparoscopy group (4% vs 10.3%, respectively; P = .17). No patients in the laparoscopy group and 6 patients operated by other techniques had distal malfunction. There was 1 laparoscopy-related mortality and no morbidity. CONCLUSIONS: Laparoscopy is not routinely indicated in distal shunt placement or revision. However, a laparoscopy-guided procedure may lower the rate of distal malfunction in patients with previous abdominal surgeries.

Prosthetic mesh repair of large and recurrent diaphragmatic hernias.

BACKGROUND: Laparoscopic repair of large paraesophageal hernias (PEH) is associated with significant recurrence rates. Use of prosthetic mesh to complete tension-free repair of the hiatus has been suggested to decrease the recurrence rate. METHODS: Fifty-nine patients with large (n = 44) or recurrent (n = 15) PEH were operated on via the laparoscopic approach with the use of prosthetic mesh. Patients were followed with office visits and phone interviews. All patients were referred for barium studies. Data analysis included all patients, including conversions, on an intention-to-treat basis. RESULTS: Followup was completed in 56 (95%) patients. Mean followup time was 28.4 months. Forty patients (74%) had significant relief of all symptoms. Barium studies were performed in 45 patients (80.3%), including all symptomatic patients. Fifteen patients (33%) had a small sliding hernia, six (13.3%) had recurrent PEH, and four (8.8%) had narrowing of the gastroesophageal junction. Most patients with small hiatal hernias were symptomatic (60%). All responded to medical treatment. CONCLUSIONS: Laparoscopic repair of large PEH with reinforcement mesh is feasible and safe with excellent short-term results. Long-term followup shows a low PEH recurrence requiring reoperation, but a significant number of patients develop symptomatic recurrent small hiatal hernias that can be managed nonoperatively.

Laparoscopic implantation of the Tenckhoff catheter for the treatment of end-stage renal failure and congestive heart failure: experience with the pelvic fixation technique.

BACKGROUND: Peritoneal dialysis is a widely accepted route for renal replacement. With the advent of endoscopy, many surgical techniques for the prevention of catheter failure have been proposed. OBJECTIVES: To evaluate the outcomes of patients undergoing laparoscopic Tenckhoff catheter implantation using the pelvic fixation technique. METHODS: Data analysis was retrospective. All procedures were performed under general anesthesia. A double-cuffed catheter was inserted using two 5 mm trocars and one 10 mm trocar, fixing its internal tip to the dome of the bladder and its inner cuff to the fascia. Catheter failure was defined as persistent peritonitis/exit-site/tunnel infection, severe dialysate leak, migration or outflow obstruction. RESULTS: LTCI was performed in 34 patients. Mean patient age was 65 +/- 17 years. In 12 of the 34 patients the indication for LTCI was end-stage renal failure combined with NYHA class IV congestive heart failure. Operative time was 35 +/- 15 minutes. A previous laparotomy was performed in 9 patients. Hospital stay was 1.5 +/- 0.6 days. The first continuous ambulatory peritoneal dialysis was performed after 20 +/- 12 days. Median follow-up time was 13 months. There were several complications, including 5 (14%) exit-site/tunnel infections, 27 episodes (0.05 per patient-month) of bacterial peritonitis, 3 (9%) incisional hernias, 1 case of fatal intraabdominal bleeding, 2 (5.8%) catheter migrations (functionally significant), and 10 (30%) cases of catheter plugging, 8 of which were treated successfully by instillation of urokinase and 2 surgically. A complication-mandated surgery was performed in 8 patients (23.5%). The 1 year failure-free rate of the catheter was 80.8%. One fatal intraabdominal bleeding was recorded. CONCLUSIONS: LTCI is safe, obviating the need for laparotomy in high risk patients. Catheter fixation to the bladder may prevent common mechanical failures.

Laparoscopic surgery may be associated with severe pain and high analgesia requirements in the immediate postoperative period.

OBJECTIVE: To assess the immediate (0-4 hours) postoperative pain level in patients after laparoscopy and laparotomy whose analgesic requirement in the Post-Anesthesia Care Unit (PACU) exceeds standard morphine therapy. BACKGROUND DATA: Clinical observation has raised the suspicion that laparoscopic surgery may be associated with more intense immediate postoperative pain than expected. METHODS: This prospective study assessed the 24-hour pain intensity and analgesia requirements in patients who underwent similar abdominal surgery via laparoscopy or laparotomy under standardized general anesthesia and whose pain in the PACU was resistant to 120 microg/kg intravenous morphine. RESULTS: Of 145 sampled PACU patients, 67 were in pain (> or =6 of 10 VAS) within a 30-minute postoperative period. They were then given up to 4 intravenous boluses of 15 microg/kg morphine + 250 microg/kg ketamine. The pain VAS of 36 laparotomy patients was 4.14 +/- 2.14 (SD) and 1.39 +/- 0.55 at 10 and 120 minutes, respectively, after 1.33 +/- 0.59 doses of morphine + ketamine; the pain VAS of 31 laparoscopy patient was 6.06 +/- 1.75 and 2.81 +/- 1.14, respectively (P < 0.0005) following 2.0 +/- 0.53 doses (P = 0.0005). Diclofenac 75 mg intramuscular usage was similar (P = 0.43) between the groups up to 9 hours after surgery but was higher in the laparotomy group by 24 hours (P = 0.01). Pain scores at 24 hours after surgery were lower for the laparoscopy patients (3.01 +/- 0.87) compared with their laparotomy counterparts (4.45 +/- 0.98, P < 0.001). CONCLUSIONS: Among patients after abdominal surgery with severe immediate (0-4 hours) postoperative pain, laparoscopic patients are a significant (46%) proportion, and their pain is more intense, requiring more analgesics than painful patients (54%) do after laparotomy. By 24 hours, the former are in less pain than the latter.

Treatment of intra-gastric band migration following laparoscopic banding: safety and feasibility of simultaneous laparoscopic band removal and replacement.

BACKGROUND: Intra-gastric band migration (band erosion) following laparoscopic adjustable gastric banding (LAGB) is a known complication requiring revisional surgery. Management has most often involved band removal and suturing of the stomach wall, followed by delayed replacement at a third operation. We report our experience with simultaneous band removal and replacement. METHODS: Between May 2001 and December 2003, we performed 754 laparoscopic operations using the Lap-Band (R). Patients developing band erosion were treated by laparoscopic band removal and immediate replacement of a new band following gastric wall repair. RESULTS: 16 patients (2.1%) developed band erosion after a mean of 23 months following surgery (range 11-40 months). Patients presented with epigastric pain (6), port-site bulge (3) or were asymptomatic (7), band erosion being suspected during fluoroscopy for band adjustment and confirmed by gastroscopy. Postoperatively, 11 patients developed fever that responded to antibiotics. No patient suffered from intra-abdominal infection, wound infection, pneumonia or pulmonary embolism. Mean hospital stay was 4 days (range 1-8 days). CONCLUSION: Band erosion following LAGB can be treated safely with simultaneous laparoscopic band removal, gastric wall suturing and immediate replacement of the band, thereby preventing weight gain, the appearance of co-morbidities and the need for additional surgery.

Laparoscopic adrenalectomy: indications, technique, complications and follow-up.

BACKGROUND: Developments in laparoscopic surgery have rendered it an efficient tool for many complex surgical procedures. In the last few years, laparoscopic adrenalectomy has become a more viable option for removal of adrenal pathology, with many surgeons preferring it to the conventional open technique. OBJECTIVES: To describe the indications, technique, complications and follow-up of patients undergoing laparoscopic adrenalectomy in our department. METHODS: The hospital files of 30 patients who underwent the procedure were reviewed. There were 19 females and 11 males with a mean age of 45 years. Indications for surgery differed and included hypersecreting adenoma, pheochromocytoma, suspected malignancy, and incidentaloma. RESULTS: Of the 31 laparoscopic adrenalectomies performed, 11 were right, 18 were left, and 1 was bilateral. The conversion rate to an open procedure was 3%. The mean duration of procedure was 120 minutes. Only one patient required blood transfusion. Complications occurred in 20% of patients, all reversible. There was no mortality. Mean hospitalization duration was 3.4 days and median follow-up 17 months. There were no late complications. All patients operated on for benign diseases are alive. CONCLUSIONS: Laparoscopic adrenalectomy appears to be a useful tool for the treatment of a range of adrenal pathologies.

[Left paraduodenal hernia: a report of a case and a review of clinical and diagnostic CT findings].

Internal hernias are an uncommon cause of small bowel obstruction. Paraduodenal hernias have been considered until recently the most common sub-type. Due to non-specific and intermittent signs and symptoms the diagnosis of these hernias is notoriously difficult. We report a case of a paraduodenal hernia diagnosed correctly with abdominal computed tomography that was confirmed at surgery and review the clinical and imaging findings of these hernias.