Validation of the peak bilirubin criterion for outcome after partial hepatectomy.

INTRODUCTION: Postoperative liver failure (PLF) is a dreaded complication after partial hepatectomy. The peak bilirubin criterion (>7.0 mg/dL or ≥120 µmol/L) is used to define PLF. This study aimed to validate the peak bilirubin criterion as postoperative risk indicator for 90-day liver-related mortality. METHODS: Characteristics of 956 consecutive patients who underwent partial hepatectomy at the Maastricht University Medical Centre or Royal Free London between 2005 and 2012 were analyzed by uni- and multivariable analyses with odds ratios (OR) and 95% confidence intervals (95%CI). RESULTS: Thirty-five patients (3.7%) met the postoperative peak bilirubin criterion at median day 19 with a median bilirubin level of 183 [121-588] µmol/L. Sensitivity and specificity for liver-related mortality after major hepatectomy were 41.2% and 94.6%, respectively. The positive predictive value was 22.6%. Predictors of liver-related mortality were the peak bilirubin criterion (p < 0.001, OR = 15.9 [95%CI 5.2-48.7]), moderate-severe steatosis and fibrosis (p = 0.013, OR = 8.5 [95%CI 1.6-46.6]), ASA 3-4 (p = 0.047, OR = 3.0 [95%CI 1.0-8.8]) and age (p = 0.044, OR = 1.1 [95%CI 1.0-1.1]). CONCLUSION: The peak bilirubin criterion has a low sensitivity and positive predictive value for 90-day liver-related mortality after major hepatectomy.

Ciliated foregut cyst of the pancreas: another differential in the diagnosis of cystic pancreatic lesions.

CONTEXT: With the more frequent use of cross sectional imaging, the detection of cystic pancreatic incidentalomas has become a relatively common entity. The commonest cystic incidentalomas are neoplastic. Pseudocysts are the most single common pathological entity. Foregut cystic lesions as a pathological entity are rare but mostly observed in the mediastinum. Ciliated foregut cysts of the pancreas are very rare and an extremely uncommon cause of a cystic lesion within the pancreas. CASE REPORT: We present herewith an uncommon case of a large cystic lesion, confirmed as a ciliated foregut cyst on final histology arising from the body and tail of the pancreas. The lesion was very effectively treated with a laparoscopic distal pancreatectomy and splenectomy. CONCLUSION: The rarity of the lesion makes the case worth reporting.

Rare presentation of Brunner's gland adenoma: another differentiation in patients with recurrent "idiopathic" pancreatitis.

BACKGROUND: Brunner's gland adenoma (BGA) is an unusual benign neoplasm arising from Brunner's glands in the duodenum. When symptomatic it presents either with duodenal obstruction or bleeding. However, pancreatitis secondary to ampullary obstruction from a BGA is very rare. METHODS: A 23-year-old female presented with recurrent episodes of "idiopathic" pancreatitis. She was extensively investigated and was found to have a large polypoid BGA, intermittently obstructing the ampulla. This created a ball-valve effect causing secondary intermittent obstruction of the pancreatic duct resulting in pancreatitis. The condition was cured surgically, through transduodenal excision of the BGA. We reviewed the surgical literature pertaining to these unusual and similar causes of obstructive pancreatitis, not related to gallstones. RESULTS: BGA of the duodenum is a rare cause of pancreatitis. Extensive investigations should be carried out in all cases of unexplained pancreatitis before classifying the condition as "idiopathic". Discovery of a lesion of this nature gives an opportunity to provide a permanent surgical cure. CONCLUSIONS: BGA adds an unusual etiology for pancreatitis. All patients with pancreatitis should undergo extensive investigations before being termed "idiopathic". Surgical excision of the BGA provides a definitive curative treatment for the adenoma and pancreatitis.

Cystic lesions of the pancreas: current trends in approach and management.

The more frequent deployment of cross-sectional imaging for various abdominal conditions has resulted in an increased detection of cystic pancreatic lesions, particularly cystic pancreatic neoplasms. Cystic pancreatic lesions may be neoplastic or non-neoplastic. They may appear radiologically similar and often present a diagnostic dilemma; they need to be diagnosed and differentiated with accuracy in order to offer optimum treatment. Some of the cystic neoplasms are potentially malignant and have a wide spectrum of histological variation from the frankly benign 'adenomas' to invasive adenocarcinomas .When identified, these cystic lesions need a systematic work up and a diagnostic algorithm should be followed to its logical conclusion. This article reviews these cystic lesions of the pancreas, neoplastic and pseudocysts, and aims to update readers with the current trends in their diagnosis and management.

Pancreaticoduodenectomy for advanced duodenal and ampullary adenomatosis in familial adenomatous polyposis.

BACKGROUND: Patients with familial adenomatous polyposis (FAP) develop duodenal and ampullary polyps that may progress to malignancy via the adenoma-carcinoma sequence. OBJECTIVE: The aim of this study was to review a large series of FAP patients undergoing pancreaticoduodenectomy for advanced duodenal and ampullary polyposis. METHODS: A retrospective case notes review of all FAP patients undergoing pancreaticoduodenectomy for advanced duodenal and ampullary adenomatosis was performed. RESULTS: Between October 1993 and January 2010, 38 FAP patients underwent pancreaticoduodenectomy for advanced duodenal and ampullary polyps. Complications occurred in 29 patients and perioperative mortality in two. Postoperative histology revealed five patients to have preoperatively undetected cancer (R = 0.518, P < 0.001). CONCLUSIONS: Pancreaticoduodenectomy in FAP is associated with significant morbidity, but low mortality. All patients under consideration for operative intervention require careful preoperative counselling and optimization.

Undiagnosed Hepatic Tuberculosis Presenting With Intraabdominal Rupture and Hemoperitoneum, Requiring Urgent Hepatic Resection.

Tuberculosis (TB) affecting the liver is unusual, and isolated liver TB presenting as a liver abscess more so, even in countries where the disease is endemic. As clinical symptoms and imaging are not typical, a high index of suspicion is necessary for diagnosis. We present here a lady who was admitted with fever and chills. Ultrasound imaging showed a liver abscess. She developed bleeding into the abscess cavity, necessitating an emergency right liver resection. Final histology confirmed mycobacterial granulomatous infection of the liver. Isolated hepatic abscess of tubercular origin is a rare cause of hemorrhage but should be considered as a differential diagnosis. Suspicious features on computerized tomography (CT) scan should prompt microbiological assessment of aspirate from the abscess, establishing the diagnosis, so appropriate treatment can be started, avoiding such complications.

Robotic Surgery for Malignant Liver Disease: a Systematic Review of Oncological and Surgical Outcomes.

Robot-assisted laparoscopic surgery is yet another modification of minimally invasive liver surgery. It is described as feasible and safe from the surgical point of view; however, oncological outcomes need to be adequately analysed to justify the use of this technique when resecting malignant liver tumours. We reviewed existing English medical literature on robot-assisted laparoscopic liver surgery. We analysed surgical outcomes and oncological outcomes. We analysed operative parameters including operative time, type of hepatectomy, blood loss, conversion rate, morbidity and mortality rates and length of stay. We also analysed oncological outcomes including completeness of resection (R status), recurrence, survival and follow-up data. A total of 582 patients undergoing robot-assisted laparoscopic liver surgery were analysed from 17 eligible publications. Only 5 publications reported survival data. The overall morbidity was 19% with 0.2% reported mortality. R0 resection was achieved in 96% of patients. Robotic liver surgery is feasible and safe with acceptable morbidity and oncological outcomes including resection margins. However, well-designed trials are required to provide evidence in terms of survival and disease-free intervals when performed for malignancy.

Neoadjuvant chemotherapy does not affect future liver remnant growth and outcomes of associating liver partition and portal vein ligation for staged hepatectomy.

BACKGROUND: The only potentially curative treatment for patients with colorectal liver metastases is hepatectomy. Associating liver partition and portal vein ligation for staged hepatectomy has emerged as a method of treatment for patients with inadequate future liver remnant. One concern about associating liver partition and portal vein ligation for staged hepatectomy is that preoperative chemotherapy may negatively affect the volume increase of the future liver remnant and outcomes. METHODS: This study from the International Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy Registry (NCT01924741) includes 442 patients with colorectal liver metastases registered from 2012-2016. Future liver remnant hypertrophy (absolute increase, percent increase, and kinetic growth rate) and clinical outcome were analyzed retrospectively in relation to type and amount of chemotherapy. The analyzed groups included patients with no chemotherapy, 1 regimen of chemotherapy, >1 regimen, and a group that received monoclonal antibodies in addition to chemotherapy. RESULTS: Ninety percent of the patients received neoadjuvant oncologic therapy including 42% with 1 regimen of chemotherapy, 44% with monoclonal antibodies, and 4% with >1 regimen. Future liver remnant increased between 74-92% with the largest increase in the group with 1 regimen of chemotherapy. The increase in milliliters was between 241 mL (>1 regimen) and 306 mL (1 regimen). Kinetic growth rate was between 14-18% per week and was greatest for the group with 1 regimen of chemotherapy. No statistical significance was found between the groups with any of the measurements of future liver remnant hypertrophy. CONCLUSION: Neoadjuvant chemotherapy, including monoclonal antibodies, does not negatively affect future liver remnant growth. Patients with colorectal liver metastases who might be potential candidates for associating liver partition and portal vein ligation for staged hepatectomy should be considered for neoadjuvant chemotherapy.

Radiological tumor density and lymph node size correlate with survival in resectable adenocarcinoma of the pancreatic head: A retrospective cohort study.

INTRODUCTION: Tumors within the pancreatic head show a variable density and enhancement on computerized tomography (CT). The relationship between the radiological appearance of pancreatic adenocarcinoma on CT and survival remains unclear. The aim of this study was to evaluate the relationship between the tumor density on CT and survival. We also evaluated the correlation between lymph node (LN) size and overall survival in patients undergoing pancreaticoduodenectomy for head of pancreas adenocarcinoma. MATERIALS AND METHODS: Case records of patients undergoing pancreaticoduodenectomy for the adenocarcinoma of pancreas head, between 2005 and 2009, were evaluated. CT was interpreted to document tumor density - Hounsfield unit (HU) and LN size of enlarged LNs. Histology was analyzed to review tumor differentiation and LN status. Survival was correlated with LN size and tumor density (HU). RESULTS: Increasing tumor density was significantly associated with an adverse outcome (P = 0.042, hazard ratio [HR] 1.034, 1.002-1.067 95% confidence interval [95% CI]). Patients with well-differentiated tumors had significantly lower tumor density as compared to moderately differentiated tumors (39.00 ± 26.00 vs. 71.31 ± 21.03 HU, P = 0.005). LN size more than 1 cm irrespective of LN status strongly correlated with the survival and was found to be an important prognostic factor (19.37 ± 2.71 months vs. 27.44 ± 2.74 months; P = 0.025; HR 2.70; 1.09-6.68 95% CI). CONCLUSION: Increasing pancreatic tumor density and the lymph nodal size of more than 1 cm are strong predictors of unfavorable overall survival for resectable adenocarcinoma of the pancreatic head. Further studies are required to identify the value of these proposed prognostic factors.

Primary hepatic leiomyoma: unusual cause of an intrahepatic mass.

Leiomyomas are benign lesions arising from the smooth muscle layer. They are most commonly detected either within the gastrointestinal or genitourinary tracts. Primary hepatic leiomyoma (PHL) is a rare pathology. It is an isolated pathology within the liver, without evidence of any other coexisting leiomyomas. Very few cases have been described in literature. PHL may occur in healthy individuals although an association with immunodeficiency and Epstein-Barr virus (EBV) infection has been observed. Majority of the reported cases have been in females. A 20-year-old female patient presented with abdominal symptoms. MRI confirmed an 8 cm mass, with very low signal intensity on T2 images and peripheral rim enhancement on gadolinium. A laparoscopic left lateral sectorectomy was performed. Final histopathology confirmed the presence of benign lesion with spindle cell and smooth muscle proliferation and a fibro-vascular stroma compatible with a leiomyoma. There was no evidence of any leiomyomatous lesion elsewhere in the body. A rare diagnosis of PHL was therefore established. Acknowledging the rare incidence of this lesion, we report the same and review the relevant literature. PHL is usually a retrospective diagnosis, confirmed on histo-pathology assessment of the resected specimen. Liver resection is required in these patients due to the presence of symptoms, in the presence of a solid mass lesion within the liver. Surgery is thus definitive, diagnostic cum therapeutic.

A novel rat model of liver regeneration: possible role of cytokine induced neutrophil chemoattractant-1 in augmented liver regeneration.

BACKGROUND: Liver resection is the mainstay of treatment for most of the liver tumors. Liver has a unique capability to restore the lost volume following resection, however, most of the primary tumors grow in a liver with preexisting parenchymal diseases and secondary tumors often present in multiple liver lobes precluding a safe curative resection. Two-stage hepatectomy and portal vein ligation (PVL) are used to achieve a safer future remnant liver volume (FRLV), however, these procedures take several weeks to achieve adequate FRLV. A recently introduced faster alternative two-stage hepatectomy, also know as associated liver partitioning and portal vein ligation for staged hepatectomy (ALPPS), produces a desirable FRLV in days. METHODS: To have an insight into the mechanism of ALPPS associated liver regeneration, we reproduced a rat model of ALPPS and compared the results with the PVL group. RESULTS: Our results convincingly showed an advantage of the ALPPS procedure over PVL group in terms of early regeneration, however, in 1-week time the amount of regeneration was comparable. An early regeneration in the ALPPS group coincided with an early entry of hepatocytes into the cell proliferation phase, a significant increase in portal pressure and increase in hepatic enzymes in the ALPPS group compared with the PVL group. According to the protein array evaluation of 29 cytokines/chemokines, cytokine induced neutrophil chemoattractant-1 had the highest expression whereas IL-6 had the highest fold (>6 vs PVL group) expression at the early phase of regeneration in the ALPPS group. CONCLUSIONS: This unique rat model of ALPPS would help to improve our understanding about the liver generation process and also will help in further refinement of the ALPPS procedure for the clinical benefit.

Monosegment ALPPS hepatectomy: extending resectability by rapid hypertrophy.

BACKGROUND: Liver remnant function limits major liver resections to generally leave patients with ≥2 Couinaud segments. Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) induces extensive hypertrophy and allows surgeons to perform extreme liver resections. METHODS: The international ALPPS registry (NCT01924741; 2011-2014) was screened for novel resection type with only 1 segment remnant. The anatomy of lesions and indications for ALPPS, operative technique, complications, survival, and recurrence were evaluated. RESULTS: Among 333 patients, 12 underwent monosegment ALPPS hepatectomies in 6 centers, all for extensive bilobar colorectal liver metastases. All patients were considered unresectable by conventional means, and all had a response to or no progression after chemotherapy before surgery. In 2 patients, the liver remnant consisted of segment 2, in 2 of segment 3, in 6 of segment 4, and in 2 of segment 6. Median time to proceed to stage 2 was 13 days and median hypertrophy of the liver remnant was 160%. There was no mortality. Four patients experienced liver failure, but all recovered. Complications higher than Dindo-Clavien IIIa occurred in 4 patients with no long-term sequelae. At a median follow-up of 14 months, 6 patients are tumor free and 6 patients have developed recurrent metastatic disease. CONCLUSION: ALPPS allows systematic liver resections with monosegment remnants, a novelty in liver surgery. Because such resections are difficult to conceive without rapid hypertrophy, we propose to name such resections after the segments constituting the liver remnant rather than the segments removed.

Late splenic metastasis after curative resection for oesophageal carcinoma.

The spleen is an unusual site of distant metastasis from solid tumours. While contiguous involvement of the spleen may occur in tumours arising from the stomach, pancreas or colon; the spleen as the seat of distant metastasis is a rare occurrence. We report herewith one such instance of metastatic involvement of the spleen in an operated case of carcinoma oesophagus.

Portal vein embolization and ligation for extended hepatectomy.

Portal vein occlusion through embolization or ligation (PVE, PVL) offers the possibility of increasing the future liver remnant (FLR) and thus reducing the risk of hepatic failure after extended hepatectomy We reviewed the indications, scope and applicability of PVE/PVL in treatment of primary and secondary liver tumours. A thorough PubMED, Embase, Ovid and Cochrane database search was carried out for all original articles with 30 patients or more undergoing either PVE and any patient series with PVL, irrespective of number with outcome measure in at least one of the following parameters: FLR volume change, complications, length of stay, time to surgery, proportion resectable and survival data. PVE can be performed with a technical success in 98.9 % (95 % confidence interval 97-100) patients, with a mean morbidity of 3.13 % (95 % CI 1.21-5.04) and a median in-hospital stay of 2.1 (range 1-4) days (very few papers had data on length of stay following PVE). The mean increase in volume of the FLR following PVE was 39.75 % (95 % CI 30.8-48.6) facilitating extended liver resection after a mean of 37.13 days (95 % CI 28.51-45.74) with a resectability rate of 76.88 % (95 % CI 70.91-82.84). Morbidity and mortality following such extended liver resections after PVE is 26.58 % (95 % CI 19.20-33.95) and 2.59 % (95 % CI 1.34-3.83) respectively with an in-patient stay of 13.57 days (95 % CI 9.8-17.37). However following post-PVE liver hypertrophy 6.29 % (95 % CI 2.24-10.34) patients still have post-resection liver failure and up to 14.2 % (95 % CI -8.7 to 37) may have positive resection margins. Up to 4.80 % (95 % CI 2.07-7.52) have failure of hypertrophy after PVE and 17.46 % (95 % CI 11.89-23.02) may have disease progression during the interim awaiting hypertrophy and subsequent resection. PVL has a greater morbidity and duration of stay of 5.72 % (95 % CI 0-15.28) and 10.16 days (95 % CI 6.63-13.69) respectively; as compared to PVE. Duration to surgery following PVL was greater at 53.6 days (95 % CI 32.14-75.05). PVL induced FLR hypertrophy by a mean of 64.65 % (95 % CI 0-136.12) giving a resectability rate of 63.68 % (95 % CI 56.82-70.54). PVL failed to produce enough liver hypertrophy in 7.4 % of patients (95 % CI 0-16.12). Progression of disease following PVL was 29.29 (95%CI 15.69-42.88). PVE facilitates an extended hepatectomy in patients with limited or inadequate FLR, with good short and long-term outcomes. Patients need to be adequately counselled and consented for PVE and EH in light of these data. PVL would promote hypertrophy as well, but clearly PVE has advantages as compared to PVL on account of its inherent "minimally invasive" nature, fewer complications, length of stay and its feasibility to have shorter times to surgery.

The impact of pancreatic duct drainage following pancreaticojejunostomy on clinical outcome.

BACKGROUND: The aim of this meta-analysis is to evaluate the effect of stenting the pancreatic duct during pancreaticojejunostomy formation on perioperative outcomes. METHODS: Primary outcome measures were operative mortality and pancreatic fistula. Secondary outcomes were length of hospital stay, reoperation, delayed gastric emptying, estimated blood loss, and length of operation. Internal and external pancreatic stents were grouped together for the purposes of analysis. RESULTS: Six trials were included in this analysis comprising 732 patients. Pancreatic stent placement had no significant effect on operative mortality; however, there was a non-significant trend towards reduced pancreatic fistula. Estimated blood loss, length of operation, and length of hospital stay were significantly increased in association with pancreatic stent placement. There were no significant effects on reoperation or delayed gastric emptying. CONCLUSION: This analysis demonstrates a trend towards reduced pancreatic fistula with the use of pancreatic stents in pancreaticojejunostomy. However, there were insufficient data to confidently reject the null hypothesis that stenting has no beneficial effect. Further research is required to identify whether in certain subgroups, such as those with soft pancreatic texture and a non-dilated duct, stents may have a more important role in reducing fistula formation.

Portal vein embolisation for extended hepatectomy: single-centre experience.

BACKGROUND: Portal vein embolisation (PVE) induces contra-lateral liver hypertrophy to facilitate an extended hepatectomy. AIM: This paper aims to analyse our data on PVE and extended hepatectomy. Outcome measures included success of PVE, feasibility of resections, operative morbidity and survival. METHODS: A retrospective analysis of data collected prospectively on 33 patients (2004-2008) was performed. Survival curves were estimated by the Kaplan-Meier (Breslow) method. Significance was defined as p < 0.05. RESULTS: A total of 31 patients had successful PVE. There were 24 patients who underwent surgery. Significant hypertrophy of residual liver was noted from 230.15 (pre-embolisation) to 428.50 ml (post-embolisation) (median, p < 0.0001). A total of 16 patients had hepatectomy (14: R0; 2: R1) with a single mortality (6.25%) and 56.25% morbidity, and a median length of stay of 17 days. Median overall survival was 14 (95% CI 7.8-20.2) months. Patients who underwent resection had a median disease-specific survival of 33 (95% CI 4-62) months compared with 8.6 (95% CI 0-19.9) months for patients without resection (p = 0.14). For patients with primary hepato-biliary tumours, the median disease-specific survival was 7.9 (95% CI 4.5-11.3) months compared with a median survival of 19.7 (95% CI 0-42.2) months for patients with metastases (p = 0.07). CONCLUSIONS: PVE is safe, facilitates R0 resection and offers the best chance of cure, especially for liver metastases.

Hand-sewn versus stapled oesophago-gastric anastomosis: systematic review and meta-analysis.

OBJECTIVE: In this meta-analysis, data from relevant randomised controlled trials has been pooled together to gain a consensus in the comparison of outcome following hand-sewn versus stapled oesophago-gastric (OG) anastomoses. METHODS: Medline, Embase, Cochrane, trial registries, conference proceedings and reference lists were searched for randomised controlled trials comparing hand-sewn and stapled OG anastomoses. Primary outcome measures were 30-day mortality, anastomotic leakage and stricture. Secondary outcomes were operative time, cardiac complications and pulmonary complications. RESULTS: Nine randomised trials were included in this meta-analysis. There was no significant difference between the groups for 30-day mortality (pooled odds ratio = 1.71; 95% CI = 0.822 to 3.56; P = 0.15) and anastomotic leakage (pooled odds ratio = 1.06; 95% CI = 0.62 to 1.80; P = 0.83). There was a significantly increased rate of anastomotic stricture associated with stapled OG anastomosis (pooled odds ratio = 1.76; 95% CI = 1.09 to 2.86; P = 0.02). DISCUSSION: Meta-analysis of randomised controlled trials comparing hand-sewn with stapled OG anastomosis demonstrates that a stapled anastomosis is associated with a shorter operative time but with an increased rate of post-operative anastomotic stricture.

The role of integrated F-18-FDG-PET scanning in the detection of M1 disease in oesophageal adenocarcinoma and impact on clinical management.

INTRODUCTION: The aim of this study was to evaluate the efficacy of F-18-fluorodeoxyglucose positron emission tomography (FDG-PET) scanning in the staging of oesophageal adenocarcinoma. METHODS: One hundred four patients with biopsy-proven adenocarcinoma underwent (18)F-FDG-PET scan. FDG avid lesions were further investigated to their diagnostic conclusion. RESULTS: Nineteen patients (18.26%) were found to have non-loco-regional FDG uptake. Of the patients, 3.84% were found to have M1 disease and 7.69% were found to have a second primary tumour. The sensitivity and specificity of FDG-PET scanning to detect metastatic disease in our series was 57.14% and 84.53%, respectively. The overall diagnostic accuracy was 82.69%. CONCLUSIONS: PET scanning improves staging and prevents unnecessary surgery in patients with M1 disease. It represents a good adjunct to computed tomography scanning and endoscopic ultrasound in the staging of oesophageal adenocarcinoma. The detection of asymptomatic coexisting synchronous cancers is an added benefit provided by PET scanning over similar diagnostic modalities.

Diagnosis and localisation of insulinoma: the value of modern magnetic resonance imaging in conjunction with calcium stimulation catheterisation.

CONTEXT: Preoperative localisation of insulinoma improves cure rate and reduces complications, but may be challenging. OBJECTIVE: To review diagnostic features and localisation accuracy for insulinomas. DESIGN: Cross-sectional, retrospective analysis. SETTING: A single tertiary referral centre. PATIENTS: Patients with insulinoma in the years 1990-2009, including sporadic tumours and those in patients with multiple endocrine neoplasia syndromes. INTERVENTIONS: Patients were identified from a database, and case notes and investigation results were reviewed. Tumour localisation by computed tomography (CT), magnetic resonance imaging (MRI), octreotide scanning, endoscopic ultrasound (EUS) and calcium stimulation was evaluated. MAIN OUTCOME MEASURE(S): Insulinoma localisation was compared to histologically confirmed location following surgical excision. RESULTS: Thirty-seven instances of biochemically and/or histologically proven insulinoma were identified in 36 patients, of which seven were managed medically. Of the 30 treated surgically, 25 had CT (83.3%) and 28 had MRI (90.3%), with successful localisation in 16 (64%) by CT and 21 (75%) by MRI respectively. Considered together, such imaging correctly localised 80% of lesions. Radiolabelled octreotide scanning was positive in 10 out of 20 cases (50%); EUS correctly identified 17 lesions in 26 patients (65.4%). Twenty-seven patients had calcium stimulation testing, of which 6 (22%) did not localise, 17 (63%) were correctly localised, and 4 (15%) gave discordant or confusing results. CONCLUSIONS: Preoperative localisation of insulinomas remains challenging. A pragmatic combination of CT and especially MRI predicts tumour localisation with high accuracy. Radionuclide imaging and EUS were less helpful but may be valuable in selected cases. Calcium stimulation currently remains useful in providing an additional functional perspective.

Routine underwater seal drains are not required after transthoracic oesophagectomy: a pilot study.

OBJECTIVE: Underwater seal drainage of the pleural cavity has been standard practice after transthoracic oesophagectomy. However these chest tubes cause pain and hamper mobility, thereby causing significant morbidity and delaying recovery. We postulated that if complete lung expansion and optimum pulmonary function could be achieved and maintained following a transthoracic oesophagectomy using simple gravity aided transabdominal tube drainage of the pleural cavity, then these may be a simpler alternative to the conventional underwater seal chest drains. METHODS: A total of 50 patients had transthoracic oesophagectomy for oesophageal cancer. Of the cohort, 44 patients were fitted with the transabdominal drain described and hence had 'modified pleural drainage' following the oesophagectomy. All patients had a posterior mediastinal drain placed in either the right or the left pleural cavity during the oesophagectomy. The tube drain was inserted into the pleural cavity from the abdomen and placed into the desired position across the diaphragmatic hiatus. The drain was managed in the conventional manner and patients were monitored postoperatively for any developing pleural collections through serial chest X-rays. Respiratory function was closely monitored. RESULTS: The drains were removed without any significant respiratory complications by the 8th postoperative day in 86% of the patients. Only three patients (7%) developed clinically significant recurrent pleural effusions, causing respiratory compromise meriting further drainage. This was easily and safely managed using fine bore pigtail drains inserted under ultrasound guidance. CONCLUSION: Transabdominal gravity aided tube drainage of the mediastinum and the pleural cavity is an effective and safe means of draining the chest, following uncomplicated transthoracic oesophagectomy.