Spermatic cord liposarcomas incidentally found during hernia surgery: is histology of any lipoma mandatory? A review of the literature.

Purpose: Liposarcomas found incidentally during open or laparoscopic inguinal hernia surgery are extremely rare. It is unclear, whether any adipose tissue being removed during inguinal hernia surgery must be sent for histology due to the potential risk of liposarcoma of the spermatic cord. This study aims to evaluate the frequency of liposarcomas incidentally found in the inguinal canal during hernia surgery and tries to derive evidence-based recommendations regarding the optimal management of any fatty tissue found in the inguinal canal.Methods: A literature review of the PubMed/Medline electronic databases between January 1980 and January 2019 was performed using the search terms 'inguinal hernia' and 'liposarcoma'. There was only one study available on this topic. Therefore, an additional literature review was performed analyzing all reports on patients with incidentally detected liposarcomas of the spermatic cord in the inguinal canal during hernia surgery.Results: There was only one retrospective study evaluating the frequency of inguinal liposarcoma found at hernia operations with a frequency of less than 0.1%. There were 18 cases of spermatic cord liposarcomas that were truly found incidentally during operation for an unsuspected symptomatic or incarcerated inguinal hernia. These included 16 case reports with a total of 18 patients and 19 liposarcomas. All patients were male with a median age of 62.5 years (range: 24-86 years) years. Median size of liposarcoma was 10.5 cm (range: 3-30 cm). In seven patients, the inguinal liposarcoma was an extension of a retroperitoneal sarcoma. Treatment consisted of radical orchidectomy during the primary operation in 12 patients. Three out of the seven patients with retroperitoneal extension of the tumor underwent a secondary operation with complete resection of the tumor.Conclusions: Currently, there is no evidence-based recommendation available regarding the management of lipomas detected during open or laparoscopic inguinal hernia surgery. Due to the extremely low risk of the presence of a liposarcoma, routine histologic examination cannot be recommended unless the diameter exceeds 10 cm.

[Impact of the Nursing Personnel Strengthening Act on minimally invasive surgery exemplified by right-sided hemicolectomy from an economic perspective]. / Auswirkungen des Pflegepersonalstärkungsgesetzes auf die minimal-invasive Chirurgie am Beispiel der Hemikolektomie rechts aus ökonomischer Perspektive.

BACKGROUND: In the past, a reduced length of postoperative hospital stay was considered a sufficient trade-off to refinance the additional costs associated with minimally invasive surgery; however, with the implementation of the Nursing Personnel Strengthening Act and disincorporation of nursing costs, this argumentation needs to be fundamentally reevaluated. METHOD: Using right-sided hemicolectomy as an example, a retrospective case analysis was conducted. Cost reductions associated with the length of hospital stay were compared before and after the introduction of the revised German diagnosis-related groups (aG-DRG) and offset against the increased material and personnel costs. RESULTS: Among the analyzed cases, the utilization of minimally invasive surgical techniques led to a substantial cost reduction per case compared to conventional surgical treatment. After the introduction of the aG-DRGs the financial benefits of a shortened hospital stay are greatly diminished and cannot be used to refinance the expenses necessary to perform minimally invasive surgery. From a strictly economical perspective, there is a strong incentive to only perform open surgical procedures. CONCLUSION: Disincorporation of nursing costs has destabilized the fragile concept of indirect refinancing of advanced operative techniques by the financial incentives associated with a shorter hospital stay. In order to comply with statutory regulations to implicate a performance-based funding, there is an urgent necessity to adjust the grouping algorithms for minimally invasive surgical procedures to the corresponding flat rates.

Assessment of pancreatic hardness-surgeon versus durometer.

BACKGROUND: This study reports the first results of durometrically measured hardness of human pancreas and investigates its correlation to palpatory determined hardness, grade of pancreatic fibrosis, and preoperatively determined radiodensity. METHODS: Fifty-two patients with pancreatic resections were prospectively recruited. Hardness of samples from pancreatic cancer, chronic pancreatitis, and normal pancreas was measured using a durometer on a 0-100 Shore units (SU) scale. Three pancreatic surgeons palpated the pancreas and reported their assessment of hardness on a subjective 0-100 "Bochum units" (BU) scale. Radiodensity and fibrosis of pancreatic tissue were used for comparison. RESULTS: Pancreatic hardness differed significantly in normal pancreas, chronic pancreatitis, and pancreatic cancer; 30 SU, 51 SU, and 65.8 SU, respectively. Palpatory hardness of normal pancreas was 20 BU and of pancreatitis 60 BU. It correlated well to durometric readings: r(2)=0.56, P<0.00001. Fibrosis grade and radiodensity correlated neither to durometry nor to palpation. Pancreatic leak developed 4/20 (20%) patients with normal pancreas vs. 1/32 (3.1%) with chronic pancreatitis in the resection margin, P<0.05. CONCLUSIONS: Palpatory assessment of pancreatic hardness performed by experienced surgeons correlated well to durometric measurements and remains the method of choice for intraoperative decision making. Durometry was more precise and should be considered in studies on pancreatic texture and for teaching purposes. Hardness and fibrosis grade appeared to be independent characteristics of pancreatic texture.

Bacteribilia after preoperative bile duct stenting: a prospective study.

STUDY DESIGN: A prospective analysis of intraoperative bile duct cultures in patients undergoing surgery for both, malignant or benign periampullary diseases at the Department of Surgery, St Josef Hospital, Bochum, Germany, during a period of 18 months, between January 2004 and June 2005. GOALS: The goals of the presented study were to investigate the effects of preoperative bile duct stenting on intraoperative bile duct cultures and postoperative outcome in patients undergoing pancreatic surgery. BACKGROUND: In pancreatic surgery, bile duct stenting is often aimed at improving postoperative outcome. As implantation of xenograft material in the main bile duct facilitates bacterial contamination and cholangitis, a critical evaluation of stenting is mandatory. STUDY: In all patients with a hepaticojejunostomy (n=80), a bile duct culture was collected during the operation. All patients received antibiotic prophylaxis perioperatively and a retrograde flushing of bile ducts with warm saline after bile duct resection. Fifty-one percent (41/80) patients had biliary drainage before surgery, whereas 49% (39/80) were operated without preoperative draining procedures. RESULTS: After bile duct stenting, 98% of patients had a positive bile culture, whereas only 21% of infected bile was seen in patients without drainage (P<0.001). Despite infected bile, only 2% stented patients developed acute cholangitis postoperatively, versus 13% patients in the group without stent (P=0.231). After stenting, major complications occurred in 12%, versus 8% in patients without stent (P=0.817). CONCLUSIONS: Preoperative biliary drainage leads to an almost 100% bacterial contamination of bile ducts. With hospital-adjusted antibiotic prophylaxis and retrograde flushing of bile ducts, the postoperative rate of acute cholangitis and morbidity is not elevated. A critical evaluation of benefits from preoperative biliary drainage for each patient is necessary.

Redo-surgery following curative resection of pancreatic carcinoma: the difference between true and suspected recurrence.

BACKGROUND: Improving results have led to an extension of indications for re-resection of recurrent pancreatic carcinoma. METHODS: Among 410 patients who received surgery for histologically proven pancreatic cancer, 17 underwent re-resection for a suspected local recurrence and were evaluated for overall survival, clinicopathological and perioperative data. RESULTS: At the initial operation, resection was curative (R0/R1) in all 17 patients. Indication for re-resection was a suspected or proven recurrence of pancreatic cancer in all patients. Re-resection was possible in 5 patients. The remaining patients received a redo of the pancreaticojejunostomy or bilioenteric anastomosis (n = 2), exploration with biopsy (n = 4), and a palliative bypass (n = 6). Perioperative mortality was 6%. Median overall survival was 25 months (range 10-152 months) and 7 months following re-resection (5-29 months). In 5 of 17 patients, histology showed chronic pancreatitis (n = 4) or a benign stricture at the hepaticojejunostomy (n = 1), whereas all other patients had histologically proven recurrence. Re-resection or redo of the anastomosis was possible in 5 of 5 patients with chronic pancreatitis but only in 2 of 12 patients with true recurrence (p = 0.003). CONCLUSIONS: Curative reoperation for recurrent pancreatic carcinoma is rarely feasible. Due to the potential for chronic pancreatitis or benign strictures as an underlying pathology, operable patients should be explored.

Pancreatic redo procedures: to do or not to do -- this is the question.

BACKGROUND: Pancreatic redo procedures belong to the most difficult abdominal operations because of altered anatomy, significant adhesions, and the potential of recurrent disease. We report on our experience with 15 redo procedures among a series of 350 consecutive pancreatic operations. PATIENT AND METHODS: From January 1, 2004 to May 31, 2006 a total of 350 patients underwent pancreatic surgery in our department. There were 15 patients identified who had pancreatic redo surgery for benign (14) or malignant (1) disease. Perioperative parameters and outcome of 15 patients undergoing redo surgery after pancreatic resections were evaluated. RESULTS: Operative procedures included revision and redo of the pancreaticojejunostomy after resection of the pancreatic margin (6), completion pancreatectomy (3), conversion from duodenum-preserving pancreatic head resection to pylorus-preserving pancreaticoduodenectomy (3), classic pancreaticoduodenectomy after nonresective pancreatic surgery (1), redo of left-sided pancreatectomy (1), and classic pancreaticoduodenectomy after left-sided pancreatectomy (1). Histology revealed chronic pancreatitis in 14 and a mucinous adenocarcinoma of the pancreas in 1 patient. Median operative time was 335 min (235-615 min) and median intraoperative blood loss was 600 ml (300-2,800 ml). Median postoperative ICU stay was 20 h (4-113 h) and median postoperative hospital stay was 15 days (7-30 days). There was no perioperative mortality and morbidity was 33%. CONCLUSION: Pancreatic redo surgery can be performed with low morbidity and mortality. Redo surgery has a defined spectrum of indications, but to achieve good results surgery may be performed at high-volume centers.

The balanced induction of K-ras codon 12 and 13 mutations in mucosa differs from their ratio in neoplastic tissues.

The aim of this study was to compare the ratio of K-ras codon 12 and 13 mutations in various tissues of colorectal cancer patients. Multiple samples of inconspicuous mucosa and a sample of carcinoma tissue were taken from 36 colorectal cancer patients (group I) and these results were compared with those from polyp and carcinoma tissues of another 48 colorectal cancer patients (group II). A polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay was used to detect the respective point mutations. The results of this assay were complemented by sequencing the K-ras mutations. In mucosa tissue, the ratio of codon 12 and 13 mutations was nearly equal (0.9:1) whereas the respective ratio in tumour tissue showed a strong preponderance of K-ras codon 12 mutations (14:1, p=0.004). In polyp tissue of patients from group II, the ratio was 2.7:1 and that in carcinomas was 19:1 (p=0.053). The prevalence of both types of mutation was 14.6% in all mucosa samples, corresponding to 30.6% of group I patients. The K-ras mutation rate in carcinoma tissue of the same patients was 38.9%. Similarly, 33.4% of all polyp and 41.7% of all carcinoma samples from group II harboured K-ras codon 12 and/or 13 mutations. Sequencing confirmed 59 of 60 K-ras codon 12 mutations, but due to the detection limit for sequencing (1:10(4)) only 10 of 20 K-ras codon 13 mutations were confirmed. It is concluded that after balanced induction K-ras codon 12 mutations increase in frequency relative to K-ras codon 13 mutations during tumour progression.

Combination treatment of CC531-lac-Z rat liver metastases by chemoembolization with pemetrexed disodium and gemcitabine.

PURPOSE: The aim of this study was to evaluate the combination effect of pemetrexed disodium (MTA; Alimta; LY 231514) and gemcitabine (GEM) administered by hepatic artery and portal vein chemoembolization (HACE and PVCE) in a colorectal cancer rat liver metastasis model. MATERIALS AND METHODS: Proliferation studies on CC531-lac-Z rat colon cancer cells were performed using the MTT assay to obtain the optimal combination schedule of the two antineoplastic agents. To generate diffuse liver metastasis, 4 x 10(6) tumor cells were implanted into the portal vein of male WAG/Rij rats. MTA (30 mg/kg, 60 mg/kg, and 90 mg/kg) was administered locoregionally by portal vein chemoembolization (PVCE) and compared with repeated systemic intravenous injection. GEM (50 mg/kg) was also given locoregionally by hepatic artery chemoembolization (HACE) as well as systemically. All routes of administration were examined alone as well as in combination. Efficacy of treatment in terms of liver metastases burden was determined at the end of the experiment by measuring the beta-galactosidase activity of CC531-lac-Z cells with a chemoluminescence assay. RESULTS: Combination experiments in vitro showed a more than additive tumor cell reduction after sequential exposure to MTA preceding GEM (observed/expected ratio [O/E] = 0.73). Experiments with the reverse sequence (GEM-->MTA) resulted only in additive combination effects (O/E ratio = 1.08). Simultaneous drug exposure showed less than additive combination effects (O/E ratios > or = 1.25). In vivo, locoregional administration by HACE with GEM was significantly more effective than systemic intravenous bolus treatment (P = 0.03). Portal vein chemoembolization with MTA performed immediately after tumor cell inoculation was ineffective. Repeated systemic treatment with MTA yielded a slight reduction in tumor cell load that was significant versus control at the medium and high doses (60 mg/kg, P = 0.009; 90 mg/kg, P = 0.046) but not versus intraportal chemoembolization. The combination treatment of systemic (60 and 90 mg/kg) or locoregional (60 mg/kg) MTA with HACE using GEM (50 mg/kg) resulted in more than 80% tumor growth inhibition; this antineoplastic combination effect was maximally additive. CONCLUSION: A regimen-dependent synergistic combination effect of both drugs was found in vitro. In animals, hepatic artery chemoembolization with GEM was superior to systemic intravenous bolus treatment. Portal vein chemoembolization with MTA was ineffective. The optimal in vitro regimen of MTA (intravenous or PVCE) preceding GEM (HACE) resulted in a maximally additive tumor growth inhibition. The results indicate that MTA and GEM can successfully be combined and favor further evaluation in patients.

Chemoembolization of rat liver metastasis with irinotecan and quantification of tumor cell reduction.

PURPOSE: Hematogenic metastasis of patients with colorectal cancer most frequently effects the liver; the prognosis of affected patients is dramatically worsened by the presence of this lesion. The aim of this study was to evaluate the effect of hepatic arterial chemoembolization (HACE) with irinotecan versus 5-fluorouracil as a standard agent in a rat liver metastasis model. MATERIALS AND METHODS: Diffuse liver metastasis was induced by injecting 4 x 10(6) CC531-lac-Z rat colorectal carcinoma cells into the portal vein of male Wag/Rij rats. Irinotecan (10 mg/kg, 30 mg/kg, and 60 mg/kg) and 5-fluorouracil (40 mg/kg, 60 mg/kg, and 90 mg/kg) were administered concomitantly with degradable starch microspheres (30 mg/kg) for temporary embolization. The tumor cell load was determined quantitatively using a chemoluminescence assay. RESULTS: HACE with irinotecan induced a complete remission in 44% of the animals and the highest dose reduced the mean tumor cell load by 66% (P < 0.001). In contrast, the highest dose of 5-FU caused a reduction of only 18% (P = 0.026) and altogether 23% complete remissions were observed in response to 5-FU. The sensitivity of CC531-lac-Z cells versus irinotecan (IC50 32 pM after 72 h) and 5-FU (IC50 80 microM) mirrored the effects observed in vivo on a qualitative basis. CONCLUSION: In conclusion, the effect of HACE with irinotecan surpassed that of HACE with 5-FU and prompts further investigation in clinical trials.

Chemoembolization of rat liver metastasis with microspheres and gemcitabine followed by evaluation of tumor cell load by chemiluminescence.

An orthotopic, isogenic rat model was used to determine the potential of chemoembolization (CHE) for reducing the tumor cell load of a diffusely metastatic liver. Seven days after injecting CC531-lac-Z cells intraportally to male WAG/Rij rats, tumor positive animals were treated by injection into the hepatic artery with solvent (n=17), degradable starch microspheres (DSM, 30 mg/kg; n=16), DSM plus 5-fluorouracil (5-FU, dosages: 90, 60, and 40 mg/kg) or DSM plus gemcitabine (Gem, dosages: 100, 80, 50, and 10 mg/kg). After 3 more weeks the experiment was terminated, the livers were weighted and the number of CC531-lac-Z cells per liver was determined. Injection of DSM reduced the tumor cell load by 21% (T/C%=79), the combination with 5-FU caused a stimulation of growth at 40 mg/kg (T/C%=291; n=10), but effected dose-dependent reductions in tumor cell number at 60 mg/kg (T/C%=86; n=16), and 90 mg/kg (T/C=19; n=17). None of these effects was significantly different from controls. The combination of DSM plus Gem was toxic at the highest dose (100 mg/kg), but well tolerated and highly effective at 80 mg/kg (T/C%= 16; n=12), 50 mg/kg (T/C%=9; n=12), and 10 mg/kg (T/C%=26; n=14). These results were significantly different from controls (p<0.05), respectively. In summary, the comparison of CHE with 5-FU or Gem shows that the efficacy of Gem in reducing the hepatic tumor cell load was significantly higher and its therapeutic ratio was greater than that of 5-FU.

The difficult hepaticojejunostomy after pancreatic head resection: reconstruction with a T tube.

BACKGROUND: After pancreatic head resection, bile leaks from a difficult hepaticojejunostomy secondary to a small or fragile common hepatic duct may be reduced by a T tube at the side of the anastomosis. METHODS: A retrospective analysis of patients who underwent a difficult hepaticojejunostomy without or with a T tube was performed. RESULTS: In 48% (55/114) of patients, a T tube was placed at the side of the hepaticojejunostomy; 52% (59/114) did not have a T tube. Bile leaks occurred in 12% (14/114) (9% [5/55] in patients with a T tube vs 15% [9/59] without a T tube, P = .316). Bile leaks were associated with mortality, abscess formation, hemorrhage, and sepsis. Seven percent (8/114) of patients required revisional laparotomy (2% [1/55] with a T tube vs 12% [7/59] without a T tube, P = .036). Mortality was not different between the groups. Minor T-tube-associated complications occurred in 15% (8/55) without major complications. CONCLUSIONS: Augmentation of anastomosis with a T tube cannot prevent biliary leakage but does reduce the severity of bile leaks, resulting in less reoperations.

Treatment of acute delayed visceral hemorrhage after pancreatic surgery from hepatic arteries with covered stents.

BACKGROUND: Delayed visceral hemorrhage following pancreatic surgery is a rare but life-threatening complication. Usually hemorrhage originates from pseudoaneurysms secondary to pancreatic or biliary fistula. Re-laparotomy is often associated with high morbidity and mortality. Endovascular occlusion with metallic coils can stop pseudoaneurysmatic bleeding, but hepatic artery occlusion can result in severe organ damage. Interventional treatment with covered stents is an alternative providing persistent organ perfusion. RESULTS: In our department endovascular stenting for visceral hemorrhage was introduced in November 2008. From November 2008 until October 2009, 303 patients underwent pancreatic surgery at our institution. Among those, four patients were successfully treated with covered stents for delayed visceral hemorrhage. In all four patients bleeding originated from hepatic arteries. Mean onset of hemorrhage was 24 days after surgery. Endovascular stenting was successful in all four patients. None of these patients required re-operation or died during the study. CONCLUSION: Treatment of delayed visceral hemorrhage from hepatic arteries after pancreatic surgery with covered stents is safe and effective. Endovascular stenting is associated with a lower morbidity than re-laparotomy or coil embolisation. Emergency angiography with endovascular stenting should be considered for all patients with delayed hemorrhage from hepatic arteries after pancreatic surgery.

Reconstruction of the common hepatic artery at the time of total pancreatectomy using a splenohepatic bypass.

Arterial involvement by a periampullary adenocarcinoma is often a contraindication for resection, since an R0 resection cannot be achieved. This is usually observed in cases with involvement of the superior mesenteric artery. Involvement of the common hepatic artery, however, requires a bypass procedure if the gastroduodenal artery was divided during the resection. In such cases, the splenic artery can be used as an inflow-source provided that there is no stenosis of the celiac trunk and the splenic blood flow is preserved via the short gastric arteries. We describe a technique used in four cases for the reconstruction of the common hepatic artery following a segmental resection of this vessel en bloc with a periampullary tumor during pancreatectomy. The inflow is maintained by a splenohepatic bypass using the splenic artery.

Indications and early outcomes for total pancreatectomy at a high-volume pancreas center.

BACKGROUND: This study aimed to analyse the most common current indications for total pancreatectomy (TP) at a high-volume pancreas center. METHOD: Prospectively collected data on indications and short-term outcome of all TP's performed from January 2004 until June 2008 were analysed. RESULTS: The total pancreatectomies (TP) were 63, i.e., 6.7% of all pancreatic procedures (n = 948). Indications for TP were classified into 4 groups: tumors of advanced stage, n = 23 (36.5%), technical problems due to soft pancreatic tissue, n = 18 (28.6%), troubles due to perioperative surgical complications, n = 15 (23.8%), and therapy-resistant pain due to chronic pancreatitis, n = 7 (11.1%). Surgical complications occurred in 23 patients (36.5%). The mortality in elective TP was 6.25%. Median postoperative stay was 21 days. Mortality, morbidity and the other perioperative parameters differed substantially according to the indication for pancreatectomy. CONCLUSION: Total pancreatectomy is definitely indicated for a limited range of elective and emergency situations. Indications can be: size or localisation of pancreatic tumor, trouble, technical diffuculties and therapy-refractory pain in chronic pancreatitis. A TP due to perioperative complications (troubles) after pancreatic resections is doomed by extremely high morbidity and mortality and should be avoided.

TME quality in rectal cancer surgery.

BACKGROUND: The concept of total mesorectal excision has revolutionised rectal cancer surgery. TME reduces the rate of local recurrence and tumour associated mortality. However, in clinical trials only 50% of the removed rectal tumours have an optimal TME quality. PATIENTS: During a period of 36 months we performed 103 rectal resections. The majority of patients (76%; 78/103) received an anterior resection. The remaining patients underwent either abdominoperineal resection (16%; 17/103), Hartmann;s procedure (6%; 6/103) or colectomy (2%; 2/103). RESULTS: In 90% (93/103) TME quality control could be performed. 99% (92/93) of resected tumours had optimal TME quality. In 1% (1/93) the mesorectum was nearly complete. None of the removed tumours had an incomplete mesorectum. In 98% (91/93) the circumferential resection margin was negative. Major surgical complications occurred in 17% (18/103). 5% (4/78) of patients with anterior resection had anastomotic leakage. 17% (17/103) developed wound infections. Mortality after elective surgery was 4% (4/95). CONCLUSION: Optimal TME quality results can be achieved in all stages of rectal cancer with a rate of morbidity and mortality comparable to the results from the literature. Future studies should evaluate outcome and local recurrence in accordance to the degree of TME quality.

Identification of patients at risk for development of tertiary peritonitis on a surgical intensive care unit.

BACKGROUND: Tertiary peritonitis (TP) is defined as a severe recurrent or persistent intra-abdominal infection after adequate surgical source control of secondary peritonitis (SP). The aim of this study was to analyze the characteristics of patients with SP who will further develop TP in order to define early diagnostic markers for TP. STUDY DESIGN: Over a 1-year period, all patients on the surgical intensive care unit (ICU) with SP were prospectively assessed for the development of TP applying the definition of the ICU consensus conference. The Mannheim Peritonitis Index (MPI), C-reactive protein (CRP) and Simplified Acute Physiology Score II (SAPS II) were assessed at the initial operation (IO) that was diagnostic for SP and in the postoperative period. RESULTS: Among 69 patients with SP, 15 patients further developed TP, whereas 54 patients did not develop TP. Compared to SP, patients with transition to TP had significantly higher MPI at IO (28.6 vs. 19.8; p < 0.001), relaparotomy rate (2.00 vs. 0.11; p < 0.001), mortality (60% vs. 9%; p < 0.001), duration of ICU stay (14 vs. 4 days; p < 0.005), as well as SAPS II (45.1 vs. 28.4; p < 0.005) and CRP (265 mg/dL vs. 217 mg/dL; p < 0.05) on the second postoperative day after IO. CONCLUSIONS: The MPI at IO as well as CRP and SAPS II at the second postoperative day helps to identify patients at risk for tertiary peritonitis.

Intraductal papillary mucinous neoplasms of the pancreas.

Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are now a well-recognized category of slowly growing tumors with a remarkably better prognosis, even when malignant, than pancreatic ductal adenocarcinoma. Their clinical and pathohistologic features have been increasingly attracting the attention of clinicians since their first description 25 years ago. Despite its burgeoning volume recently, accumulated literature devoted to IPMN still provides a low level of evidence with regard to diagnosis, treatment, and prognosis. Therefore, we performed a Medline-based systematic review of the literature aimed at clearly defining the clinicopathologic characteristics of pancreatic IPMN and determining the best currently available evidence-based principles of diagnosis and management of patients with this disease.

Tailored resective pancreatic surgery for pediatric patients with chronic pancreatitis.

BACKGROUND: Surgical treatment for chronic pancreatitis (CP) in children comprises predominantly nonresective draining procedures. The purpose of this study was to identify indications, techniques, and results of organ-preserving resective pancreatic procedures for pediatric CP at our institution. PATIENTS AND METHODS: A retrospective chart review was performed of all children undergoing pancreatic surgery for CP over a period of 4 years. RESULTS: Overall, 6 pediatric patients (3 male, 3 female, ages 7-18 years) underwent a duodenum-preserving pancreatic head resection (3), a middle segmental pancreatic resection (2), or a distal pancreatectomy (1) for CP of different etiologies (idiopathic 2, posttraumatic 2, pancreas divisum 1, situs inversus 1). No mortality or major surgical complication occurred. Mean operative time was 294 min (207-412 min) and intraoperative blood loss was 541 mL (100-1300 mL). Postoperative hospital stay was 13 days (10-18 days). No endocrine or exocrine insufficiency occurred during follow up of 46 months (25-50 m), and pain control was improved in 5 of 6 patients. CONCLUSIONS: Tailored organ-preserving resective pancreatic surgery can be performed with low morbidity and mortality in pediatric patients with CP and not responding to conservative treatment.

Comparison between open and laparoscopic technique in the management of perforated gastroduodenal ulcers.

GOALS: The aim of this study was to evaluate our results of laparoscopic treatment of perforated gastroduodenal ulcers during a 5-year period and to compare the outcome of open and laparoscopic surgery. BACKGROUND: The value of laparoscopic treatment of gastroduodenal ulcers is still controversially debated because its superiority to conventional open surgery has not been established. STUDY: From January 1996 to December 2001, 24 patients were treated laparoscopically and 31 patients underwent conventional open suture repair. The results of these patients were retrospectively reviewed. RESULTS: There were 55 patients with a mean age of 55 years (range 18-92 years) who were eligible for the study. Patients with laparoscopic repair had a lower mean ASA score (2 vs. 2.9; P = 0.02) and a less severe Mannheimer peritonitis index (16.5 vs. 21; P = 0.00001) compared with patients with open repair. Three patients who were begun by the laparoscopic approach had to be converted to open surgery (12.5%). Three patients who underwent open repair died postoperatively (5.5%). There was no difference between treatment groups regarding operative time, morbidity, or postoperative hospital stay. The laparoscopic group required significantly fewer analgesics postoperatively (2.2 vs. 4 dosages; P = 0.04). CONCLUSIONS: Laparoscopic treatment of perforated gastroduodenal ulcers is an effective treatment option and should be considered in suited patients for the initial approach.

Endovascular treatment and complete regression of an infected abdominal aortic aneurysm.

PURPOSE: To report a case of successful endovascular treatment of an infected abdominal aortic aneurysm (AAA) following Salmonella septicemia. CASE REPORT: A 60-year-old man was admitted for rapid onset of urinary frequency, fever, and suprapubic pain extending to the flanks. Blood cultures were positive for Salmonella enteritidis, and appropriate antibiotic treatment was started. After 4 weeks, fever ceased and the C-reactive protein fell to 5.8 mg/dL, but the erythrocyte sedimentation rate remained unchanged. Back pain prompted computed tomography, which showed a large AAA with a very irregular aortic wall suspicious of impending rupture. A tube stent-graft was introduced under general anesthesia from a left groin incision and deployed immediately below the renal arteries; a proximal type I endoleak was suspected but not repaired. Oral antibiotic therapy was continued for 2 months after discharge. By 6 months, the endoleak had sealed with a concomitant decrease in the maximal diameter of the aneurysm from 7.4 to 5.6 cm. At 4 years, the aneurysm sac was no longer visible. CONCLUSIONS: Although experience is limited, endovascular grafting in combination with antibiotic therapy in selected infected aneurysms might represent an effective low-risk alternative to conventional surgery with the potential to restore normal vascular anatomy.