Current management of pancreatic fistula after pancreaticoduodenectomy.

BACKGROUND: Pancreatic fistula (PF) is a major and serious complication following pancreaticoduodenectomy (PD). The purpose of this study was to outline our management of PF after PD. METHODS: A retrospective review of a prospectively collected database of 396 patients undergoing PD for various indications at Loyola University Medical Center and Hines Veterans Administration Hospital from July 1, 1990, to December 31, 2005. Patients were divided group 1 (no PF) and group 2 (PF). Each group was compared regarding preoperative, intraoperative, and postoperative outcomes. RESULTS: Of the patients included in the study, 65 patients (16%) developed a PF. PF was more common after PD for ampullary neoplasms (28%), duodenal neoplasms (35%), and serous cystic neoplasms (44%), and was uncommon after PD for pancreatic cancer (6%). Associated complications with PF was 51% when compared with patients with no PF (21%; P

Spectrum of cystic neoplasms of the pancreas and their surgical management.

BACKGROUND: Owing to increased awareness and the widespread use of abdominal ultrasonography and computed tomography, an increasing number of cystic neoplasms are being identified. Cystic neoplasms of the pancreas are divided into the following 4 main groups: serous cystic neoplasms, mucinous cystic neoplasms, solid pseudopapillary neoplasms, and intraductal pancreatic mucinous neoplasms. OBJECTIVE: To review our experience with cystic neoplasms of the pancreas at our institution from January 1992 through September 2002. METHODS: Medical records were reviewed for age, sex, clinical signs and symptoms, diagnosis, surgical treatment, morbidity, mortality, and histologic features. RESULTS: Seventy-three patients (49 women and 24 men) underwent surgical resection of a cystic neoplasm of the pancreas from January 1992 through September 2002. The most common presenting symptom was abdominal pain. Other symptoms included nausea, emesis, weight loss, jaundice, and pancreatitis. Most patients (73%) had no complications. The most common complication (10%) was pancreatic fistula. There were 3 deaths. CONCLUSIONS: Cystic neoplasms of the pancreas are an increasing entity. Long-term survival of patients with these tumors is generally better than that of patients with adenocarcinoma of the pancreas and mandates aggressive resectional therapy in most patients. Resection of these tumors can be done with resultant low morbidity and mortality rates.

Neoadjuvant chemoradiotherapy for locally advanced esophageal cancer: experience at a single institution.

HYPOTHESIS: Patients receiving neoadjuvant chemoradiotherapy followed by surgery (CRS) undergo downstaging of their tumor and have improved survival when compared with patients undergoing surgery followed by adjuvant chemoradiotherapy (SCR). DESIGN: Retrospective study. SETTING: Tertiary-care university medical center. PATIENTS: One hundred twenty-three patients with squamous cell carcinoma and adenocarcinoma of the esophagus underwent Ivor-Lewis esophagectomy from January 1, 1990, through December 31, 2001. Of these, 31 received CRS; 27, SCR; and 65, surgery alone. INTERVENTIONS: Patients were candidates for neoadjuvant or adjuvant therapy if they had locally advanced disease (T3/T4 N0 or any T stage with N1). Neoadjuvant and adjuvant therapies were nonrandomized and based on the preference of the treating oncologist and surgeon. MAIN OUTCOME MEASUREMENTS: Pathological downstaging was analyzed in the patients receiving CRS. Operative mortality, postoperative morbidity, median survival, and overall survival were compared between the CRS and SCR groups. RESULTS: Pathological downstaging (as characterized by TNM staging) was observed in 20 (64%) of the patients receiving CRS. Complete pathological responses occurred in 5 (16%) of the patients undergoing CRS. No 30-day mortality was observed in either treatment group. No statistical difference in survival was observed between groups, although a trend suggested improved survival with neoadjuvant therapy (3-year survival in CRS and SCR groups was 45% and 22%, respectively; P =.15). Complete pathological responders in the CRS group had a 1-year survival of 80% compared with 29% in nonresponders (P =.25). No statistical differences were observed between groups in relation to blood loss, length of hospital stay, mortality, or morbidity. CONCLUSIONS: Neoadjuvant chemoradiotherapy effectively downstages cancer in patients with locally advanced esophageal disease. Morbidity and operative mortality were not significantly different between patients receiving neoadjuvant and adjuvant therapy. The difference in overall survival between the 2 groups did not reach statistical significance, although a trend at 3 years was observed.

A comparison of pancreaticogastrostomy and pancreaticojejunostomy following pancreaticoduodenectomy.

This retrospective study compares the results of pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) in our institution, which has extensive experience in both techniques. Between the years of June 1995 and June 2001, 214 patients underwent pancreaticoduodenectomy (PD) at our institution. Of these 177 had PG and 97 had pancreatojejunostomy (PJ). There were 117 (54.6%) males and 97 (45.3%) females with a mean age of 64.2 +/- 12.4 years. Indications for surgery were pancreatic adenocarcinoma in 101 (47.2%), ampullary adenocarcinoma in 36 (16.9%), distal bile duct adenocarcinoma in 22 (10.2%), duodenal adenocarcinoma in 9 (4.2%), and miscellaneous causes in 46 (21.4%) of patients. Preoperatively, significant differences in the groups were that the patients undergoing PJ were significantly younger than those undergoing PG. Also noted preoperatively, was that the patients undergoing PG had a significantly lower direct bilirubin than those undergoing PJ. With regard to intraoperative parameters, operative time was significantly shorter in the PJ group when compared to the PG group. When the patients who did not develop fistula (N = 186) were compared to those who developed fistula (N = 28) the significant differences were that the patients who developed fistula were more likely to have hypertension preoperatively and a higher alkaline phosphatase. They also showed a significantly higher drain amylase and were likely to have surgery for ampullary, distal bile duct or duodenal carcinoma rather than pancreatic adenocarcinoma. In addition, those patients who developed fistula had a significantly longer postoperative stay, a larger number of intraabdominal abscesses and leaks at the biliary anastomosis. Thirty-day mortality was significantly higher in the PJ group compared to the PG (4 vs. 0, P = 0.041). There was a significantly larger number of bile leaks in the PJ group when compared to the PG (6 vs. 1, P = 0.048). In addition, the PJ group required a significantly larger number of new CT guided drains to control infection (8 vs. 2, P = 0.046) and the PJ group required a larger number of re-explorations to control infection or bleeding (5 vs. 0, P = 0.018). However, the pancreatic fistula rate was not different between the two groups (12% [PG] vs. 14% [PJ]). This retrospective analysis shows that safety of PG can be performed safely and is associated with less complications than PJ and proposes PG as a suitable and safe alternative to PJ for the management of the pancreatic remnant following PD.

The effect of preoperative biliary stenting on postoperative complications after pancreaticoduodenectomy.

BACKGROUND: Preoperative biliary drainage (PBD) in jaundiced patients undergoing pancreaticoduodenectomy remains controversial. METHODS: Patients presenting with obstructive jaundice who subsequently underwent pancreaticoduodenectomy from January 1996 to June 2002 were included in the study (n = 212). Patients with preoperative biliary stents (n = 154) were compared with patients without preoperative drainage (n = 58). RESULTS: Patients in the stented group required a longer operative time (mean 6.8 hours versus 6.5 hours) and had greater intraoperative blood loss (mean 1207 mL versus 1122 mL) compared with the unstented group, (P = 0.046 and 0.018). No differences were found with respect to operative mortality (2%), incidence of pancreatic fistula (10% versus 14%), or intraabdominal abscess (7% versus 5%). Wound infection occurred more often in the stented group (8% versus 0%, P = 0.039). CONCLUSIONS: PBD was associated with increased operative time, intraoperative blood loss, and incidence of wound infection. Although PBD did not increase major postoperative morbidity and mortality, it should be used selectively in patients undergoing pancreaticoduodenectomy.

Distal pancreatectomy: does the method of closure influence fistula formation?

The appropriate closure of the pancreatic remnant after distal pancreatectomy is still debated. Suture techniques, stapled closure, and pancreaticoenteric anastomosis all have their supporters. In this study we have reviewed our data from distal pancreatectomy to determine whether the type of remnant closure or underlying pathologic process had any relation to postoperative fistula formation. We performed a retrospective chart review of patients undergoing distal pancreatectomy at our institution between 1993 and 2001. The charts were reviewed for morbidity and mortality. These were then related to the type of closure of the pancreatic stump. From 1993 to 2001 a total of 86 patients underwent distal pancreatectomy. Data were available on 85 patients. Indications for surgery were pancreatic tumor (69%), pancreatitis (14%), trauma (7%), and extra pancreatic disease (9%). Pancreatic fistula occurred in 14 per cent (N = 12), intra-abdominal abscess in 8 per cent (N = 7), and wound infection in 2 per cent (N = 2). There was no mortality in the series. The incidence of pancreatic fistula formation was not related to method of closure of the pancreatic remnant nor to the underlying pathologic process. Postoperative pancreatic fistulas will close spontaneously even without total parenteral nutrition.

Octreotide does not prevent postoperative pancreatic fistula or mortality following Pancreaticoduodenectomy.

The role of octreotide in preventing pancreatic fistula following pancreaticoduodenectomy (PD) remains controversial. The purpose of our study was to report our experience with octreotide in 266 patients undergoing PD from 1995 to 2002. There were 150 males and 116 females. Patients were divided into two groups. Group 1 did not receive octreotide (N = 61). Group 2 received octreotide (N = 205). The average patient age was 66.2 years in the control group and 63.6 years in the octreotide group. One hundred fifty patients were male and 116 were female. Thirty-day mortality for both groups was 1.9 per cent. The incidence of pancreatic fistula was 12 per cent. Fistula occurrence in the octreotide group was 13 per cent and in the no-octreotide group 8 per cent (P = 0.34). Common complications in the no-octreotide group were pancreatic leak (10%), pancreatic fistula (8%), and delayed gastric emptying (8%). Common complications in the octreotide group were pancreatic leak (18%), pancreatic fistula (13%), intra-abdominal abscess (7%), and arrhythmia or myocardial infarction (7%). The only statistically different variable was the incidence of arrhythmia or myocardial infarction (P = 0.026). Octreotide did not reduce pancreatic fistula, other complications, or mortality. Octreotide may contribute cardiac morbidity. Octreotide cannot be recommended to prevent mortality or postoperative complications after PD.

Solitary hepatic gastrinoma treated with laparoscopic radiofrequency ablation.

BACKGROUND: This is a case of a solitary hepatic gastrinoma in a 65-year-old male. The patient was diagnosed with Zollinger-Ellison syndrome in 1991. He had negative radiologic and surgical explorations at that time. He was maintained on proton-pump inhibitors for the next 10 years without symptoms. METHODS: A computed tomographic (CT) scan done in April 2001 demonstrated a 5-cm right hepatic lesion. Radionucleotide scanning with octreotide demonstrated intense activity in the same area in the right hepatic lobe. His serum gastrin was 317 pg/mL. He underwent laparoscopic radiofrequency ablation of the lesion. RESULTS: Treatment resulted in a 6-cm ablative area giving a 1-cm margin on the tumor. One- and 3-month follow-up CT scans demonstrated adequate ablation of the tumor. An octreotide scan done 3 months postoperatively did not reveal any areas of abnormal uptake. CONCLUSION: We report success with laparoscopic radiofrequency ablation as an alternative to major hepatic resection in patients with a solitary hepatic gastrinoma.

Clinical and pathologic features influencing survival in patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma.

OBJECTIVE: The aim of the study was to determine the clinicopathological features that influence survival in patients with resected pancreatic ductal adenocarcinoma (PDA). METHODS: The study used a single institution retrospective review of patients undergoing pancreaticoduodenectomy (PD) for PDA from 1993 to 2010. RESULTS: Two hundred forty-six consecutive cases of resected PDA were identified: 128 males (52 %), median age 68 years. Median hospital length of stay was 8 days and 30-day mortality rate was 2.4 %. There were 101 (41.1 %) postoperative complications, 77 % of which were Dindo-Clavien Grade 3 or less. Overall survival was 85, 63, 25, and 15 % at 6 months, 1 year, 3 years, and 5 years, respectively, with a median survival of 17 months. Multivariate Cox proportional hazard modeling demonstrated lymph node ratio was negatively correlated with survival at all time points. Preoperative hypertension was a poor prognostic factor at 6 months, 3 years, and 5 years. The absence of postoperative complications was protective at 6 months whereas pancreatic leaks were associated with worse survival at 6 months. Abdominal pain on presentation, operative time, and estimated blood loss were also associated with decreased survival at various time points. CONCLUSION: The strongest prognostic variable for short- and long-term survival after PD for PDA is lymph node ratio. Short-term survival is influenced by the postoperative course.

Quality of life and symptoms after surgery for gastroesophageal cancer: a pilot study.

Oncologic outcomes of gastroesophageal surgery may be similar, but little is known about the impact on patients' postoperative symptom experience and quality of life (QOL). The purpose of this pilot study was to describe overall QOL and symptom experience of individuals who underwent either total gastrectomy with Roux-en-Y esophagojejunostomy or esophagogastrectomy for adenocarcinoma of the gastroesophageal junction. The Gastroenterology Quality of Life Index (GQLI) and the Life After Gastric Surgery (LAGS), developed by the investigators for measuring symptom frequency, were used to measure variables of interest. The sample (n = 27) had a relatively high QOL, but experienced difficulties with eating patterns, physical functioning, socialization, and happiness. There were significant differences between the two procedures related to QOL and symptom frequency in that individuals who had the total gastrectomy fared somewhat better. Further, patients who had esophagogastrectomy had greater symptom frequency and significantly poorer QOL. Although initially compelling, these data warrant further investigation into the QOL and symptom impact in a more diverse population of patients with cancer of the stomach or esophagus. These results, however, suggest several areas where nursing interventions could help these patients.