Surgeon's Experience May Circumvent Operative Volume in Improving Early Outcomes After Pancreaticoduodenectomy.

Introduction Pancreaticoduodenectomy (PD) is a complex procedure with a significant proportion of postoperative complications and improving but notable mortality. PD was the prototype procedure that initiated the lingering debate about the relationship of better operative outcomes when performed at higher-volume centers. This has not translated into practice. Impediments include the absence of a universally accepted definition of a high-volume center among others. Contrary evidence suggests equivalent outcomes for PD at low-volume centers when performed by experienced hepatobiliary surgeons. We reviewed our perioperative outcomes for PD from an earlier period as a low-volume center with an experienced team. Methods A longitudinal study of all PDs completed in our department between 2012 and 2017 was performed. Results A total of 28 PD were performed during this period. Pylorus-preserving PD was performed in 23 patients and classical PD in the remaining. A separate Roux-en-Y loop was used for high-risk pancreatic anastomosis in six cases. The mean patient age was 49.3±12.4 years. The male-to-female ratio was 1.3:1. Preoperative drainage procedures were carried out in 19 patients. The mean serum total bilirubin level was 3.98(±4.5) mg/dL. There was no 90-day mortality. Postoperative complications included wound infection in 10 (36.7%) and respiratory complications in 10 (36.7%) patients. Postoperative bleeding requiring intervention occurred in one patient, and two patients had an anastomotic leak (one pancreatojejunostomy (PJ) and one gastrojejunostomy (GJ)). Delayed gastric emptying (DGE) was noted in three (10.7%) patients. The mean length of hospital stay was 14±7 days. The median overall survival (OS) was 84 months. Conclusion Comparable early outcomes can be achieved at low-volume centers for patients undergoing PD with an experienced team, optimal patient selection, and the ability to rescue for complications.

A prospective randomized trial of N-acetyl cysteine administration during cold preservation of the donor liver for transplantation.

AIMS: N-acetyl cysteine (NAC), an anti oxidant and a glutathione precursor, is effective in ameliorating liver injury of Tylenol overdose. There is experimental evidence that it also reduces ischemia reperfusion (I/R) injury. This clinical study was undertaken to study the effect of NAC administered in the donor operation. METHODS: 22 patients were randomized to receive NAC (IV & Portal flush) or no NAC (Control Group) during donor operation. Peak AST levels and 1-hour post-reperfusion biopsies were used to assess I/R injury. Episodes of acute rejection were recorded together with immunosuppressive drug levels. RESULTS: There were 4 exclusions (re-exploration for post-operative hemorrhage x3, OLT for acute liver failure x1). The two groups (n = 9 each) were matched for recipient and donor ages and sex. Viral hepatitis accounted for cirrhosis in 3 patients in NAC Group and 6 patients in Control Group. Statistically, Cold and warm ischemia times were not significantly different as was the use of blood and blood products in both groups. Serum peak AST levels were similar and post- reperfusion biopsy showed moderate to severe reperfusion injury in 3 recipients in the NAC Group and 4 in the Control Group. Excluding ones associated with low Tacrolimus levels (n = 4), there were 6 episodes of acute rejection (2- mild, 4- moderate) in the NAC Group and 5 in the Control Group (3- mild,1- moderate, 1- severe). CONCLUSION: In this pilot study, NAC administered during donor operation did not show a protective effect on I/R injury or on acute cellular rejection.

Evaluation of the POSSUM scoring system for comparative audit in pancreatic surgery.

BACKGROUND: Wide variations exist in the reported morbidity and mortality rates for major pancreatic resections. The Physiological and Operative Scoring System for enUmeration of Morbidity and mortality (POSSUM) was developed for comparative audit in general surgical patients. It has also been found to be reliable for audit in colorectal, thoracic and vascular surgery with minor modifications. AIMS: To evaluate POSSUM and its modification for mortality, P-POSSUM, in pancreatic surgery. METHODS: Retrospective analysis of 50 patients undergoing partial pancreaticoduodenectomy (PD) (46 tumours, 4 chronic pancreatitis) using the POSSUM and P-POSSUM as predictors of morbidity and mortality. These were then compared with the observed values. RESULTS: The POSSUM-predicted mortality was 26%. The P-POSSUM predicted a mortality risk of 6%. The observed mortality was 4%. Using POSSUM for morbidity, the predicted value was 76%. The observed morbidity was 46%. The risk scores for patients with and without morbidity were similar (66.4 +/- 11.0 vs. 68.8 +/- 12.9, p = 0.49). CONCLUSIONS: While P-POSSUM appeared satisfactory for predicting mortality risk, POSSUM overestimated morbidity and mortality for PD in a specialist centre. Modifications are needed prior to its application for comparative audit in pancreatic surgery.

Isolated Roux Loop duct-to-mucosa pancreaticojejunostomy avoids pancreatic leaks in pancreaticoduodenectomy.

BACKGROUND: Over the last decade the operative mortality associated with pancreaticoduodenectomy (PD) has decreased. Pancreatic anastomotic leaks resulting in pancreatic bed sepsis and fistulae, however, remain a significant cause of both morbidity and mortality. The optimal method of reconstruction to minimise pancreatic leaks is controversial. AIM: To review the experience of Roux loop duct-to-mucosa pancreaticojejunostomy in a consecutive series of patients undergoing pancreatic head resection. METHODS: Over the 6-year period (1993-1998), 41 patients underwent pancreatic head resections for benign (n = 5) and malignant disease (n = 36). There were 19 males and the median age was 62 years (range 29-83). An isolated Roux loop pancreaticojejunostomy was performed in all cases. RESULTS: Median duration of surgery was 8 h and the median postoperative stay was 16 days. The mean peri-operative blood transfusion was 2.9 units (SD 1.9). The incidence of major complications was 12% and there was 1 death (2.4%). There were no pancreatic leaks or fistulae. CONCLUSIONS: The low complication rate and the absence of pancreatic fistulae in this series would suggest that Roux loop duct-to-mucosa pancreatic reconstruction should be more widely adopted.