R0 but not R1/R2 resection is associated with better survival than palliative photodynamic therapy in biliary tract cancer.

BACKGROUND: There is a need for better management strategies to improve the survival and quality of life in patients with biliary tract cancer (BTC). AIM: To assess prognostic factors for survival in a large, non-selective cohort of patients with BTC. METHOD: We compared outcomes in 321 patients with a final diagnosis of BTC (cholangiocarcinoma n = 237, gallbladder cancer n = 84) seen in a tertiary referral cancer centre between 1998 and 2007. Survival according to disease stage and treatment category was compared using log-rank testing. Cox's regression analysis was used to determine independent prognostic factors. RESULTS: Eighty-nine (28%) patients underwent a surgical intervention with curative intent, of whom 38% had R0 resections. Among the 321 patients, 34% were given chemo- and/or radiotherapy, 14% were palliated with photodynamic therapy (PDT) and 37% with biliary drainage procedures alone. The overall median survival was 9 months (3-year survival, 14%). R0-resective surgery conferred the most favourable outcome (3-year survival, 57%). Although patients palliated with PDT had more advanced clinical T-stages, their survival was similar to those treated with attempted curative surgery but who had positive resection margins. On multivariable analysis, treatment modality, serum carbohydrate-associated antigen 19-9, distant metastases and vascular involvement were independent prognostic indicators of survival. CONCLUSION: In this large UK series of BTC, palliative PDT resulted in survival similar to those with curatively intended R1/R2 resections. Surgery conferred a survival advantage only in patients with R0 resection margins, emphasising the need for accurate pre-operative staging.

Methods of cystic duct occlusion during laparoscopic cholecystectomy.

BACKGROUND: During laparoscopic cholecystectomy, it is necessary to occlude the cystic duct permanently. Traditionally, this has been performed through the application of non-absorbable metal clips. Use of absorbable materials to occlude the cystic duct has been suggested as an alternative for metal clips for various reasons. OBJECTIVES: To assess the benefits and harms of the different methods of occlusion of cystic duct in patients undergoing laparoscopic cholecystectomy. SEARCH STRATEGY: We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until August 2010. SELECTION CRITERIA: We included all randomised clinical trials comparing different methods of occlusion of cystic duct. DATA COLLECTION AND ANALYSIS: We collected the data on the characteristics, methodological quality, bile duct injury, bile leaks, operating time, and incidence of recurrent common bile duct stone from each trial. We analysed the data with both the fixed-effect and the random-effects model using RevMan Analysis. For each outcome we calculated the risk ratio (RR) in the presence of more than one trial for the outcome or mean difference (MD) with 95% confidence intervals (CI) based on intention-to-treat analysis. In the presence of only one trial under a dichotomous outcome, we performed the Fisher's exact test. MAIN RESULTS: Three trials including 255 patients qualified for this review. In two of the trial, a total of 150 patients were randomised to absorbable clips (n = 75) and non-absorbable clips (n = 75). In the third trial, a total of 105 patients were randomised to absorbable ligatures (n = 53) and non-absorbable clips (n = 52). All three trials were of high risk of bias. There was no difference in the morbidity between the groups. There was statistically significant longer operating time (MD 12.00 minutes, 95% CI 1.59 to 22.41) in the absorbable ligature group than non-absorbable clips. The duration and method of follow-up were not adequate to determine the incidence of long-term complications. AUTHORS' CONCLUSIONS: We are unable to determine the benefits and harms of different methods of cystic duct occlusion because of the small sample size, short period of follow-up, and lack of reporting of important outcomes in the included trials. Adequately powered randomised trials with low risk of bias and with long periods of follow-up and assessing all of the important outcomes for patients and professionals are necessary.

The use of a rapid in situ test in the detection of central venous catheter-related bloodstream infection: a prospective study.

BACKGROUND: Acridine orange leukocyte cytospin (AOLC) is a highly sensitive and specific test for the detection of catheter-related bloodstream infection (CRBSI). We evaluated the role of the AOLC test in early detection or exclusion of CRBSI and compared the cost of managing patients with suspected CRBSI. METHODS: On the day of clinical suspicion of CRBSI, blood samples were obtained from the catheters for the AOLC test, and peripheral blood samples were obtained for quantitative blood cultures. Catheters with positive AOLC results were immediately removed for culture and replaced if necessary. Catheters with negative AOLC tests were left in situ. We compared the catheter lifespan in patients with suspected CRBSI who had positive and negative AOLC tests and calculated the cost of using the AOLC test to prevent indiscriminate catheter removal. RESULTS: Fifty patients with suspected CRBSI were tested and prospectively followed up. Catheters were removed in 10 patients (20%) with a positive AOLC test, and CRBSI was confirmed in each case subsequently. Selective removal of catheters based on AOLC tests significantly extended the lifespan of catheters compared with an indiscriminate removal of catheters based on clinical suspicion of CRBSI (median, 24 versus 11 days; p < .0001). The cost of an AOLC test and selective catheter replacement strategy was significantly lower than the cost of routine removal and replacement of catheters (median, pounds sterling 9.53 versus pounds sterling 64.20; p < .0001). CONCLUSION: The AOLC test enables a rapid detection of CRBSI, avoids unnecessary removal of catheters, and provides a cost-efficient management approach in patients with suspected CRBSI.

Lymphoplasmacytic sclerosing pancreatitis and retroperitoneal fibrosis.

Although cases of lymphoplasmacytic sclerosing pancreatitis (LSP) associated with idiopathic retroperitoneal fibrosis have been reported, the association is rare. We describe a 74-year-old man who presented with obstructive jaundice and weight loss. Nineteen months earlier, he had been diagnosed with idiopathic retroperitoneal fibrosis and treated with bilateral ureteric stents. Initial investigations were suggestive of a diagnosis of LSP, however, a malignant cause could not be ruled out. He underwent an exploratory laparotomy and frozen sections confirmed the diagnosis of LSP. An internal biliary bypass was performed using a Roux loop of jejunum, and the patient made an uneventful recovery. This case illustrates the difficulty in distinguishing LSP from pancreatic carcinoma preoperatively.

Total gastric necrosis due to aberrant arterial anatomy and retrograde blood flow in the gastroduodenal artery: a complication following pancreaticoduodenectomy.

Patients with coeliac artery occlusion often remain asymptomatic due to the rich collateral blood supply (pancreaticoduodenal arcades) from the superior mesenteric artery. However, division of the gastroduodenal artery (GDA) during pancreaticoduodenectomy may result in compromised blood supply to the liver, stomach and spleen. Postoperative complications associated with this condition are rarely reported in the literature. We report two cases of coeliac artery occlusion encountered during pancreaticoduodenectomy, one of which was complicated by hepatic ischaemia and total gastric infarction postoperatively. Based on our experience and review of the literature, a management algorithm for coeliac artery stenosis encountered during pancreaticoduodenectomy is proposed.