RESUMO
BACKGROUND: Robotic central pancreatectomy (CP) has emerged in recent years as a noninferior approach to open CP and may offer improved patient-reported outcomes and reduction in incisional hernias. METHODS: All patients who underwent open and robotic CP between (2013 and 2022) were selected, and perioperative outcomes were analyzed. Patients who underwent robotic CP were interviewed over the phone to assess patient-reported postoperative outcomes. RESULTS: A total of 18 CP operations (56%-open vs. 44%-robotic) were identified. The overall median age was 67 years (interquartile range: 60-72), and 50% (n = 9) of patients were female. Median length of surgery was statistically longer for robotic CP (411 vs. 138 min, p = 0.002); all other intraoperative variables were similar. Postoperatively, a similar number of patients in the open and robotic cohorts developed clinically significant postoperative pancreatic fistulas (37.5% vs. 30%, p = 1) and major complications (37.5% vs. 20%, p = 0.60), respectively. No patients in the robotic cohort developed an incisional hernia, compared to 40% (n = 4) in open (p = 0.08). All patients returned to a baseline level of activity and reported a high quality of life. CONCLUSION: With the exception of longer operative times, robotic CP is a noninferior, definitive resection technique for select lesions of the middle pancreas. Additionally, the robotic approach may result in a reduction in incisional hernia development.
Assuntos
Hérnia Incisional , Laparoscopia , Neoplasias Pancreáticas , Procedimentos Cirúrgicos Robóticos , Humanos , Feminino , Idoso , Masculino , Pancreatectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Hérnia Incisional/complicações , Hérnia Incisional/cirurgia , Qualidade de Vida , Neoplasias Pancreáticas/patologia , Laparoscopia/métodos , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Pancreatoduodenectomy (PD) for duodenal adenoma (DA) resection may be associated with excessive surgical risk for patients with potentially benign lesions, given the absence of pancreatic duct obstruction. We examined factors associated with final malignant pathology and evaluated the postoperative course of patients with DA versus pancreatic ductal adenocarcinoma (PDAC). METHODS: We retrospectively analyzed patients with DA who underwent PD from 2008 to 2018 and assessed the accuracy rate of preoperative biopsy and factors associated with final malignant pathology. Complications for DA patients were compared with those of matched PDAC patients. RESULTS: Forty-five consecutive patients who underwent PD for DA were identified, and the preoperative biopsy false negative rate was 29. Factors associated with final malignant pathology included age over 70 years, preoperative biliary obstruction, and common bile duct diameter > 8 mm (p < 0.05). Compared with patients with PDAC (n = 302), DA patients experienced more major complications (31% vs. 15%, p < 0.01), more grade C postoperative pancreatic fistulas (9% vs. 1%, p < 0.01), and greater mortality (7% vs. 2%, p < 0.05). Propensity score matched patients with DA had more major complications following PD (32% vs. 12%, p < 0.05). CONCLUSIONS: Preoperative biopsy of duodenal adenomas is associated with a high false-negative rate for malignancy, and PD for DA is associated with higher complication rates than PD for PDAC. These results aid discussion among patients and surgeons who are considering observation versus PD for DA, especially in younger patients without biliary obstruction, who are less likely to harbor malignancy.
Assuntos
Adenoma , Neoplasias Pancreáticas , Adenoma/cirurgia , Idoso , Feminino , Humanos , Masculino , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Estudos RetrospectivosRESUMO
A woman in her 40s underwent evaluation for abdominal pain, jaundice and acholic stools and was diagnosed with metastatic pancreatic head adenocarcinoma. She was enrolled in a clinical trial investigating the benefits of ibrutinib with nab-paclitaxel and gemcitabine, and subsequently received modified FOLFIRINOX. Over the course of 6 years on chemotherapy, she experienced complete regression of the pancreatic and liver lesions, as well as normalisation of her tumour markers. She has been off chemotherapy for 6 months with no evidence of disease and normal tumour markers. Despite advances in chemotherapy and surgical options, metastatic pancreatic adenocarcinoma continues to carry a grim prognosis. This case report demonstrates a rare case of a long-term survivor of unresectable metastatic pancreatic adenocarcinoma treated with chemotherapy alone.
Assuntos
Adenocarcinoma , Protocolos de Quimioterapia Combinada Antineoplásica , Leucovorina , Oxaliplatina , Neoplasias Pancreáticas , Humanos , Neoplasias Pancreáticas/tratamento farmacológico , Neoplasias Pancreáticas/patologia , Feminino , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/secundário , Leucovorina/uso terapêutico , Oxaliplatina/uso terapêutico , Oxaliplatina/administração & dosagem , Gencitabina , Paclitaxel/uso terapêutico , Paclitaxel/administração & dosagem , Desoxicitidina/análogos & derivados , Desoxicitidina/uso terapêutico , Desoxicitidina/administração & dosagem , Fluoruracila/uso terapêutico , Irinotecano/uso terapêutico , Adulto , Albuminas/uso terapêutico , Albuminas/administração & dosagem , Pessoa de Meia-Idade , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/tratamento farmacológico , Resultado do TratamentoRESUMO
Meckel's diverticulum is the most common gastrointestinal congenital anomaly and may present with lower gastrointestinal bleeding, abdominal pain, and nausea. Imaging and endoscopic findings can be similar to those of Crohn's disease, including transmural inflammation, stricturing, and superficial ulceration frequently in the distal ileum. Here, we present a case series of three patients who were initially diagnosed with Crohn's disease and ultimately found to have Meckel's diverticulum alone on final pathology. This single-institution case series, the largest in the literature, highlights the importance of maintaining a high index of suspicion for Meckel's diverticulum, especially in the absence of microscopic evidence of inflammatory bowel disease.
RESUMO
BACKGROUND: Necrotizing pancreatitis (NP) may result de novo or following procedures such as ERCP or partial pancreatectomy (post-procedural), and may require surgical debridement. Video-assisted retroperitoneal debridement (VARD) is a standard approach for NP that employs a 5 cm incision with varying degrees of blind and open debridement. We describe our technique and outcomes of a modified VARD called laparoscopic-assisted pancreatic necrosectomy (LAPN) performed through a single 12 mm incision that uses direct laparoscopic visualization during debridement. METHODS: At one medical center, all LAPN patients (2012-2020) were assessed for demographics, disease factors, and outcomes. Bivariate logistic regression analyses were performed to identify factors independently associated with recovery after LAPN for patients with de novo vs post-procedural necrosum. RESULTS: Over 9 years, 60 patients underwent LAPN for NP. Median age was 57 years (IQR: 47-66) and 43 (69%) were men. Pancreas necrosum was de novo in 39 (63%) patients and post-procedural in 23 (37%). NP resolved with a median of 1 LAPN procedure and median hospitalization was 33 days. The LAPN major morbidity rate and in-hospital mortality rate were 47% and 5%. No significant differences were seen between NP etiology cohorts, although post-procedure NP patients trended towards a faster clinical recovery to baseline compared to de novo patients (193 vs 394 days; p-value = .07). CONCLUSIONS: LAPN offers a smaller incision with excellent visualization and non-inferior outcomes, regardless of etiology, with likely faster recovery for patients with post-procedural vs de novo necrotizing pancreatitis.
Assuntos
Laparoscopia , Pancreatite Necrosante Aguda , Masculino , Humanos , Pessoa de Meia-Idade , Feminino , Desbridamento/métodos , Pâncreas/cirurgia , Laparoscopia/métodos , Pancreatite Necrosante Aguda/cirurgia , Espaço Retroperitoneal/cirurgia , Drenagem/métodos , Resultado do TratamentoRESUMO
A woman in her 80s was evaluated for a liver mass. She had a history of what was reported as pancreatic acinar cell carcinoma resected with a pancreatoduodenectomy 10 years prior at another institution. Liver biopsy showed metastatic pancreatoblastoma (PB) and staging imaging showed no evidence of additional metastatic disease. She underwent laparoscopic non-anatomic partial hepatectomy and recovered uneventfully. The liver pathology was reviewed along with slides from her initial pancreatoduodenectomy, and both were noted to be consistent with PB. PB contains similar histological characteristics to pancreatic acinar cell carcinoma. Distinguishing between the two diagnoses is critical for accurately defining the prevalence, clinical course and prognosis associated with PB.
Assuntos
Carcinoma de Células Acinares , Neoplasias Pancreáticas , Feminino , Humanos , Idoso , Carcinoma de Células Acinares/patologia , Neoplasias Pancreáticas/patologia , Fígado/patologia , Erros de Diagnóstico , Neoplasias PancreáticasRESUMO
BACKGROUND: Hand hygiene is paramount in preventing the spread of healthcare-associated infections especially during disease epidemics. Compliance rates with hand hygiene policies remain below 50% internationally and may be lower in the outpatient care setting. This study assessed the impact of the patient empowerment model on hand hygiene compliance among healthcare providers. METHODS: From October 2016 to May 2017, patients from a large ambulatory oncology centre were prospectively enrolled. Patients were instructed to observe healthcare providers for hand hygiene compliance and to remind healthcare providers where it was not observed during at least three consecutive encounters. Healthcare provider reactions to this intervention were rated by patients. Patients' hand hygiene knowledge and beliefs were objectively elicited pre and post-study. RESULTS: Thirty patients with a median age of 52 years (range 5-91) completed the study for a total of 190 healthcare provider encounters. When initial hand hygiene was not observed, patients offered a reminder in 71 (37.4%) encounters, did not offer a reminder in 73 (38.4%) encounters and forgot to offer a reminder in 24 (14.2%) encounters. Patients perceived positive or neutral reactions in 76.8% of encounters and negative or surprised reactions in 23.2% of encounters. Healthcare provider compliance improved from 11.6% to 48.9% with intervention. Patient hand hygiene knowledge improved by 16% following the study. CONCLUSIONS: Patient-empowered hand hygiene may be a useful adjunct for improving hand hygiene compliance among healthcare providers and improving patient hand hygiene knowledge, although it may confer an emotional burden on patients.
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BACKGROUND: Uterine carcinosarcomas (UCS) are rare tumors that carry a poor prognosis and high recurrence rate. Standard treatment consists of surgical resection and chemotherapy, though the benefit of adjuvant radiotherapy (RT) has yet to be determined. This study assessed survival rates between patients with UCS who underwent surgical resection alone and patients who underwent combinations of surgery, chemotherapy, and RT. MATERIALS AND METHODS: We conducted a retrospective review of all patients who underwent surgical resection for UCS between 1993 and 2011 at a single institution. We assessed 3-year disease-free survival, locoregional recurrence-free survival, distant metastases-free survival (DMFS), and overall survival rates and utilized Kaplan-Meier modeling to analyze differences between UCS treatment modalities. RESULTS: Twenty-four patients underwent UCS surgical resection between 1993 and 2011. The mean age was 61 (range: 39 to 75 y). Of these patients, 100% (n=24) underwent surgical resection, 25% (n=6) underwent surgery and adjuvant chemotherapy, 29% (n=7) underwent surgery and adjuvant RT, and 33% (n=8) underwent surgery and adjuvant chemotherapy and RT. At 3 years median follow, there was no significant difference in overall survival between treatment modalities. The addition of radiation therapy conferred increased DMFS in patients undergoing surgery irrespective of adjuvant chemotherapy (44% vs. 83%, P=0.0211).In patients receiving adjuvant chemotherapy, the significant increase in DMFS persisted with the addition of RT (P=0.0310). Lymph node involvement (n=8) was associated with a lower locoregional recurrence-free survival (38% vs. 92%, P=0.0029). CONCLUSIONS: RT may offer a potential benefit in reducing the rate of distant metastases, though there were no statistically significant improvements in survival metrics.
Assuntos
Carcinossarcoma/secundário , Pelve/efeitos da radiação , Radioterapia Adjuvante , Radioterapia Conformacional , Neoplasias Uterinas/radioterapia , Adulto , Idoso , Carcinossarcoma/tratamento farmacológico , Carcinossarcoma/radioterapia , Carcinossarcoma/cirurgia , Quimioterapia Adjuvante , Terapia Combinada , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Metástase Linfática , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/epidemiologia , Estadiamento de Neoplasias , Estudos Retrospectivos , Neoplasias Uterinas/tratamento farmacológico , Neoplasias Uterinas/cirurgiaRESUMO
Molecular surveillance provides a powerful approach to monitoring the resistance status of parasite populations in the field and for understanding resistance evolution. Oxamniquine was used to treat Brazilian schistosomiasis patients (mid-1970s to mid-2000s) and several cases of parasite infections resistant to treatment were recorded. The gene underlying resistance (SmSULT-OR) encodes a sulfotransferase required for intracellular drug activation. Resistance has a recessive basis and occurs when both SmSULT-OR alleles encode for defective proteins. Here we examine SmSULT-OR sequence variation in a natural schistosome population in Brazil â¼40years after the first use of this drug. We sequenced SmSULT-OR from 189 individual miracidia (1-11 per patient) recovered from 49 patients, and tested proteins expressed from putative resistance alleles for their ability to activate oxamniquine. We found nine mutations (four non-synonymous single nucleotide polymorphisms, three non-coding single nucleotide polymorphisms and two indels). Both mutations (p.E142del and p.C35R) identified previously were recovered in this field population. We also found two additional mutations (a splice site variant and 1bp coding insertion) predicted to encode non-functional truncated proteins. Two additional substitutions (p.G206V, p.N215Y) tested had no impact on oxamniquine activation. Three results are of particular interest: (i) we recovered the p.E142del mutation from the field: this same deletion is responsible for resistance in an oxamniquine selected laboratory parasite population; (ii) frequencies of resistance alleles are extremely low (0.27-0.8%), perhaps due to fitness costs associated with carriage of these alleles; (iii) that four independent resistant alleles were found is consistent with the idea that multiple mutations can generate loss-of-function alleles.