The role of preoperative C-reactive protein and procalcitonin as predictors of post-pancreaticoduodenectomy infective complications: A prospective observational study.

INTRODUCTION: The common causes of morbidity after pancreaticoduodenectomy (PD) are infective complications. Till date, no specific preoperative markers have been identified to determine the probability of developing infective complications. We have studied the factors predicting the occurrence of the infective complication/s in the present study. METHODS: The present prospective observational study included 133 consecutive patients who underwent PD from January 2011 to June 2016 at a specialized hepatopancreaticobiliary surgical oncology unit. The surgeries were done using a standardized technique. Postoperative complications were segregated into two categories-(a) infective (e.g. cholangitis) and (b) non-infective (e.g. delayed gastric emptying). Increased age, preoperative serum albumin levels, preoperative biliary stenting, pre-stenting serum bilirubin levels, duration of common bile duct stenting, preoperative C-reactive protein [CRP], and procalcitonin [PCT] were evaluated. RESULTS: Overall morbidity rate was 48.8%. Morbidity associated with infective complications was 21.8%. Increased age, preoperative serum albumin levels, and pre-stenting serum bilirubin levels did not increase the rate of the infective complications. The association between preoperative PCT and preoperative CRP with the infective complications was significant with a p-value of <0.01 (6.75E-07) and <0.01 (4.80E-10), respectively. In the multivariate analysis, only the elevated preoperative procalcitonin was a statistically significant predictor of postoperative infective complications. CONCLUSION: Preoperative PCT and CRP levels done 48 h before surgery are sensitive, specific, easily available, and cost-effective predictors of infective complications after PD.

Transduodenal ampullectomy for ampullary tumors.

Transduodenal ampullectomy (TDA) is indicated for large ampullary tumors, for presence of dysplasia on endoscopic biopsy, for poor surgical candidates for pancreaticoduodenectomy, and in cases not indicated for endoscopic ampullectomy. Retrospective review of data from 2009 to 2015 revealed 11 patients who underwent TDA. Magnetic resonance imaging cholangiopancreatography (MRI-MRCP), contrast-enhanced computed tomography (CECT) scan, side-viewing endoscopy, and endoscopic ultrasound (EUS) were used for investigating the patients as required. Preoperative biopsy was done in all. Out of the 11 patients, only one had recurrence. Two patients had adenocarcinoma and were treated with pancreaticoduodenectomy. TDA is a safe surgical procedure for treatment of well-selected benign ampullary pathologies. It is also a treatment option for the cases of ampullary adenomas not amenable to endoscopic resection.

IgG4-associated sclerosing cholangitis masquerading as hilar cholangiocarcinoma.

IgG4-sclerosing cholangitis (IgG4-SC) commonly presents with type 1 autoimmune pancreatitis. Isolated IgG4-SC is rare. Differentiating IgG4-SC from cholangiocarcinoma preoperatively is challenging due to overlapping radio-clinical manifestations and difficult preoperative histology. We present three cases preoperatively diagnosed and surgically treated as hilar cholangiocarcinoma. First and second cases presented with cholangiocarcinoma with portal vein involvement and third with a malignant-appearing hilar stricture. On histopathology, IgG4-SC was diagnosed in the first two cases. Third patient had raised serum IgG4, and histopathology was inconclusive for IgG4-SC and negative for malignancy. However, she responded to steroid therapy.