Risk factors and outcomes of conversion in minimally invasive distal pancreatectomy: a systematic review.

PURPOSE: The reported conversion rates for minimally invasive distal pancreatectomy (MIDP) range widely from 2 to 38%. The identification of risk factors for conversion may help surgeons during preoperative planning and patient counseling. Moreover, the impact of conversion on outcomes of MIDP is unknown. METHODS: A systematic review was conducted as part of the 2019 Miami International Evidence-Based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR). The PubMed, Cochrane, and Embase databases were searched for studies concerning conversion to open surgery in MIDP. RESULTS: Of the 828 studies screened, eight met the eligibility criteria, resulting in a combined dataset including 2592 patients after MIDP. The overall conversion rate was 17.1% (range 13.0-32.7%) with heterogeneity between studies associated with the definition of conversion adopted. Only one study divided conversion into elective and emergency conversion. The main indications for conversion were vascular involvement (23.7%), concern for oncological radicality (21.9%), and bleeding (18.9%). The reported risk factors for conversion included a malignancy as an indication for surgery, the proximity of the tumor to vascular structures in preoperative imaging, higher BMI or visceral fat, and multi-organ resection or extended resection. Contrasting results were seen in terms of blood loss and length of stay in comparing converted MIDP and completed MIDP patients. CONCLUSION: The identified risk factors for conversion from this study can be used for patient selection and counseling. Surgeon experience should be considered when contemplating MIDP for a complex patient. Future studies should divide conversion into elective and emergency conversion.

The role of older age and obesity in minimally invasive and open pancreatic surgery: A systematic review and meta-analysis.

BACKGROUND/OBJECTIVES: The aim of this study was to assess the impact of older age (≥70 years) and obesity (BMI ≥30) on surgical outcomes of minimally invasive pancreatic resections (MIPR). Subsequently, open pancreatic resections or MIPR were compared for elderly and/or obese patients. METHODS: A systematic review was conducted as part of the 2019 Miami International Evidence-Based Guidelines on MIPR (IG-MIPR). Study quality assessment was according to The Scottish Intercollegiate Guidelines Network (SIGN). A meta-analysis was performed to assess the impact of MIPR or open pancreatic resections in elderly patients. RESULTS: After screening 682 studies, 13 observational studies with 4629 patients were included. Elderly patients undergoing laparoscopic distal pancreatectomy (LDP) had less blood loss (117 mL, p < 0.001) and a shorter hospital stay (3.5 days p < 0.001) than elderly patients undergoing open distal pancreatectomy (ODP). Postoperative pancreatic fistula (POPF) B/C, major complication and reoperation rate were not significantly different in elderly patients undergoing either laparoscopic or open pancreatoduodenectomy (OPD). One study compared robot PD with OPD in obese patients, indicating that patients with robotic surgery had less blood loss (mean 250 ml vs 500 ml, p = 0.001), shorter operative time (mean 381 min vs 428 min, p = 0.003), and lower rate of POPF B/C (13% vs 28%, p = 0.039). CONCLUSION: The current available limited evidence does not suggest that MIPR is contraindicated in elderly or obese patients. Additionally, outcomes in MIPR are equal or more beneficial compared to the open approach when applied in these patient groups.

Risk of gastric or peritoneal recurrence, and long-term outcomes, following pancreatic cancer resection with preoperative endosonographically guided fine needle aspiration.

BACKGROUND AND STUDY AIMS: There have been concerns regarding tumor cell seeding along the needle track or within the peritoneum caused by preoperative endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). The aim of this study was to evaluate whether preoperative EUS-FNA is associated with increased risk of stomach/peritoneal recurrence and whether the procedure affects long term survival. METHODS: The records of patients diagnosed with malignant solid and cystic pancreatic neoplasms who underwent surgery with curative intent between 1996 and 2012 were reviewed. RESULTS: A total of 256 patients with similar baseline characteristics were included: 48 patients in the non-EUS-FNA group and 208 in the EUS-FNA group. Recurrence data were available for 207 patients. Median length of follow-up was 23 months (range 0 - 111 months). A total of 19 patients had gastric or peritoneal recurrence; 6 (15.4 %) in the non-EUS-FNA group vs. 13 (7.7 %) in the EUS-FNA group (P = 0.21). Three patients had recurrence in the stomach wall: one (2.6 %) patient in the non-EUS-FNA group vs. two patients (1.2 %) in EUS-FNA group (P = 0.46). A total of 16 patients had peritoneal recurrence: 5 patients (12.8 %) in the non-EUS-FNA group and 11 patients (6.5 %) in the EUS-FNA group (P = 0.19). In a multivariate analysis, undergoing EUS-FNA was not associated with increased cancer recurrence or decreased overall survival. CONCLUSION: Pre-operative EUS-FNA was not associated with an increased rate of gastric or peritoneal cancer recurrence in patients with resected pancreatic cancer. Two patients had gastric wall recurrence following the procedure, but this may be explained by direct tumor extension. This suggests that EUS-FNA is not associated with an increased risk of needle track seeding.

Current status of laparoscopic distal pancreatectomy.

Distal pancreatectomy is the therapeutic option of choice for patients with a benign or malignant lesion located in the body and/or tail of the pancreas when surgical intervention is indicated. With recent advances in and wide spread use of imaging studies, lesions of the pancreas are being diagnosed more commonly and it is likely that this will translate into an increased number of patients undergoing surgical resection. The laparoscopic approach to pancreatic resections has not been adopted as rapidly as it has for most other general surgical procedures. This is despite the fact that the current literature appears to validate laparoscopy as an acceptable and safe approach for distal pancreatectomy in patients with benign lesions, and has demonstrated the known benefits inherent to the laparoscopic technique. These benefits include lower intraoperative blood loss, less pain and analgesic requirements, earlier return of bowel function, and shorter recovery and hospital stay. Yet controversy still exists for the role of laparoscopy in the resection of malignant lesions. Recent reports however, have shown that laparoscopic distal pancreatectomy can safely be performed in known malignancies and, most importantly, after a laparoscopic oncological resection, the oncological benchmarks that have been related to survival, (such as negative surgical margins and number of peripancreatic lymph nodes resected), can also be accomplished. We sought to review the current literature on distal pancreatectomy, specifically the indications, laparoscopic approaches, splenectomy and spleen-preserving techniques, intraoperative and short-term outcomes, morbidity, mortality and oncological outcomes.

Prophylactic abdominal drainage or no drainage after distal pancreatectomy (PANDORINA): a binational multicenter randomized controlled trial.

BACKGROUND: Prophylactic abdominal drainage is current standard practice after distal pancreatectomy (DP), with the aim to divert pancreatic fluid in case of a postoperative pancreatic fistula (POPF) aimed to prevent further complications as bleeding. Whereas POPF after pancreatoduodenectomy, by definition, involves infection due to anastomotic dehiscence, a POPF after DP is essentially sterile since the bowel is not opened and no anastomoses are created. Routine drainage after DP could potentially be omitted and this could even be beneficial because of the hypothetical prevention of drain-induced infections (Fisher, Surgery 52:205-22, 2018). Abdominal drainage, moreover, should only be performed if it provides additional safety or comfort to the patient. In clinical practice, drains cause clear discomfort. One multicenter randomized controlled trial confirmed the safety of omitting abdominal drainage but did not stratify patients according to their risk of POPF and did not describe a standardized strategy for pancreatic transection. Therefore, a large pragmatic multicenter randomized controlled trial is required, with prespecified POPF risk groups and a homogeneous method of stump closure. The objective of the PANDORINA trial is to evaluate the non-inferiority of omitting routine intra-abdominal drainage after DP on postoperative morbidity (Clavien-Dindo score ≥ 3), and, secondarily, POPF grade B/C. METHODS/DESIGN: Binational multicenter randomized controlled non-inferiority trial, stratifying patients to high and low risk for POPF grade B/C and incorporating a standardized strategy for pancreatic transection. Two groups of 141 patients (282 in total) undergoing elective DP (either open or minimally invasive, with or without splenectomy). Primary outcome is postoperative rate of morbidity (Clavien-Dindo score ≥ 3), and the most relevant secondary outcome is grade B/C POPF. Other secondary outcomes include surgical reintervention, percutaneous catheter drainage, endoscopic catheter drainage, abdominal collections (not requiring drainage), wound infection, delayed gastric emptying, postpancreatectomy hemorrhage as defined by the international study group for pancreatic surgery (ISGPS) (Wente et al., Surgery 142:20-5, 2007), length of stay (LOS), readmission within 90 days, in-hospital mortality, and 90-day mortality. DISCUSSION: PANDORINA is the first binational, multicenter, randomized controlled non-inferiority trial with the primary objective to evaluate the hypothesis that omitting prophylactic abdominal drainage after DP does not worsen the risk of postoperative severe complications (Wente etal., Surgery 142:20-5, 2007; Bassi et al., Surgery 161:584-91, 2017). Most of the published studies on drain placement after pancreatectomy focus on both pancreatoduodenectomy and DP, but these two entities present are associated with different complications and therefore deserve separate evaluation (McMillan et al., Surgery 159:1013-22, 2016; Pratt et al., J Gastrointest Surg 10:1264-78, 2006). The PANDORINA trial is innovative since it takes the preoperative risk on POPF into account based on the D-FRS and it warrants homogenous stump closing by using the same graded compression technique and same stapling device (de Pastena et al., Ann Surg 2022; Asbun and Stauffer, Surg Endosc 25:2643-9, 2011).

Local resection for ampullary tumors. Is there a place for it?

Two of 14 patients with adenomas were without disease 25 and 43 months after ampullary resection. Two patients with an initial diagnosis of malignant neoplasm had no recurrence at 75 and 40 months; one underwent pancreatoduodenectomy at 8 months because of recurrence. Six of nine patients with initial diagnoses of villous adenoma were without disease at 1, 2, 16, 23, 46, and 51 months; three underwent conversion to pancreatoduodenectomy because of invasive carcinoma. Frozen-section studies revealed adenocarcinoma in two patients with villous adenoma but failed to show invasion in one patient. One patient with villous adenoma was mistakenly thought to have carcinoma based on results of frozen-section studies. Local ampullary resection is valuable in treating benign and selected premalignant and malignant ampullary lesions. The threshold for conversion to pancreatoduodenectomy should be low unless ampullectomy is performed with palliative intent.

Detection of the cancer-prone colon, using transepithelial impedance analysis.

Alterations in ionic conductance may represent an early mitogenic signal; therefore, impedance analysis was used to examine differences in the electrical properties of the distal colon in a cancer-susceptible (CF1) and a cancer-resistant (DBA) strain of mouse following administration of the carcinogen dimethylhydrazine. The electrical conductance of the surface colonic epithelium increased in CF1 mice from a mean (+/- SEM) of 41.1 +/- 3.0 milliSiemens.cm-2 (mS.cm-2) in controls to 52.6 +/- 3.1 mS.cm-2 following dimethylhydrazine treatment. The conductance decreased in the cancer-resistant DBA group from 154.6 +/- 44.1 mS.cm-2 in controls to 35.1 +/- 17.2 mS.cm-2 following dimethylhydrazine treatment. This difference in response to the carcinogen may partly explain differences in susceptibility noted between these two species. Epithelial impedance analysis may be of use in the early detection of the colon at risk for subsequent cancer development.

Colonic epithelial impedance analysis in a murine model of large-bowel cancer.

Death rates from large-bowel cancer have remained essentially unchanged over the past 40 years because the diagnosis is made late, after the tumor has spread to other sites. This study was undertaken to examine whether alterations in mucosal electrical capacitance precede the development of gross malignancy, since this parameter may reflect functional or structural changes in the colonocyte plasma membrane, which is of importance in the regulation of cell growth. Distal colonic mucosal capacitance was decreased at low frequencies after only four weeks of treatment with the carcinogen dimethylhydrazine in C1 mice. Alterations in electrical capacitance may be a useful marker in identifying patients with a propensity to develop large-bowel cancer.

Resection of hepatic metastases from colorectal carcinoma. The registry data.

When liver metastases from colorectal carcinoma are detected, the surgeon must decide whether or not the patient is a candidate for resection. Even though long-term survival after resection is far from optimal, the relegation of patients to nonresective treatment means denying them the only chance for cure currently available. Better understanding of liver anatomy and improvement in resection techniques have decreased the morbidity and mortality. The RHM and the GITSG reports have better defined the prognostic factors for resections of colorectal liver metastases and allowed for a better understanding of the indications for resection. During the last decades, liver resection has been extended to older patients, patients with multiple liver lesions, and patients with larger solitary metastases. At the same time, anatomic rather than wedge resections are more common, and it is preferable to perform the colon and liver resection at different stages. The end result has been a marked increase in the number of hepatic resections performed for colorectal liver metastases during the last two decades.

Hepatoma registry of the Western world. Repeat Hepatic Resection Registry.

The western HCC registry comprised data from 322 patients who underwent hepatic resection for HCC over a 50-year period. The majority of patients had lesions > 4 cm and were symptomatic at presentation. Lesions were mostly unicentric. Cirrhosis was not a prevalent problem, unlike the East. In the most recent decade, 1980-1989, we noted a significant decrease in operative mortality from 19% to 10% overall, and 15% to 4% in the noncirrhotic group. We identified four variables that resulted in poorer postresectional outcome: cirrhosis, regional nodal disease, multicentric disease, and tumor-free resectional margin < 1 cm. Although these factors are associated with a poorer outcome after resection, whether they should serve as contraindications to surgery should be determined by individual surgeons, taking into account the patient's overall status, concomitant risk factors, and treatment objectives.

Safe performance of difficult laparoscopic cholecystectomies.

Laparoscopic cholecystectomy has been advocated for the treatment of uncomplicated symptomatic gallstone disease, but has not been widely advocated for the management of more complicated gallbladder disease such as acute cholecystitis, previous surgery, or common duct stones. During the last 9 months, 360 patients underwent laparoscopic removal of their gallbladder. A total of 138 had a complicated presentation, making surgery more difficult. This article discusses the management of these patients with acute cholecystitis, previous surgery, or common duct disease. Using the described techniques, there were no complications or mortality. Laparoscopic management of difficult gallbladder problems is safe and effective.

Techniques of laparoscopic cholecystectomy. The difficult operation.

Laparoscopic cholecystectomy has settled as the treatment of choice for patients with gallstone disease. Injury to the bile ducts, still the main drawback of the technique, is decreasing progressively with better understanding of the mechanisms of injury and adequate training. With the expansion of indications for laparoscopic cholecystectomy, more difficult operations are being performed. Adequate understanding of the obstacles that may arise during the laparoscopic procedure as well as knowledge of specific maneuvers to deal with the difficult operation are important for the success and safety of the procedure.

Management of recurrent and metastatic colorectal carcinoma.

When metastatic or recurrent disease from colorectal carcinoma is detected, the surgeon must decide whether a patient is a candidate for resection. Although long-term survival after resection is not optimal, the relegation of patients to nonresective treatment means denying them the only chance for cure currently available. When isolated disease involving the liver, lung, or region of the primary carcinoma is documented, curative resection must be considered. Symptomatic patients may also obtain maximal palliation from resection, diversion, or a bypass procedure. Chemotherapy for the treatment of recurrent disease is palliative and probably should be considered only within clinical trials. Future alternative methods of treatment or new chemotherapeutic regimens need to be studied to improve survival and quality of life.

Leiomyosarcoma of the rectum.

Leiomyosarcoma of the rectum is a rare entity. Approximately 150 cases have been described in the literature. Differentiation from its benign counterpart, leiomyoma, and other connective-tissue tumors is often difficult, but it is important because each tumor has an entirely different prognosis. The case of a patient in whom an 11 x 5.5 cm leiomyosarcoma of the rectum was surgically excised by abdominoperineal resection is presented. Literature review shows disagreement over the therapeutic approach, most likely due to the lack of a large series of patients with this disease. At present, a selective treatment approach appears to be the most advocated. Lesions less than 2.5 cm in size and limited to the bowel wall can still be treated by wide local excision. More radical surgical resection is indicated for larger tumors and those extending outside the bowel wall.

Thymic carcinoid.

Carcinoid of the thymus is a rare neoplasm. Differentiation from thymoma is important because they have entirely different prognosis. A patient in whom a 19 x 18 x 12 cm carcinoid tumor of the thymus was surgically removed is presented. The tumor metastasized to peritracheal and internal mammary nodes, and invaded the SVC, pleura, lung, and pericardium. This is apparently the largest reported tumor of its kind. Prior to induction of anesthesia cardiopulmonary bypass and rigid bronchoscopy were readily available. Awake intubation was utilized. Even though long-term prognosis is poor, an aggressive surgical approach and adjuvant radiotherapy may achieve extended survival with excellent quality of life. Central aspects of the disease as well as pivotal therapeutic points are discussed.

Small bowel obstruction and its management.

We present a retrospective analysis of 105 instances of small bowel obstruction (SBO) in 80 patients admitted to our hospital over a ten year period. Adhesions accounted for 73% of the cases and secondary involvement by malignancy for 13%. Appendectomy, colorectal and other pelvic procedures were the most frequent surgical antecedents responsible for the adhesions. In the 86% of cases with a temperature over 100 degrees F there was significant morbidity, mortality and/or strangulation, and this sign also foretold a prolonged hospital stay. Leukocytosis, when present along with abdominal tenderness also predicted a prolonged hospital stay. Strangulation occurred in 4.7% of the instances and was accompanied by at least one of the "classical symptoms". Fourty-five percent of the instances were successfully managed by conservative measures alone, whereas 55% had had surgical treatment. The mean hospital stay for all cases was 15.3 days. The morbidity rate for this series was 21% with a mortality of 3.8%. The largest single cause of death was related to malignant disease (three of four cases). When post-operative adhesions were the etiology, the hospital stay was 8.5 +/- 1.3 days for those treated with conservative measures compared with 16.5 +/- 1.8 days for those in whom a surgical procedure was performed (p less than 0.0001). This latter group also has a higher morbidity (32% compared to 5% for the non-operative group).

Simplified perioperative management in vertical banded gastroplasty.

Vertical Banded Gastroplasty (VBG) is the most commonly performed weight loss operation in the United States and is of proven adjunctive benefit in the treatment of morbid obesity. In an attempt to reduce the hospital related complications associated with morbidly obese patients we simplified the perioperative management of 244 patients undergoing VBG. Our goals were early feeding, early ambulation and a short hospital stay. Neither nasogastric tube nor Foley catheter was used after surgery. Mean postoperative stay was 3.24 +/- 0.8. Forty-one patients (16.8%) developed significant complications. Only two of these had a nosocomial complication (0.8%). The remaining 39 patients had technical complications not related to the protocol of simplified perioperative care. Short hospital stay and simplified perioperative management are feasible and safe for the large majority of patients undergoing VBG and may, in fact, significantly decrease the nosocomial morbidity common to this type of patients.

ZIP4 is a novel diagnostic and prognostic marker in human pancreatic cancer: a systemic comparison between EUS-FNA and surgical specimens.

Aberrant expression of a zinc transporter ZIP4 in pancreatic ductal adenocarcinoma (PDAC) has been shown to contribute to tumor progression and is a potential target for individualized therapy. The overall objective of this study was to determine whether ZIP4 could serve as a novel diagnostic and prognostic marker in human PDAC, and if it can be assessed by minimally invasive sampling using endoscopic ultrasound guided fine needle aspiration (EUS-FNA). Immunohistochemistry was performed to compare ZIP4 expression in the PDAC samples obtained from EUS-FNA and matched surgical tumors (parallel control). Samples were reported by sensitivity, specificity, and predictive values, all with 95% confidence intervals (CI). A total of 23 cases with both FNA and surgical specimens were evaluated. We found that ZIP4 was significantly overexpressed in tumor cells from both sets of samples. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ZIP4 for the diagnosis of PDAC were 72.9%, 72.5%, 76.1%, and 69.0% in EUS-FNA samples, and were 97.9%, 65.4%, 83.9%, and 94.4% in surgical specimens, respectively. The association between the positive rate of ZIP4 expression in FNA and surgical samples is statistically significant (P=0.0216). Both the intensity and percentage of ZIP4 positive cells from the surgical samples correlated significantly with tumor stage (P=0.0025 and P=0.0002). ZIP4 intensity level in FNA samples was significantly associated with tumor differentiation and patient survival. These results indicate that EUS-FNA is capable of non-operative detection of ZIP4, thus offering the potential to direct pre-operative detection and targeted therapy of PDAC.

A simplified stent dressing technique using elastic rubber bands.

Several techniques of securing dressings over a skin grafted area have been developed. Many of these entail cumbersome and time-consuming procedures. A simple, easy to learn, and very effective method is presented.