Outcomes From Minimal Access Retroperitoneal and Open Pancreatic Necrosectomy in 394 Patients With Necrotizing Pancreatitis.

OBJECTIVE: To examine the outcomes from minimal access retroperitoneal pancreatic necrosectomy (MARPN) and open pancreatic necrosectomy (OPN) for severe necrotizing pancreatitis in a single center. BACKGROUND: The optimal management of severe pancreatic necrosis is evolving with a few large center single series. METHODS: Between 1997 and 2013, patients with necrotizing pancreatitis at the Liverpool Pancreas Center were reviewed. Outcome measures were retrospectively analyzed by intention to treat. RESULTS: There were 394 patients who had either MARPN (274, 69.5%) or OPN (120, 30.5%). Complications occurred in 174 MARPN patients (63.5%) and 98 (81.7%) OPN patients (P < 0.001). OPN was associated with increased postoperative multiorgan failure [42 (35%) vs 56 (20.4%), P = 0.001] and median (inter-quartile range) Acute Physiology and Chronic Health Evaluation II score 9 (6-11.5) vs 8 (5-11), P < 0.001] with intensive care required less frequently in MARPN patients [40.9% (112) vs 75% (90), P < 0.001]. The mortality rate was 42 (15.3%) in MARPNs and 28 (23.3%) in OPNs (P = 0.064). Both the mortality and the overall complication rates decreased between 1997-2008 and 2008-2013 [49 (23.8%) vs 21 (11.2%) P = 0.001, respectively; and 151 (73.3%) vs 121 (64.4%), P = 0.080, respectively). Increased mortality was independently associated with age (P < 0.001), preoperative intensive care stay (P = 0.014), and multiple organ failure (P < 0.001); operation before 2008 (P < 0.001) and conversion to OPN (P = 0.035). MARPN independently reduced mortality odds risk (odds ratio = 0.27; 95% confidence interval = 0.12-0.57; P < 0.001). CONCLUSIONS: Increasing experience and advances in perioperative care have led to improvement in outcomes. The role of MARPN in reducing complications and deaths within a multimodality approach remains substantial and should be used initially if feasible.

Management and Outcome of 64 Patients with Pancreatic Serous Cystic Neoplasms.

BACKGROUND: The optimal management approach to pancreatic serous cystic neoplasms (SCNs) is still evolving. METHODS: Consecutive patients with SCN managed at the Liverpool Pancreas Cancer Centre between 2000 and 2013 were retrospectively reviewed. RESULTS: There were 64 patients consisting of 39 women (60.9%) and 25 men (39.1%). Forty-seven patients (73.4%) had surgical removal and 17 (26.6%) were observed. The possibility of a non-SCN malignancy was the predominant indication for resection in 27 (57.4%) patients. Postoperative morbidity occurred in 26 (55.3%) patients with 2 (4.3%) deaths. An increased risk of resection was associated with patient's age (p = 0.011), diagnosis before 2009 (p < 0.001), pain (p = 0.043), possibility of cancer (p = 0.009) and a solid SCN component on imaging (p = 0.002). Independent factors associated with resection were a diagnosis before 2009 (p = 0.005) and a solid SCN component (p < 0.001). Independent factors associated with shorter time to surgical resection were persistent pain (p = 0.003) and a solid SCN component (p = 0.007). CONCLUSION: There was a reduction in the proportion of resections with the application of an observe-only policy for asymptomatic patients with more definite features of SCN. Improved criteria are still required in the remainder of patients with uncertain features of SCN in deciding for intervention or surveillance.

Classification of R1 resections for pancreatic cancer: the prognostic relevance of tumour involvement within 1 mm of a resection margin.

AIMS: The current Royal College of Pathologists guidelines for pancreatoduodenectomy specimen reporting recommend that microscopic evidence of tumour within 1 mm of a resection margin (RM) should be classified as R1. No clinical evidence exists to justify this classification. The aim of this study was to identify the proportion of pancreatoduodenectomy specimens in which 'equivocal' RMs are present (tumour involvement within 1 mm of, but not directly reaching, one or more resection margins) and whether the survival of these patients was similar to that of patients with 'unequivocal' RM involvement. METHODS AND RESULTS: Patients with histologically confirmed pancreatic ductal adenocarcinoma undergoing pancreatoduodenectomy between 1997 and 2007 (n = 163) were identified from a prospective database. One hundred and twenty-eight cases (79%) were classified as R1. Of these, 57 (45% of all R1 cases) were based on 'equivocal' margin involvement. There was no significant difference in overall survival between equivocal and unequivocal R1 resections (log rank, P = 0.102). All R1 resections had a poorer survival on univariate (log rank, P = 0.013), but not multivariate, analysis (Cox, P = 0.132). CONCLUSIONS: Our results indicate that cases with microscopic tumour involvement within 1 mm of a resection margin should be considered synonymous with incomplete excision for resected pancreatic cancer.

A preoperative prognostic score for resected pancreatic and periampullary neuroendocrine tumours.

BACKGROUND/AIMS: To identify potential preoperative prognostic factors in resected pancreatic and periampullary neuroendocrine tumours. METHODS: Clinico-pathological data for 54 consecutive patients with pancreatic or periampullary neuroendocrine tumours referred to our institution over a 10-year period were identified from a prospective database. RESULTS: 34 patients underwent pancreatic resection (12 males, 22 females; median age 54 (IQR 44-71) years). There was a single 30-day mortality (3%). Nodal status (log rank, p = 0.652), microscopic resection margin involvement (p = 0.549) and tumour size (p = 0.122) failed to exhibit any prognostic value. Only the presence of malignant tumour characteristics was associated with poorer overall survival (p = 0.008). Analysis of preoperative parameters showed that age >60 years (p = 0.056), platelet-lymphocyte ratio >300 (p = 0.008), alkaline phosphatase levels >125 U/l (p = 0.042) and alanine aminotransferase >35 U/l (p = 0.016) were adverse prognostic factors. A risk stratification score was generated where each adverse preoperative parameter was allocated a score of 1. A cumulative score of < or =1 was defined as low risk, while a score of > or =2 was defined as high risk. Median overall survival in the high-risk group was 10.4 months, while the median survival in the low-risk group was >60 months (p < 0.001). CONCLUSION: Significant prognostic information can be gained from routine preoperative biochemistry and haematology results in resected pancreatic and periampullary neuroendocrine tumours. These findings merit further evaluation in a larger patient cohort.

Density of middle turbinate subepithelial mucous glands in patients with chronic rhinosinusitis.

OBJECTIVE: Histologic changes have not been systematically assessed in chronic rhinosinusitis. Quantitative histochemical studies evaluated the extent of sinus disease and gland density in the middle turbinates. STUDY DESIGN AND SETTING: Sinus computed tomography scans of 34 patients with chronic rhinosinusitis were retrospectively graded 0 to IV according to the May classification. Middle turbinates from patients with chronic rhinosinusitis (n = 46) and normal patients (n = 7) were harvested during endoscopic sinus surgery. The areas of Alcian blue-stained glands were assessed in paraffin sections using a computer-assisted microscopy video system. RESULTS: Alcian blue-stained glands occupied 7.94% of normal mucosa. The staining in all grade III rhinosinusitis subjects was increased to 12.94% (P < 0.01). In contrast, grade IV pansinusitis was associated with nasal polyposis (6 of 6) with decreased gland area (3.04%, P < 0.01). When polyp patients were excluded from grade III rhinosinusitis, the Alcian blue-staining area was 17.68% (P < 0.01). CONCLUSIONS: Distinct polypoid and glandular histopathologic patterns are present in chronic rhinosinusitis.