Lymph node 8a as a prognostic marker for poorer prognosis in pancreatic and periampullary carcinoma.

OBJECTIVES: An investigation of patients with pancreatic carcinoma aims to identify those who will benefit from surgery. Physical examination, radiology and laboratory findings are helpful. Most prognostic markers, such as lymph node status, micro metastasis and tumour differentiation, are not preoperatively accessible. Metastatic disease in lymph node 8a (Ln8a) in patients operated for pancreatic carcinoma has been reported to be a predictor of shorter overall survival (OS). This lymph node can be assessed preoperatively through resection (possibly even with laparoscopy) and subsequent histopathology. The value of the procedure is disputed. The aim of this study is to investigate whether metastatic disease in Ln8a is a predictor of decreased OS. MATERIALS AND METHODS: In patients with suspected pancreatic or periampullary carcinoma, who were operated with pancreatoduodenectomy (PD), Ln8a was separately resected and analysed with standard and immuno-histochemical methods. Patients with or without metastasis in Ln8a were compared regarding OS. RESULTS: Between 2008 and 2011, 122 consecutive patients were eligible and 87 were resected and had LN8a analysed separately. Sixteen patients were Ln8a + and 71 were Ln8a-. Patients with Ln8a + had a significantly reduced median OS as compared to patients with Ln8a- (0.74 (95% CI 0.26-1.26) versus 5.91 years (95% CI 2.91-), p < .001). CONCLUSION: Ln8a + was associated with a marked reduction of OS, indicating a possible role in the future preoperative workup in patients with a suspicion of pancreatic cancer.

[Guidelines for management of patients with pancreatic cancer]. / Riktlinjer för handläggning av patienter med pankreascancer.

The incidence of pancreatic cancer has fallen during the last ten years in Sweden. Early signs and symptoms of the disease are still undiscovered and when diagnosis is made the disease is incurable in most patients. Transabdominal ultrasonography is the first-line imaging test followed by spiral computed tomography (CT) and magnetic resonance imaging (MRI) if required for definite diagnosis. Spiral CT is also the imaging test of choice for assessment of resectability of the tumor. Surgical removal of the tumor is the only chance of cure. Markedly improved hospital mortality after pancreaticoduodenectomy is reported and an association between hospital volume and outcome of the operation has been established. Longterm survival after attempted curative resection continues to be dismal, however. Adjuvant treatment should not be given outside clinical studies. Palliative treatment has improved thanks to progress in the field of endoscopy, interventional radiology and in management of pain and nutrition. Palliative chemotherapy should only be given selectively outside clinical studies. Radiotherapy has no proven effects on survival. Special pancreatic cancer treatment teams with catchment areas of 2-4 million inhabitants are recommended by international authorities.

EUS-guided drainage is more successful in pancreatic pseudocysts compared with abscesses.

AIM: To compare the results for endoscopic ultrasound (EUS)-guided drainage of clear fluid pancreatic pseudocysts with the results for abscess drainage. METHODS: All patients referred for endoscopic drainage of a fluid collection were prospectively included. The outcome was recorded. RESULTS: Altogether 26 pseudocysts or abscesses were treated in 25 (6 female) patients. One endoscopist performed the procedures. Non-infected pseudocysts were present in 15 patients and 10 patients had infected fluid collections. The cyst size ranged between 28 cm × 13 cm and 5 cm × 5 cm. The EUS drainage was successful in 94% of the pseudocysts and in 80% of the abscesses (P = 0.04). The complication rate in pseudocysts was 6% and in abscesses was 30% (P = 0.02). Recurrence of a pseudocyst occurred in one patient (4%) after 6 mo; the patient was successfully retreated. CONCLUSION: EUS-guided drainage of pseudocysts is associated with a higher success rate and a lower complication rate compared with abscess drainage.

Palliation of malignant gastroduodenal obstruction with open surgical bypass or endoscopic stenting: clinical outcome and health economic evaluation.

Gastroduodenal outlet obstruction is a complication of advanced gastrointestinal malignant disease. In the past it was usually treated by an open surgical bypass procedure. During the last decade, endoscopic self-expandable stents (SEMS) have been used. The aim of this study was to compare these two palliative strategies concerning clinical outcome and health economy. A series of 36 patients with incurable malignant disease and gastroduodenal outlet obstruction syndrome were treated in a prospective study. According to the attending hospital and endoscopist on duty, 21 of the 36 patients were endoscopically treated with SEMS and 15 underwent an open surgical gastroenteroanastomosis. Health economic evaluation was based on the monetary charges for each patient associated with the procedure, postoperative care, and hospital stay. The hospital stay was 7.3 days for the stented group compared with 14.7 days for the open surgery group ( p > 0.05). The survivals were 76 and 99 days, respectively (NS). In the stented group all 15 patients (100%) alive after 1 month were able to eat or drink, and 11 (73%) of them tolerated solid food. In the surgical bypass group,9 out of 11 (81%) patients alive after 1 month could eat or drink, and 5 of them (45%) could eat solid food. The mean charges (U.S. dollars) during the hospital stay were $7215 for the stented group and $10,190 for the open surgery group ( p < 0.05). Palliation of the gastroduodenal obstruction in patients with malignant disease were at least as good, and the charges were lower for the endoscopic stenting procedure than for an open surgical bypass.

Efficacy of an anterior as compared with a posterior laparoscopic partial fundoplication: results of a randomized, controlled clinical trial.

OBJECTIVE: The aim of the study was to compare the efficacy and mechanical consequences of 2 partial fundoplications performed laparoscopically under the framework of a randomized, controlled clinical trial. SUMMARY BACKGROUND DATA: Although laparoscopic total fundoplication procedures have proven their effectiveness in the control of gastroesophageal reflux, problems remain with the functional consequences after a supra-competent gastric cardia high-pressure zone. Partial fundoplications have been found to be associated with fewer mechanical side effects. PATIENTS AND METHODS: During a 2-year period, 95 patients with gastroesophageal reflux disease were enrolled into a randomized, controlled single-institution clinical trial comparing a partial posterior (Toupét, n = 48) fundoplication and an anterior partial wrap (Watson, n = 47). All patients were assessed postoperatively at predefined time points, and the 12-month follow-up data are presented in terms of clinical results and 24-hour pH monitoring variables. RESULTS: Both patient groups were strictly comparable at the time of randomization. All operations were completed laparoscopically, and no serious complications were encountered. During the first postoperative year, a difference regarding the control of reflux symptoms was observed in favor of the posterior fundoplication. Esophageal acid exposure (% time pH <4) was substantially reduced by both operations but to a significantly lower level after a Toupét compared with the Watson partial fundoplication (1.0 +/- 0.3 vs. 5.6 +/- 1.1 mean +/- SEM; p < 0.001). Postfundoplication symptoms were infrequently recorded with no difference between the groups. CONCLUSIONS: When performing a laparoscopic partial fundoplication, the posterior modification (Toupét) offers advantages in terms of better reflux control compared with an anterior type (Watson).

Impact of choice of therapeutic strategy for acute cholecystitis on patient's health-related quality of life. Results of a randomized, controlled clinical trial.

BACKGROUND: The aim of this prospective, randomized study was to determine if health related quality of life is affected by the choice of surgical strategy in the management of acute cholecystitis. MATERIAL AND METHODS: After diagnostic workup, patients were randomized to one of two groups: (1) early laparoscopic cholecystectomy (i.e. within 7 days after onset of symptoms) or (2) initial conservative treatment followed by delayed laparoscopic cholecystectomy. Seventy-four patients entered the early operation group and 71 patients were assigned to the delayed operation strategy. Assessments of quality of life were made at 1, 3 and 6 months after surgery, and in the delayed operation group also one month after the initial conservative treatment. RESULTS: The gastrointestinal symptom scores were significantly better in three dimensions (diarrhea, indigestion, abdominal pain) one month after surgery for the acute operation group (p < 0.01). Three and 6 months after the operation we were unable to detect any significant differences between the groups. The patients in the delayed operation group did not appear to suffer from more symptoms in the period of time waiting for their elective operation. Psychological general well-being showed no major differences between the groups. CONCLUSION: Cholecystectomy in the acute phase of acute cholecystitis offers a significant reduction of gastrointestinal symptoms during the first postoperative month and to that associated improved quality of life in this group of patients.