The Yield of Fever, Inflammatory Markers and Ultrasound in the Diagnosis of Acute Cholecystitis: A Validation of the 2013 Tokyo Guidelines.

BACKGROUND: Each year, 1-4 % of people with known gallstones become symptomatic, either presenting with biliary colic or as acute cholecystitis. The distinction between both diagnoses remains challenging. To aid the proper diagnosis, the revised 2013 Tokyo Guidelines (TG 2013) were proposed with a self-acclaimed diagnostic accuracy of over 90 %. However, this accuracy has not been verified by others so far. OBJECTIVE: To determine the accuracy of the TG 2013 guidelines in the diagnosis of acute cholecystitis both in its single components of fever, inflammatory markers and US features and of the combined application of the TG 2013 guidelines as a whole. METHODS: A 5-year retrospective analysis equal to the TG 2013 validation process of all emergency cholecystectomies for acute cholecystitis or persistent biliary pain with an ultrasound performed during the same admission. Acute cholecystitis at histology was the golden standard. RESULTS: Inclusion criteria were met by 169 patients with a prevalence of acute cholecystitis of 52.7 %. The individual features of fever, gallbladder wall thickening and probe tenderness were not significant in univariate analysis. In multivariate analysis only, neutrophil count was an independent predictor. The combined application of the TG 2013 guidelines led to a better sensitivity of 83.1 % at the cost a reduced specificity of 37.5 % compared to neutrophil count alone. The accuracy was therefore only 60.3 %, which was well below the TG 2013 report. CONCLUSION: The 2013 Tokyo Guidelines were slightly better in predicting acute cholecystitis but over diagnosed two-thirds of normal gallbladders compared to neutrophil count alone.

Adverse tumor biology associated with mesenterico-portal vein resection influences survival in patients with pancreatic ductal adenocarcinoma.

BACKGROUND: Although pancreatoduodenectomy (PD) with mesenterico-portal vein resection (VR) can be performed safely in patients with resectable pancreatic ductal adenocarcinoma (PDAC), the impact of this approach on long-term survival is controversial. PATIENTS AND METHODS: Analyses of a prospectively collected database revealed 122 consecutive patients with PDAC who underwent PD with (PD+VR) or without (PD-VR) VR between January 2004 and May 2012. Clinical data, operative results, and survival outcomes were analysed. RESULTS: Sixty-four (53 %) patients underwent PD+VR. The majority (84 %) of the venous reconstructions were performed with a primary end-to-end anastomosis. Demographic and postoperative outcomes were similar between the two groups. American Society of Anesthesiologists (ASA) score, duration of operation, intraoperative blood loss, and blood transfusion requirement were significantly greater in the PD+VR group compared with the PD-VR group. Furthermore, the tumor size was larger, and the rates of periuncinate neural invasion and positive resection margin were higher in the PD+VR group compared with the PD-VR group. Histological venous involvement occurred in 47 of 62 (76 %) patients in the PD+VR group. At a median follow-up of 29 months, the median overall survival (OS) was 18 months for the PD+VR group, and 31 months for the PD-VR group (p = 0.016). ASA score, lymph node metastasis, neurovascular invasion, and tumor differentiation were predictive of survival. The need for VR in itself was not prognostic of survival. CONCLUSIONS: PD with VR has similar morbidity but worse OS compared with a PD-VR. Although VR is not predictive of survival, tumors requiring a PD+VR have more adverse biological features.

Laparoscopic paraesophageal hernia repair: quality of life outcomes in the elderly.

Paraesophageal hernias (PEH) occur when there is herniation of the stomach through a dilated hiatal aperture. These hernias occur more commonly in the elderly, who are often not offered surgery despite the failure of medical treatment to address mechanical symptoms and life-threatening complications. The aim of this study was to assess the impact of laparoscopic repair of PEH on quality of life in an elderly population. Data were collected prospectively on 35 consecutive patients aged >70 years who had laparoscopic repair of a symptomatic PEH between December 2001 and September 2005. The change in quality of life was assessed using a validated questionnaire, the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD), and by patient interviews. Patients were assessed preoperatively, and at 6 weeks, 6 months, 12 months, 1 year, and 2 years postoperatively. Mean patient age was 77 years (range 70-85); mean American Society of Anesthesiologists class was 2.7 (range 1-3). There were 28 women and 7 men. There was one readmission for acute reherniation, which required open revision. Total complication rate was 17.1%. All complications were treated without residual disability. There was no 30-day mortality, and median hospital stay was 3 days (range 2-14). Completed questionnaires were obtained in 30 of 35 patients (85.7%). There was a significant improvement in quality of life, as measured with QOLRAD, at all postoperative time points (P < 0.001). Laparoscopic PEH repair can be performed with acceptable morbidity in symptomatic patients refractory to conservative treatment and is associated with a significant improvement in quality of life. Our data support elective repair of symptomatic PEH in the elderly, a population who may not always be referred for a surgical opinion.

The utility of FDG-PET in the preoperative staging of esophageal cancer.

Accurate staging of esophageal cancer is important when determining which patients will potentially benefit from curative surgery. The aim of this study was to evaluate the incremental effect of 2-fluoro-2-deoxyglucose positron emission tomography (FDG-PET) when used in addition to standard staging modalities. Patients referred to two surgeons in an Australian metropolitan teaching hospital with esophageal or esophago-gastric junction malignancy between May 2002 and December 2006 were included. Patients who had undergone prereferral treatment with chemotherapy or radiotherapy were excluded. Patients undergoing resection for gastrointestinal stromal tumors or high-grade dysplasia within Barrett's esophagus were also excluded. Clinical and non-clinical data were recorded prospectively. Pretreatment staging included routine CT scan and selective endoscopic ultrasound (EUS). FDG-PET was performed in patients judged to have curable disease on CT scanning and EUS. From a total of 130 eligible patients, 76 were judged to have curable disease on the basis of CT and EUS findings. Of these 76 patients, 19 (25%) were excluded from surgery due to additional information obtained from FDG-PET. The addition of FDG-PET to routine preoperative staging resulted in the exclusion from surgery of 19 (25%) patients who prior to the introduction of FDG-PET would have undergone attempted resection. FDG-PET should be performed in all patients under consideration for esophagogastric resection in order to avoid resection in patients with disseminated disease.

An experimental evaluation of ablation devices for the local treatment of the liver resection edge.

UNLABELLED: Surgical margin is the only technical variable that has an impact on long-term outcome after liver resection. In this study we compared radiofrequency (RFA), cryotherapy, diathermy and argon beam for the local treatment of liver resection edge. METHODS: Sixty eight ablations were produced on the surface of ex vivo sheep liver using the various modalities. Cryoablations were produced using both the Cryotech and the Erbe probes. Radiofrequency ablations were produced using a custom-made surface application probe and the RITA 1500 generator. Conmed 7500 system was used to produce diathermy and argon beam coagulation. RESULTS: Argon beam and the diathermy resulted in ablation to maximum depth of 3.5 mm with endpoint and spray modes at various power setting. RF ablation resulted in consistent ablations the diameter of which varied in a linear manner to the time of RF application and the depth of the ablations with the length of electrode deployment. Cryotherapy was as effective as RFA with both the cryotherapy systems but the Erbe trocar probe resulted in a deeper ablation, whereas the Cryotech paddle probe resulted in a larger diameter ablation. CONCLUSIONS: RF and cryotherapy are equally effective as liver edge ablation device. Diathermy and argon are considered less effective. Cryotherapy requires expensive complex equipment that at least with liquid nitrogen systems requires to be prepared for use and this may not be available if the need for edge treatment during resection was unplanned.

The clinical impact of early complete pancreatic head devascularisation during pancreatoduodenectomy.

BACKGROUND: Early inferior pancreaticoduodenal artery (IPDA) ligation reduces intraoperative blood loss during pancreatoduodenectomy, but the impact on oncologic and long-term outcomes remains unknown. The aim of this study was to review the impact of complete pancreatic head devascularization during pancreatoduodenectomy on blood loss, transfusion rates, and clinicopathologic outcomes. METHODS: Clinicopathologic and outcome data were retrieved from a prospective database for all pancreatoduodenectomies performed from April 2004 to November 2010 and compared between early (IPDA+; n = 62) and late (IPDA-; n = 65) IPDA ligation groups. RESULTS: Early IPDA ligation was associated with reduced blood loss (394 ± 21 vs 679 ± 24 ml, P < .001) and perioperative transfusion (P = .031). A trend toward improved R0 resection was seen in patients with pancreatic adenocarcinoma (IPDA+ vs IPDA-, 100% vs 82%; P = .059), but this did not translate to improved 2-year (IPDA+ vs IPDA-, 76% vs 65%; P = .426) or overall (P = .82) survival. CONCLUSIONS: Early IPDA ligation reduces blood loss and transfusion requirements. Despite overall survival being unchanged, a trend toward improved R0 resection is encouraging and justifies further studies to ascertain the true oncologic significance of this technique.

The infracolic approach to pancreatoduodenectomy for large pancreatic head tumours invading the colon.

BACKGROUND: Tumours arising from the head of the pancreas can invade both the proximal transverse colon and its mesocolon. At laparoscopy, this may be considered a contraindication to proceeding to pancreatoduodenectomy. However, in some patients, pancreatoduodenectomy can still be performed with an R0 resection using an en-bloc resection technique by an infracolic approach. METHODS: This technique relies on the infracolic control of the superior mesenteric vein (SMV) and is based on the presence of a normal fat cuff around the superior mesenteric artery (SMA) on pre-operative imaging. The dissection is maintained along the adventitial plane of the SMA. Pancreatoduodenectomy is performed in conjunction with en-bloc resection of the transverse colon. In the event of tumour invading the SMV, this is also resected en-bloc with the pancreatic head and transverse colon. We reviewed all such cases performed at our institution between April 2004 and April 2009. RESULTS: This technique was attempted in eleven patients. In two patients, the procedure had to be abandoned because of unexpected SMA encasement by tumour. In the remaining nine patients this procedure was carried out successfully. In this paper, the infracolic approach to pancreatoduodenectomy, and the associated limitations, are described in detail. CONCLUSION: The infracolic technique may be used to deal with large pancreatic head tumours and all pancreatic surgeons should be familiar with this technique. In the absence of metastatic disease, large pancreatic head tumours involving the colon can be resected en-bloc with the pancreatic head, as long as the SMA is not encased by the tumour.

Direct percutaneous puncture embolization of a peripancreatic pseudoaneurysm presenting with haemosuccus pancreaticus.

Haemosuccus pancreaticus is a rare cause of gastrointestinal haemorrhage. It is commonly due to a pseudoaneurysm in a setting of chronic pancreatitis. Treatment of aneurysms has traditionally been surgery; however, recently percutaneous radiological intervention has achieved good results with minimum morbidity and mortality. Transcatheter embolization of aneurysms is an effective treatment option. However, not all aneurysms are accessible through this route. We describe a technique of direct puncture embolization of a pseudoaneurysm causing haemosuccus pancreaticus.

Radiologically placed temporary hepatic artery catheter for treatment of liver cancer.

Summary Hepatic artery infusion (HAI) chemotherapy is associated with higher response rates compared to systemic chemotherapy in those patients with unresectable liver malignancies. Operative hepatic artery catheter (HAC) insertion has significant morbidity and mortality, especially in patients with high-volume disease, some of whom may not respond to HAI chemotherapy. We report our experience in 45 patients with high-volume liver disease who were initially treated with HAI chemotherapy via a radiologically placed temporary HAC to try to select the responders who then went on to have an operative HAC. In these 45 patients who had 62 radiologically placed HAC, we found very few major complications, and certainly no complications such as cholecystitis, vascular or malperfusion problems.

Safety and efficacy of radiofrequency ablation of brain: a potentially minimally invasive treatment for brain tumours.

INTRODUCTION: Cerebral metastases are associated with a very poor prognosis. The best survival results are seen after surgical resection. However this involves a relatively invasive procedure and many patients are not suitable for surgical resection. We have evaluated the safety and efficacy of radiofrequency ablation of the brain in a sheep model. METHODS: We produced ablations of 1 - 3 cm diameter in the brain of sheep using the RITA starburst XL probe and RITA 1500 generator. We varied the time of RF application between 1 minute and 5 minutes and observed the animals for between 24 hours and 3 weeks for short-term and long-term effects and measured the intracranial pressure (ICP) in 2 animals following RFA. RESULTS: A total of 8 ablations were produced in 8 sheep. There was no change in the ICP measurements and there were no neurological complications in the 5 sheep with superficial ablation of up to 2 cm. Three sheep failed to regain consciousness due to large ablations near the brain stem and cerebellum. The sizes of the ablations were confirmed on necropsy and there was no other evidence of damage to the surrounding brain. Satisfactory ablation of brain was achieved at 70 degrees C and an ablation time as short as 3 minutes produced a 1.5 - 2.0 cm diameter of ablation. CONCLUSION: Cerebral RFA is a relatively safe and effective technique capable of producing a predictable ablation with no damage to surrounding brain. The potential of this technique requires further evaluation but likely advantages include the ability to treat multiple tumours and perform repeated treatment with a minimally invasive approach.