Duct-to-mucosa versus invagination pancreaticojejunostomy after pancreaticoduodenectomy: a meta-analysis.

BACKGROUND: Postoperative pancreatic fistula remains one of the most common and troublesome complications following pancreaticoduodenectomy. No consensus exists regarding the optimal pancreaticojejunostomy reconstruction technique to reduce this complication. We aimed to perform a systematic review comparing two commonly used techniques of pancreaticojejunostomy reconstruction (duct-to-mucosa versus invagination), by meta-analysis and assessment of evidence quality. METHODS: Databases searched including The Cochrane Library, Medline, PubMed, Embase, etc. Randomized controlled trials (RCTs) comparing duct-to-mucosa and invagination pancreaticojejunostomy were included. Outcomes of interest were pancreatic fistula rate, mortality, morbidity, reoperation and hospital stay. Pooled estimates were expressed as risk ratio (RR) or mean difference. RESULTS: From 321 identified abstracts, four RCTs (467 patients; duct-to-mucosa: 232; invagination: 235) were included. Pancreatic fistula rate (RR, 0.74; 95% confidence interval (CI): 0.24-2.28; P = 0.60), mortality (RR, 1.18; 95% CI: 0.39- 3.54; P = 0.77), morbidity (RR, 0.91; 95% CI: 0.69-1.21; P = 0.53), reoperation (RR, 1.09; 95% CI: 0.54-2.22; P = 0.81) and hospital stay (mean difference, -1.78; 95% CI: -4.60-1.04; P = 0.22) were similar between techniques. CONCLUSIONS: Duct-to-mucosa and invagination pancreaticojejunostomy are comparable with regards to assessed parameters. High-quality, large-volume, multi-center RCTs with standard outcome definitions are required.

Pancreatic cystic neoplasms: a review of preoperative diagnosis and management.

Pancreatic cystic neoplasms (PCNs) are a diverse group of neoplasms in the pancreas, and are more increasingly encountered with widespread abdominal screening and improved imaging techniques. The most common types of PCNs are serous cystic neoplasms (SCNs), mucinous cystic neoplasms (MCNs), and intraductal papillary mucinous neoplasms (IPMNs). Clinicians frequently feel bewildered in the differential diagnosis and subsequent management among the various types of lesions in the pancreas, which may lead to overtreatment or delayed treatment. The current review provides recent developments in the understanding of the three most common types of PCNs, the latest modalities used in preoperative diagnosis and differential diagnosis, as well as the most up to date management. Suggestions for diagnosis and differential diagnosis of SCNs, MCNs, and IPMNs are also provided for young surgeons. Better understanding of these neoplasms is essential for clinicians to make accurate diagnosis and to provide the best management for patients.

Sister Mary Joseph's nodule as a first sign of pancreatic cancer.

Sister Mary Joseph's nodule (SMJN) refers to a metastatic tumor of the umbilicus. It is a rare entity which arises from a malignancy in the intra-abdominal cavity. We herein describe a patient who presented with SMJN as his first sign of pancreatic cancer. It is an even more unusual case of SMJN. We therefore, suggest that pancreatic cancer should be included in the differential diagnosis when an umbilical mass is found. With the progress made in surgical procedures and other modalities, an early diagnosis will dramatically improve the prognosis of the patients.

Development of a Computerised Antithrombotic Risk Assessment Tool (CARAT) to optimise therapy in older persons with atrial fibrillation.

AIM: To develop and evaluate a novel Computerised Antithrombotic Risk Assessment Tool (CARAT) to aid clinicians' decision making regarding the risk-benefit of antithrombotic therapy in older patients. METHODS: CARAT was developed in an iterative process involving multidisciplinary feedback and computerisation of previously trialled algorithms. Hospital-based clinicians then applied the tool to patient cases, to evaluate its usability. RESULTS: Overall, 94% of clinicians (n= 27 yielding 216 responses) were satisfied with CARAT's format. Most (72%) clinician responses agreed with CARAT recommendations; over two-thirds agreed with estimates of stroke and bleeding risk. However, geriatricians were 3.5 times more likely to disagree with CARAT recommendations than cardiologists, particularly in cases of high fall risk. Overall, 63% responded that CARAT was at least 'somewhat useful' for clinical practice; 22% indicating it was 'very useful'. CONCLUSION: CARAT has potential as a useful decision-support tool to assist clinicians in decision making regarding appropriate antithrombotic therapy in older patients.