Incidence and treatment of splanchnic vein thrombosis in patients with acute pancreatitis: A systematic review and meta-analysis.

BACKGROUND AND AIM: This meta-analysis aimed to estimate the incidence of splanchnic vein thrombosis (SVT) in patients with acute pancreatitis and assess the effects of therapeutic anticoagulation. METHODS: Systematic searches of the Medline, Embase, and Cochrane databases were undertaken to identify studies reporting the incidence and outcomes associated with SVT in patients with acute pancreatitis. The pooled incidence, odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random effects model. PROSPERO database registration no. CRD 42021230912. RESULTS: Only 18 of the 238 studies identified met the inclusion criteria. Of the 943 patients who had SVT, 264 (28.0%) received anticoagulation. The pooled incidence of SVT at first presentation of acute pancreatitis was 15% (95% CI 5 to 26%), but was 17% (95% CI 14 to 20%) in all studies. Recanalization was more likely to occur in the anticoagulation-treated than in the untreated group (OR 0.51, 95% CI 0.31 to 0.83, P = 0.007). There were no differences in hemorrhagic complications (OR 2.27, 95% CI 0.81 to 6.37, P = 0.12) or overall mortality (OR 2.37, 95% CI 0.86 to 6.52, P = 0.10) in relation to the use of anticoagulation. The overall incidence of portal hypertension in patients was 60% (95% CI 55 to 65%). However, it was not possible to determine the incidence in each group. CONCLUSIONS: The incidence of SVT in patients with acute pancreatitis is significant. Treatment with anticoagulants improved the odds of recanalization but did not increase the risk of hemorrhagic complications or overall mortality.

Safety and Efficacy of Tranexamic Acid to Minimise Perioperative Bleeding in Hepatic Surgery: A Systematic Review and Meta-Analysis.

INTRODUCTION: Perioperative bleeding poses a major risk during liver surgery, which can result in increased transfusion requirements, morbidity, and mortality. Tranexamic acid (TXA) effectively reduces perioperative bleeding and transfusion requirements in trauma patients. However, there remains a lack of evidence of its use in liver surgery. This meta-analysis of randomised controlled trials evaluated the efficacy and safety of TXA in liver resection and transplantation. METHOD: A comprehensive search of Medline, Embase, CENTRAL and Clinicaltrials.gov databases was undertaken to identify studies from January 1947 to September 2021. The outcomes of the need for blood transfusion, thromboembolic events and mortality were extracted from the included studies. Quantitative pooling of data was based on the random effects model. RESULTS: Six studies reporting on 429 patients were included. TXA reduced the need for perioperative blood transfusion in liver resection and transplantation (OR 0.09; 95% CI 0.01 to 0.72). More importantly, TXA did not increase the incidence of thromboembolic events (OR 2.22; 95% CI 0.47 to 10.43) and mortality (OR 0.60; 95% CI 0.13 to 2.76). CONCLUSION: TXA safely reduces the need for blood transfusion in patients undergoing liver resection and transplantation.

ACE Inhibitor Therapy Does Not Influence the Survival Outcomes of Patients with Colorectal Liver Metastases Following Liver Resection.

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors have been shown to possibly influence the survival outcomes in certain cancers. The aim of this study was to evaluate the impact of ACE inhibitors on the outcomes of patients undergoing liver resection for colorectal liver metastases (CRLM). The secondary aim was to determine whether ACE inhibitors influenced histopathological changes in CRLM. METHODS: Patients treated with liver resection for CRLM over a 13-year period were identified from a prospectively maintained database. Data including demographics, primary tumour treatment, surgical data, histopathology analysis and clinical outcome were collated and analysed. RESULTS: A total of 586 patients underwent primary hepatic resections for CRLM during this period including 100 patients on ACE inhibitors. The median follow-up period was 23 (range: 12-96) months, in which 267 patients developed recurrent disease and 131 patients died. Independent predictors of disease-free survival on multivariate analysis included synchronous presentation, neoadjuvant chemotherapy, major liver resection, tumour size and number, extent of hepatic steatosis, R0 resection and presence of perineural invasion. Poorer overall survival was associated with neoadjuvant treatment, major liver resection, presence of multiple metastases, perineural invasion and positive resection margins on multivariate analysis. ACE inhibitors did not influence the survival outcome or histological presentation in CRLM. CONCLUSION: The use of ACE inhibitors did not affect the survival outcome or tumour biology in patients with CRLM following liver resection.

Outcomes of liver resection for hepatocellular carcinoma in octogenarians.

BACKGROUND: There is a dearth of information about operative outcomes in patients ≥80 years for hepatocellular carcinoma (HCC) from Western institutions. We compare the result of HCC resections in patients <80 years vs. patients ≥80 years from our institution in the UK. METHODS: We conducted a retrospective review of all patients undergoing liver resections for HCC between 2005 and 2015. Demographics, comorbidities, morbidity, mortality and survival were compared between the two age groups. RESULTS: 200 patients underwent resection for HCC in this time period. Nineteen patients were ≥80 years and 181 were <80 years. Comorbidities measured by the Charlson Comorbidity Index were significantly higher in the ≥80 group (p < 0.0001). There was no significant difference in the extent of resection in the two groups. Morbidity and mortality between the <80 years and the ≥80 years group were not significantly different (morbidity 27% vs.16%; p = 0.29) (mortality 7% vs. 0%; p = 0.11). The one-year (83.4% vs. 88.2%; p = 0.83), five-year (56.3% vs. 55.8%; p = 0.83) and the overall survival rate rates (887 days vs. 1035 days; p = 0.66) were not significantly different between the groups. DISCUSSION: Liver resection should not be precluded based on age alone; with good outcomes in patients ≥80 years justifying surgery.

Measurement of indicator genes using global complementary DNA (cDNA) amplification, by polyadenylic acid reverse transcriptase polymerase chain reaction (poly A RT-PCR): A feasibility study using paired samples from tissue and ductal juice in patients undergoing pancreatoduodenectomy.

OBJECTIVES: The aim of this study is to compare gene expression profiles in RNA isolated from pancreatic ductal juice with the RNA expression profiles of the same genes from matched intra-operative tissue samples from pancreatic tumours. METHODS: Intra-operative sampling of pancreatic juice and collection of matched tissue samples was undertaken in patients undergoing pancreatoduodenectomy for clinically suspected pancreatic cancer and a precursor lesion, main-duct intraductal papillary mucinous neoplasm. RNA was isolated and Poly A PCR was used to globally amplify the RNA. Real-time polymerase chain reaction (RT-PCR) was used to measure expression levels of 17 genes selected from microarray studies. Spearman's rank correlation test was used to examine the relationship of gene expression between pancreatic juice and tissue. The study was approved by Regional Ethics Committee. RESULTS: Mesothelin (MSLN) showed significant correlation (p < 0.008) in expression levels between paired pancreatic juice and tissue samples in pancreas cancer. In intraductal papillary mucinous neoplasms (IPMN), Matrix Metalloproteinase 7 (MMP7), showed significant correlation (p < 0.01) in the expression levels between paired pancreatic juice and tissue samples. CONCLUSION: This study confirms that RNA analysis of paired pancreatic juice and tissue samples and establishment of cDNA using poly A PCR is technically feasible. Application of the technique to non-invasively obtained pancreatic juice during endoscopic assessment of tumours and the use of gene arrays of cancer indicator genes are the next steps in development of this technique.

Evaluation of tumor M2-pyruvate kinase (Tumor M2-PK) as a biomarker for pancreatic cancer.

BACKGROUND: Expression of the dimeric M2 isoenzyme of pyruvate kinase, termed Tumor M2-PK, is increased in some human cancers. This study evaluates the potential role of pre-operative Tumor M2-PK as a marker of prognosis in patients with pancreatic malignancy. METHODS: Seventy-three consecutive patients with a clinical diagnosis of pancreatic or peri-ampullary cancer were enrolled. Their median (range) age was 66 (23-83) years. Pre-operative samples of venous blood were taken for analysis of Tumor M2-PK. The full study protocol was approved by the North West Research Ethics Committee (protocol number 06/MRE08/69). RESULTS: The mean (standard deviation) plasma Tumor M2-PK in pancreatic/peri-ampullary malignancy was 60.3 (106.5) U/ml and 22 U/ml (SD: 12 U/ml) in benign disease (p < 0.001). Multivariate Cox regression analysis showed that Tumor M2-PK (> 27 U/mL), Ca19-9 (> 39 U/ml), resection status, and disease stage were associated with poorer survival. Tumor M2-PK values greater than 27 U/ml were associated with inferior survival compared to those with lower values (hazard ratio 2.049, significantly increased risk of death, p = 0.042). CONCLUSION: This preliminary study shows that an elevated level of Tumor M2-PK (with a cutoff threshold of 27 U/mL) measured pre-operatively is associated with poorer prognosis in patients with pancreatic and peri-ampullary cancer.

Isolation and evaluation of cytogenetic effect of Brahmi saponins on cultured human lymphocytes exposed in vitro.

Major saponins of Brahmi (Bacopa monniera, Fam: Scrophulariaceae) - bacosides A and B - were isolated from the total methanol extract and characterised based on melting point, TLC, IR, (1)H NMR and (13)C NMR. They were evaluated for their in vitro cytogenetic effects on human peripheral blood lymphocytes by chromosomal aberration (CA) assay and sister chromatid exchange (SCE) assay. The frequency of chromatid type aberrations and reciprocal interchanges between sister chromatids in the treated cells was scored in comparison to the untreated control. At 30 µg/mL dose, bacoside A showed a statistically significant increase in the frequency of both CA and SCE and bacoside B showed an increase only in SCE. Our report of the genotoxicity of the saponins is significant in view of the reports of anticancer activity of Brahmi extracts.

Isolated roux loop pancreaticojejunostomy vs single loop pancreaticojejunostomy after pancreaticoduodenectomy.

BACKGROUND: Pancreatic anastomotic leaks are a major cause of morbidity and mortality following pancreaticoduodenectomy, and no single technique of reconstruction has shown to be superior. The aim of this study was to review the experience of single loop versus isolated Roux loop pancreaticojejunostomy in a series of patients undergoing pancreatic head resection. METHODS: A retrospective review involving 111 patients who underwent pancreatic head resections over 13year period (1994-2006) for malignant (n=106) and benign (n=5) disease was performed. Reconstruction of the pancreatic remnant was done using a single loop in 51 patients and by an isolated Roux loop in 60 patients. All pancreatic anastomosis were performed as a duct to mucosa anastomosis, in two layers, with pancreatic stent and closed suction drainage. Pancreatic fistula was defined as drainage of greater than 50ml of amylase rich fluid for more than 7days postoperatively. RESULTS: The two groups were comparable as regards to their demographic profiles, preoperative laboratory values and disease status in terms of pathology, pancreatic texture and pancreatic duct diameters. The overall incidence of pancreatic anastomotic leak was 11% (12) and was similar in both the groups; single loop 12% (6) and isolated Roux loop 10% (6). Isolated Roux loop pancreaticojejunostomy was associated with a significant prolongation of operative time (7.25+/-1.14h vs 6.07+/-1.12h) (p<0.05) and the need for more blood transfusion (2.25+/-0.84units vs 2.62+/-0.69units) (p<0.05). There was no significant difference in the morbidity or mortality between the two groups. Forty five percent (23) patients had complications in the single loop group and 48% (29) patients had complications in the isolated group. There were 8% (4) death in the single loop group and 8% (5) in the isolated group (p>0.05). CONCLUSION: There does not appear to be a significant difference in the rates of pancreatic fistula following either method of reconstruction. However, performance of an isolated Roux loop pancreaticojejunostomy entails a prolongation of operative time and more intraoperative requirement of blood transfusions.

Comparison of major bile duct injuries following laparoscopic cholecystectomy and open cholecystectomy.

BACKGROUND: The mechanism and extent of major bile duct injuries following laparoscopic cholecystectomy differ from those of open cholecystectomy. METHODS: To identify differences in the demographic profile, timing of injury detection, management strategies and outcome, we undertook a retrospective review and analysis of our experience with 55 major bile duct injuries following both laparoscopic and open cholecystectomies over a period of 9 years. RESULTS: Thirty-one major bile duct injuries resulted from laparoscopic cholecystectomy (56%) and 24 of them were sustained after open cholecystectomy (44%). The median time of presentation was 7 days after laparoscopic cholecystectomy and 14 days following open cholecystectomy (P < 0.001). Twenty-eight (51%) patients had injuries recognized intraoperatively in both groups, of whom 18 patients underwent an attempt at primary repair before referral. All patients required subsequent surgical intervention. There were no differences in the clinical presentations between the two groups. However, serum alkaline phosphatase, alanine aminotransferase and aspartate aminotransferase levels were significantly higher following open cholecystectomy (P < 0.05). There was no significant difference in the level of injury between the two groups. All patients underwent surgical repair in the form of a Roux-en-Y hepaticojejunostomy (including two revision hepaticojejunostomies in each group). Surgical outcome did not differ between the groups; however, better results were seen with Bismuth grades 1 and 2 strictures compared with Bismuth grades 3 and 4 strictures for both groups (P < 0.002). CONCLUSION: Major bile duct injuries following laparoscopic cholecystectomy present earlier and with lower levels of serum alkaline phosphatase, alanine aminotransferase and aspartate aminotransferase. There does not appear to be a significant difference between the Bismuth-Strasberg grading of the strictures and the type of surgery carried out.

Splenic metastasis from esophageal cancer: report of a case.

The spleen is an unusual site of metastasis from an esophageal malignancy. We herein report the case of a 25-year-old woman who underwent a transhiatal esophagectomy and adjuvant radiotherapy and chemotherapy for squamous cell carcinoma of the lower third of the esophagus with pN1 lymph node metastasis. Fifteen months following surgery she was found to have splenic metastasis infiltrating the tail of the pancreas at the hilum. A splenectomy, distal pancreatectomy, and resection of the splenic flexure with colocolic anastomosis were performed. A histological examination of the resected specimen showed squamous cell carcinoma.

Relevance of day care laparoscopic cholecystectomy in a developing nation.

Feasibility, safety and success of day care laparoscopic cholecystectomy (DCLC) has been well established in advanced countries. The information on (DCLC) is not available from developing nations. All patients of gallstone disease undergoing laparoscopic cholecystectomy under the care of the two participating surgeons at the post graduate Institute of Medical Education & Research were considered for day care laparoscopic cholecystectomy. The selection criteria were: elective cases only, patients less than 70 years, American Society of Anesthesiologists (ASA) grade I and Grade II, living within 20 Kilometers of the hospital, availability of a responsible adult carer at home, access to a telephone and a means of transportation to hospital if needed. Clinical and operative data were recorded prospectively. All patients were discharged 6 to 8 hours after surgery with the advice to contact the surgical team over phone whenever necessary or on the day after discharge. Out of the total 236 laparoscopic cholecystectomy performed over a period of 26 months, 106 patients (44.9%) underwent laparoscopic cholecystectomy as day care procedure. Five patients (4.8%) were admitted after surgery. Four patients were admitted because of conversion and one patient was admitted because of suspected myocardial infarction. Hundred and one patients (95.2%) were discharged on the same day. There was no major morbidity and patient's acceptance was high. Day care laparoscopic cholecystectomy is feasible, safe, and acceptable to patients.

Pseudoaneurysm of the superior pancreaticoduodenal artery, a rare cause of hemosuccus pancreaticus: report of a case.

Chronic pancreatitis with a pseudoaneurysm is an established cause of hemosuccus pancreaticus. We herein describe a patient with chronic alcoholic pancreatitis associated with hemosuccus pancreaticus due to a pseudoaneurysm of the anterior superior pancreaticoduodenal artery rupturing in a pseudocyst of pancreas in the head region. Angiographic embolization was unsuccessful and therefore a laparotomy, ligation, and excision of the pseudoaneurysm with external drainage of pseudocyst were performed. Hemosuccus pancreaticus is a rare cause of upper gastrointestinal bleeding. Contrast-enhanced computed tomography and angiography is diagnostic in the majority of the cases. Surgery is the treatment of choice. Selective angiographic embolization may be helpful in tiding over the emergency until surgery can be performed.

Primary small bowel melanoma: a case report.

The small intestine is the most common site of gastrointestinal metastasis from cutaneous melanoma. However, the small intestine itself is rarely the site of a primary melanotic tumour. We describe a case of primary small bowel melanoma in a 70-year-old man, and discuss the features of primary and metasttic melanoma.