Long-Term Functional Outcome After Pancreatoduodenectomy for Periampullary Carcinoma With Morphological Correlation.

OBJECTIVE: The aim of the study was to evaluate the long-term functional outcome (exocrine and endocrine) and morphological changes in remnant pancreas after pancreatoduodenectomy and its clinical impact. METHODS: Periampullary carcinoma patients with minimum follow-up of 2 years and without recurrence were included (N = 102). Exocrine insufficiency includes clinical steatorrhea and fecal elastase-1 (FE-1) levels; endocrine insufficiency, glucose levels and glycated hemoglobin; and morphological changes, main pancreatic duct (MPD) diameter and thickness of remnant pancreas. RESULTS: The mean (standard deviation) follow-up period was 59 (26) months. Of the 102 patients, 81 (80%) had severely deficient FE-1 (0-100 µg/g). The preoperative MPD was significantly more and thickness of remnant pancreas was significantly less in patients with severely deficient FE-1. Overall, 15.6% (16/102) developed steatorrhea and improved on enzyme replacement therapy. The presence of MPD stricture (P = 0.008) and weight loss (P = 0.001) were significantly associated with steatorrhea. New-onset diabetes was seen in 17% (15/90) patients, of whom 3 of 5 developed it after 4 years (range, 4-7 years). The blood glucose was controlled on oral hypoglycemics in 2 (10/15) of 3 patients. CONCLUSIONS: The assessment by FE-1 indicates loss of exocrine function in more than 90%, whereas only 1 of 6 developed steatorrhea and new-onset diabetes. Morphological changes especially MPD stricture affect the functional status of remnant pancreas.

Correlations of portal pressure in post-cholecystectomy benign biliary stricture.

AIM: Presence of portal hypertension (PH) adversely affects perioperative and long-term outcome in patients with post-cholecystectomy benign biliary stricture (PCBBS). Identification of factors related to the development of PH will help to prevent this complication. METHODS: From September 2010 to December 2012, 30 patients with PCBBS were studied prospectively for correlation of portal pressure (PP) with injury repair interval (IRI), biliary pressure (BP), severity of hepatic fibrosis (FS), severity of hepatic inflammation (IS) and obstructive biliary pathology score (OBPS). Appropriate statistical methods employed and P ≤ 0.05 (two-sided) was considered statistically significant. RESULTS: Mean PP, mean BP and median IRI were 19.4 ± 4.74 mmHg, 20.1 ± 3.99 mmHg and 145 days, respectively. Spearman's rank correlation coefficients (P-value) of PP with IRI, FS, IS and OBPS were 0.564 (0.001), 0.502 (0.004), 0.752 (0.0001) and 0.242 (0.19), respectively. Pearson correlation of PP with BP was r = 0.383 (r(2) = 0.146, P = 0.03). Spearman's rank correlation coefficients (P-value) of FS with IS and OBPS were 0.561 (0.003) and 0.371 (0.04), respectively. Spearman's rank correlation coefficient of serum bilirubin with OBPS was 0.550 (P = 0.001). Incidence of PH was 33.3% and mean fall of PP following biliary repair was 6.2 ± 1.98 mmHg (P < 0.0001). CONCLUSION: PP in patients with PCBBS has a good correlation with IS, and a fair correlation with both FS and IRI whereas PP was not directly related to BP and OBPS; further prospective trials are mandatory to confirm this correlation, and to evaluate mechanism of fall in PP following biliary decompression.

Thoracic duct injury following esophagectomy in carcinoma of the esophagus: ligation by the abdominal approach.

BACKGROUND: Thoracic duct injury (TDI) is a potentially lethal complication of esophagectomy. There is no consensus regarding when and how to intervene in these injuries. Both thoracic and abdominal approaches have been used. METHODS: Esophagectomies performed for cancer of the esophagus (n = 104) from October 2003 to July 2011 were analyzed for TDI. Diagnosis, histological type, stage, and location of tumor, neoadjuvant therapy, trans-thoracic or trans-hiatal procedure performed, nature and amount of drain output, and levels of triglyceride in the effluent were analyzed. Management of these injuries and morbidity and mortality associated with the approach taken were reviewed. RESULTS: We observed chylothorax in 9 patients. All nine patients had undergone trans-hiatal esophagectomy. All patients eventually required surgical intervention. Mass ligation of the thoracic duct was performed via the thoracic route in three patients and via the trans-abdominal approach in six others. Thoracic duct ligation was successful in all patients. One patient required a second laparotomy and repeat ligation of the duct. There were two postoperative deaths; both these patients had ligation by the thoracic route. CONCLUSIONS: Trans-abdominal ligation of the thoracic duct in patients with chylothorax after esophagectomy is technically easy and safe. It may be preferred over the trans-thoracic approach, especially after an initial trans-hiatal esophagectomy.