Rescue from complications after pancreaticoduodenectomies at a low-volume Caribbean center: Value of tailored peri-pancreatectomy protocols.

BACKGROUND: Pancreaticoduodenectomy (PD) is a technically complex operation, with a relatively high risk for complications. The ability to rescue patients from post-PD complications is as a recognized quality measure. Tailored protocols were instituted at our low volume facility in the year 2013. AIM: To document the rate of rescue from post-PD complications with tailored protocols in place as a measure of quality. METHODS: A retrospective audit was performed to collect data from patients who experienced major post-PD complications at a low volume pancreatic surgery unit in Trinidad and Tobago between January 1, 2013 and June 30, 2023. Standardized definitions from the International Study Group of Pancreatic Surgery were used to define post-PD complications, and the modified Clavien-Dindo classification was used to classify post-PD complications. RESULTS: Over the study period, 113 patients at a mean age of 57.5 years (standard deviation [SD] ± 9.23; range: 30-90; median: 56) underwent PDs at this facility. Major complications were recorded in 33 (29.2%) patients at a mean age of 53.8 years (SD: ± 7.9). Twenty-nine (87.9%) patients who experienced major morbidity were salvaged after aggressive treatment of their complication. Four (3.5%) died from bleeding pseudoaneurysm (1), septic shock secondary to a bile leak (1), anastomotic leak (1), and myocardial infarction (1). There was a significantly greater salvage rate in patients with American Society of Anesthesiologists scores ≤ 2 (93.3% vs 25%; P = 0.0024). CONCLUSION: This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring PD. Despite low volumes at our facility, we demonstrated that 87.9% of patients were rescued from major complications. We attributed this to several factors including development of rescue protocols, the competence of the pancreatic surgery teams and continuous, and adaptive learning by the entire institution, culminating in the development of tailored peri-pancreatectomy protocols.

Luminal mapping reveals mesenteric predominance of colonic adenomas and adenocarcinomas.

BACKGROUND: Previous studies have examined the relationship between colorectal tumor distribution and metastasis, but the tumor luminal location and associative risk factors promoting tumor growth remain unknown. METHODS: In this study, we mapped the luminal distribution of human colonic adenomas/adenocarcinomas and their association with various physiologic parameters. RESULTS: We identified a mesenteric predominance for colonic adenomas and adenocarcinomas. CONCLUSION: The findings of this study raise the possibility of novel mechanistic pathways in the development of adenomas and subsequent transformation into adenocarcinomas.

A pilot randomized controlled trial comparing THUNDERBEAT to the Maryland LigaSure energy device in laparoscopic left colon surgery.

BACKGROUND: The THUNDERBEAT is a multi-functional energy device which delivers both ultrasonic and bipolar energy, but there are no randomized trials which can provide more rigorous evaluation of the clinical performance of THUNDERBEAT compared to other energy-based devices in colorectal surgery. The aim of this study was to compare the clinical performance of THUNDERBEAT energy device to Maryland LigaSure in patients undergoing left laparoscopic colectomy. METHODS: Prospective randomized trial with two groups: Group 1 THUNDERBEAT and Group 2 LigaSure in a single university hospital. 60 Subjects, male and female, of age 18 years and above undergoing left colectomy for cancer or diverticulitis were included. The primary outcome was dissection time to specimen removal (DTSR) measured in minutes from the start of colon mobilization to specimen removal from the abdominal cavity. Versatility (composite of five variables) was measured by a score system from 1 to 5 (1 being worst and 5 the best), and adjusted/weighted by coefficient of importance with distribution of the importance as follow: hemostasis 0.275, sealing 0.275, cutting 0.2, dissection 0.15, and tissue manipulation 0.1. Other variables were: dryness of surgical field, intraoperative and postoperative complications, and mortality. Follow-up time was 30 days. RESULTS: 60 Patients completed surgery, 31 in Group 1 and 29 in Group 2. There was no difference in the DTSR between the groups, 91 min vs. 77 min (p = 0.214). THUNDERBEAT showed significantly higher score in dissecting and tissue manipulation in segment 3 (omental dissection), and in overall versatility score (p = 0.007) as well as versatility score in Segment 2 (retroperitoneal dissection p = 0.040) and Segment 3 (p = 0.040). No other differences were noted between the groups. CONCLUSIONS: Both energy devices can be employed effectively and safely in dividing soft tissue and sealing mesenteric blood vessels during laparoscopic left colon surgery, with THUNDERBEAT demonstrating some advantages over LigaSure during omental dissection and tissue manipulation. CLINICALTRIAL: gov # NCT02628093.

Evidence Map of Pancreatic Surgery-A living systematic review with meta-analyses by the International Study Group of Pancreatic Surgery (ISGPS).

BACKGROUND: Pancreatic surgery is associated with considerable morbidity and, consequently, offers a large and complex field for research. To prioritize relevant future scientific projects, it is of utmost importance to identify existing evidence and uncover research gaps. Thus, the aim of this project was to create a systematic and living Evidence Map of Pancreatic Surgery. METHODS: PubMed, the Cochrane Central Register of Controlled Trials, and Web of Science were systematically searched for all randomized controlled trials and systematic reviews on pancreatic surgery. Outcomes from every existing randomized controlled trial were extracted, and trial quality was assessed. Systematic reviews were used to identify an absence of randomized controlled trials. Randomized controlled trials and systematic reviews on identical subjects were grouped according to research topics. A web-based evidence map modeled after a mind map was created to visualize existing evidence. Meta-analyses of specific outcomes of pancreatic surgery were performed for all research topics with more than 3 randomized controlled trials. For partial pancreatoduodenectomy and distal pancreatectomy, pooled benchmarks for outcomes were calculated with a 99% confidence interval. The evidence map undergoes regular updates. RESULTS: Out of 30,860 articles reviewed, 328 randomized controlled trials on 35,600 patients and 332 systematic reviews were included and grouped into 76 research topics. Most randomized controlled trials were from Europe (46%) and most systematic reviews were from Asia (51%). A living meta-analysis of 21 out of 76 research topics (28%) was performed and included in the web-based evidence map. Evidence gaps were identified in 11 out of 76 research topics (14%). The benchmark for mortality was 2% (99% confidence interval: 1%-2%) for partial pancreatoduodenectomy and <1% (99% confidence interval: 0%-1%) for distal pancreatectomy. The benchmark for overall complications was 53% (99%confidence interval: 46%-61%) for partial pancreatoduodenectomy and 59% (99% confidence interval: 44%-80%) for distal pancreatectomy. CONCLUSION: The International Study Group of Pancreatic Surgery Evidence Map of Pancreatic Surgery, which is freely accessible via www.evidencemap.surgery and as a mobile phone app, provides a regularly updated overview of the available literature displayed in an intuitive fashion. Clinical decision making and evidence-based patient information are supported by the primary data provided, as well as by living meta-analyses. Researchers can use the systematic literature search and processed data for their own projects, and funding bodies can base their research priorities on evidence gaps that the map uncovers.

Different types of pancreatico-enteric anastomosis.

The pancreatico-enteric anastomosis has widely been regarded as the 'Achilles heel' of the modern day, single-stage, pancreatoduodenectomy (PD). A review of the literature was carried out to address the evolution of the pancreatico-enteric anastomosis following PD, the spectrum of anastomoses performed around the world, and finally present the current evidence in support of each anastomosis. Pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) are the most common forms of pancreatico-enteric reconstruction following PD. There is no difference in postoperative pancreatic fistula (POPF) rates between PG and PJ, as well as individual variations, except in a high-risk anastomosis where performance of a PJ may be preferred. The routine use of glue, trans-anastomotic stents or omental wrapping is of no proven benefit. Externalised trans-anastomotic stents may have a role in mitigating the risk of a clinically relevant POPF in high-risk anastomoses. Pancreatico-enteric anastomosis is an important component of reconstruction following PD even though it is fraught with the risk of development of a POPF. Adherence to the tenets of anastomotic reconstruction and performance of a safe and reproducible anastomosis with a low clinically-relevant POPF rate remain the mainstay of achieving the best outcomes. Appropriate selection and opportune use of fistula mitigation strategies may help provide optimal outcomes when faced with the need to perform a high-risk pancreatico-enteric anastomosis.

Systematic Video Documentation in Laparoscopic Colon Surgery Using a Checklist: A Feasibility and Compliance Pilot Study.

BACKGROUND: High-quality images can be readily captured during laparoscopic colon surgery, but there are no guidelines for documentation of these video data or how to best measure surgical quality from an operative video. This study evaluates the feasibility and compliance in documenting key steps during laparoscopic right hemicolectomy and sigmoid colectomy. MATERIALS AND METHODS: A retrospective review of previously recorded videos of patients undergoing laparoscopic right hemicolectomy or sigmoid colectomy from September to December 2011 in a single institution was performed. Patients' demographics, intraoperative features, postoperative complications, and variables for video recording and editing were collected. Compliance of key surgical steps was assessed using a checklist by two independent surgeons. RESULTS: Sixteen laparoscopic operations (seven right hemicolectomies and nine sigmoid colectomies) were recorded. Twelve (75%) were laparoscopic-assisted, and four (25%) were hand-assisted laparoscopic operations. Compliance with key surgical steps in laparoscopic right hemicolectomy and sigmoid colectomy was demonstrated in the majority of patients, with steps ranging in compliance from 42.9% to 100% and from 77.8% to 100%, respectively. The edited video had a median duration of 3 minutes 47 seconds (range, 1 minute 44 seconds-5 minutes 38 seconds) with a production time of nearly 1 hour and a resolution of 1440 × 1080 pixels. CONCLUSIONS: Key surgical steps during laparoscopic right hemicolectomy and sigmoid colectomy can be documented and edited into a short representative video. Standardization of this process should allow video documentation to improve quality in laparoscopic colon surgery.

Laparoscopic resection of t4 colon cancers: is it feasible?

BACKGROUND: Laparoscopic surgical treatment of T4 cancers remains a concern that is mostly associated with technical feasibility, high conversion rate, inadequate oncologic clearance, and surgical outcome. OBJECTIVE: The purpose of this work was to evaluate the short- and long-term clinical and oncologic outcomes after laparoscopic and open surgeries for T4 colon cancers. DESIGN: This was a retrospective study of patients with T4 colon cancer without metastasis (M0) who had laparoscopic or open surgery from 2003 to 2011. SETTING: The study was conducted at a single institution. PATIENTS: A total of 83 patients with pT4 colon cancer were included. MAIN OUTCOME MEASURES: R0 resection rate, morbidity and mortality within 30 postoperative days, overall survival, and disease-free survival were measured. RESULTS: Laparoscopic surgery was performed on 61 and open surgery on 22 patients. The groups were similar in overall staging (p = 0.461), with 35 (42%) of the patients at stage 2 and 48 (58%) at stage 3. A complete R0 resection was achieved in 61 (100%) of the patients who underwent laparoscopic surgery and in 21 (96%) of the patients who underwent open surgery (p = 0.265). The average number of lymph nodes harvested was 21 in the laparoscopic group and 24 in the open group (p = 0.202). Thirty-day morbidity rate was similar between the groups (p = 0.467), and the mortality rate was 0. The length of hospital and postsurgical stay was significantly shorter in the laparoscopic group (p = 0.002 and p = 0.008). The 3-year overall survival rates between the groups were 82% (range, 71%-93%) for patients who underwent laparoscopic surgery and 81% (range, 61%-100%) for those who underwent open surgery (p = 0.525), and disease-free survival was 67% (range, 54%-79%) for laparoscopic surgery and 64% (range, 43%-86%) for open surgery (p = 0.848). The follow-up time was 40 ± 25 in months in the laparoscopic group and 34 ± 26 months in the open surgery group (p = 0.325). LIMITATIONS: This was a retrospective study at a single institution. CONCLUSIONS: The study shows that laparoscopic surgery is feasible in T4 colon cancers. With comparable clinical and oncologic outcomes, this study suggests that laparoscopy may be considered as an alternative approach for T4 colon cancers with the advantage of faster recovery (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A156).

Feasibility and Safety of Laparoscopic Colon Surgery Performed Under Intravenous Sedation and Local Anesthesia Using Microinvasive (<3 mm) Instruments: An Acute and Survival Study on Porcine Model.

PURPOSE: The purpose of the study was to evaluate the feasibility and safety of performing laparoscopic intestinal surgery using local anesthesia and intravenous sedation with instruments <3 mm in diameter. METHODS: Porcine model with acute (n = 2) and the survival studies (n = 8): all female pigs, weight (median 36.4 kg, range 33.2-38.4 kg). Surgeries were performed using only intravenous sedation with ketamine-midazolam and local anesthetic infiltration at the sites of trocar insertion, with airway protection. CO2 pneumoperitoneum was maintained using pressure of 3 to 5 mm Hg. Commercially available instruments, sizes <3 mm in diameter were used. Surgical steps were as follows: (a) exploration of all quadrants of the abdomen and pelvis, (b) "running" the entire length of small bowel, (c) dissection of bowel attachments to the peritoneal sidewall, and (d) creating a 2.5 cm enterotomy in the colon and suture repair of this defect. RESULTS: All 10 surgeries were completed successfully. Animals tolerated the procedure well, with no requirement of intubation. There were no decrements in vital signs during pneumoperitoneum or surgery. Despite spontaneous respiration movements, all planned surgical maneuvers were feasible. The median length of operations was 74 minutes (range 56-165 minutes). All survival animals had an uneventful recovery; there were no infectious complications, oral intake and bowel function returned within 24 hours. CONCLUSIONS: It appears feasible and safe to perform simple laparoscopic intestinal procedures using instruments <3 mm in diameter and low CO2 insufflation pressure under local anesthesia and intravenous sedation. This methodology holds promise in the development of new approaches to intestinal surgery and disease diagnosis.

The influence of obesity on short- and long-term outcomes after laparoscopic surgery for colon cancer: a case-matched study of 152 patients.

BACKGROUND: Despite the increasing prevalence of obesity and colonic diseases, the impact of obesity on short-term and oncologic outcomes of laparoscopic colorectal surgery still remains unclear. STUDY DESIGN: Seventy-six consecutive obese patients with body mass index (BMI) ≥30 kg/m(2) who underwent laparoscopic colectomy were matched with 76 nonobese patients with BMI <30 kg/m(2). Perioperative parameters and oncologic outcomes were analyzed in the two groups. RESULTS: Obesity was associated with greater operative time (obese vs nonobese, 182 ± 59 vs 157 ± 55 min, P = .0084) and multivariate analysis identified BMI (hazard ratio 2.11, 95% confidence interval 0.64-3.56, P = .0049) as an independent predicting factor for operative time together with cancer location (hazard ratio 28.6, 95% confidence interval 14.62-42.51, P < .0001). Obesity had no adverse influence on overall morbidity (25 vs 21%, P = .563), however, or postoperative duration of stay (median 6.0 vs 5.5 days, P = .22). Furthermore, the rate of conversion to open procedure was similar between the two groups (9 vs 9%, P > .99). Regarding oncologic outcomes, there was no statistical difference in overall and disease-free survival between the two groups (5-year overall survival rate 86 vs 89%, P = .72, 5-year disease survival rate 70 vs 77%, P = .70). CONCLUSION: Laparoscopic colonic resection, when performed for selected patients, appears to be a safe and reasonable option in obese patients with colon cancer resulting in similar short-term and oncologic outcomes as nonobese patients.

Evolution of pancreatoduodenectomy in a tertiary cancer center in India: improved results from service reconfiguration.

BACKGROUND: Pancreatic cancer incidence in India is low. Over the years, refinements in technique of pancreatoduodenectomy (PD) may have improved outcomes. No data is available from India, South-Central, or South West Asia to assess the impact of these refinements. PURPOSE: To assess the impact of service reconfiguration and standardized protocols on outcomes of PD in a tertiary cancer center in India. METHODS: Three specific time periods marking major shifts in practice and performance of PD were identified, viz. periods A (1992-2001; pancreaticogastrostomy predominantly performed), B (2003-July 2009; standardization of pancreaticojejunal anastomosis), and C (August 2009-December 2011; introduction of neoadjuvant chemo-radiotherapy and increased surgical volume). RESULTS: 500 PDs were performed with a morbidity and mortality rate of 33% and 5.4%, respectively. Over the three periods, volume of cases/year significantly increased from 16 to 60 (p < 0.0001). Overall incidence of post-operative pancreatic anastomotic leak/fistula (POPF), hemorrhage, delayed gastric emptying (DGE), and bile leak was 11%, 6%, 3.4%, and 3.2%, respectively. The overall morbidity rates, as well as, the above individual complications significantly reduced from period A to B (p < 0.01) with no statistical difference between periods B and C. CONCLUSION: Evolution of practice and perioperative management of PD for pancreatic cancer at our center improved perioperative outcomes and helped sustain the improvements despite increasing surgical volume. By adopting standardized practices and gradually improving experience, countries with low incidence of pancreatic cancer and resource constraints can achieve outcomes comparable to high-incidence, developed nations. SYNOPSIS: The manuscript represents the largest series on perioperative outcomes for pancreatoduodenectomy from South West and South-Central Asia - a region with a low incidence of pancreatic cancer and a disproportionate distribution of resources highlighting the impact of high volumes, standardization and service reconfiguration.

Perioperative outcomes after ultra low anterior resection in the era of neoadjuvant chemoradiotherapy.

PURPOSE: Data on perioperative outcomes of sphincter preserving ultra low anterior resections (ULAR) following neoadjuvant chemoradiotherapy (NA-CTRT) is sparsely reported in literature. METHODS: Prospective data of 68 patients was reviewed retrospectively. Patients who received preoperative chemoradiotherapy (CTRT, Group A, n = 45) were compared with those who were operated upfront (Group B, n = 23). RESULTS: Overall, mean distance of the tumor from anal verge was 5.1 cm (range 3-8). In Groups A and B, it was 5.2 and 5.1 cm, respectively. In Group A, 3 patients had complete response, 40 had partial response and 2 had progressive disease. Overall, the mean distance of the anastomosis performed from the anal verge was 2.8 cm (range 1-4). In Groups A and B, it was 2.7 and 2.9 cm, respectively (NS). Mean blood loss in Groups A and B was 510.5 (range 200-2,200) and 345 mL (range 50-800), respectively (p = 0.037). Two patients in Group A required blood transfusion (range 1-2) compared to none in Group B. The overall complication rate was 26.5 % (18/68); in Groups A and B, it was 22.2 % and 34.8 %, respectively. There was no postoperative mortality. Postoperative stay for Groups A and B was 8 and 9.5 days (p = 0.009), respectively. In Group A, 23/45 patients, earlier planned for abdominoperineal resection, ultimately received sphincter-preserving ULAR. CONCLUSION: ULAR can be performed safely without added morbidity or mortality after neoadjuvant chemoradiation. In some cases, earlier deemed to be suitable for APR, the neoadjuvant approach improved chances of sphincter conservation.

Identifying specific surgical tools and methods for laparoscopic colorectal operations in obese patients.

OBJECTIVE: Laparoscopic operations for obese patients remain challenging due to technical difficulties at operation as well as higher comorbidities and high risk of postoperative complications. The aim of this study is to identify specific surgical tools and methods for laparoscopic colorectal operations for obese patients, applying knowledge of previous literature as well as our expertise in both laparoscopic and bariatric operations. CONCLUSIONS: Current knowledge of bariatric surgery is invaluable in establishing a "customized" approach for laparoscopic colorectal operations in obese patients. The instruments routinely used during surgery on patients with normal body mass index (BMI) should often be modified and substituted according to the patient's BMI. We believe such an approach will prove beneficial to surgeons performing laparoscopic operations on obese patients.

Gastrointestinal stromal tumors: case series of 29 patients defining the role of imatinib prior to surgery.

BACKGROUND: The aim of this study was to assess the role of neoadjuvant imatinib in redefining treatment for gastrointestinal stromal tumors (GISTs). METHODS: A total of 76 patients were reviewed. Among them, 29 patients who were administered neoadjuvant imatinib for borderline resectable and locally advanced GISTs followed by surgery were analyzed. Adjuvant imatinib was administered based on risk stratification. RESULTS: The median age of the neoadjuvant imatinib group was 51 years. The median duration of neoadjuvant imatinib administration was 8.5 months. The response rate with neoadjuvant imatinib was 79.3%. Five patients, initially considered to have locally unresectable lesions, ultimately underwent resection (three R0, two R2). Another three patients, who had M1 disease, underwent R2 resection (due to the presence of metastasis) with complete resection of the primary lesion. In 19 patients, who would have originally required extensive surgery, underwent conservative surgery (R0). In two patients, neoadjuvant imatinib did not influence the final procedure. The postoperative complication rate was 13.8%, and there were no postoperative deaths. There was one locoregional recurrence and two cases of distant metastasis. The 1-, 2-, and 3-year overall survivals were each 100%. CONCLUSIONS: Neoadjuvant imatinib for locally advanced GISTs is a safe concept for downsizing, improving resectability, and aiding organ-preserving surgery. It also improves the chance of long-term survival. Surgery, however, remains the cornerstone of curative treatment of GISTs even after neoadjuvant imatinib.

Complications as indicators of quality assurance after 401 consecutive colorectal cancer resections: the importance of surgeon volume in developing colorectal cancer units in India.

BACKGROUND: The low incidence of colorectal cancer in India, coupled with absence of specialized units, contribute to lack of relevant data arising from the subcontinent. We evaluated the data of the senior author to better define the requirements that would enable development of specialized units in a country where colorectal cancer burden is increasing. METHODS: We retrospectively analyzed data of 401 consecutive colorectal resections from a prospective database of the senior author. In addition to patient demographics and types of resections, perioperative data like intraoperative blood loss, duration of surgery, complications, re-operation rates and hospital stay were recorded and analyzed. RESULTS: The median age was 52 years (10-86 years). 279 were males and 122 were females. The average duration of surgery was 220.32 minutes (range 50-480 min). The overall complication rate was 12.2% (49/401) with a 1.2% (5/401) mortality rate. The patients having complications had an increase in their median hospital stay (from 10.5 days to 23.4 days) and the re-operation rate in them was 51%. The major complications were anastomotic leaks (2.5%) and stoma related complications (2.7%). CONCLUSIONS: This largest ever series from India compares favorably with global standards. In a nation where colorectal cancer is on the rise, it is imperative that high volume centers develop specialized units to train future specialist colorectal surgeons. This would ensure improved quality assurance and delivery of health care even to outreach, low volume centers.

The impact of obesity on perioperative outcomes after laparoscopic colorectal resection.

OBJECTIVE: It is commonly perceived that surgery in obese patients is associated with worse outcomes than in nonobese patients. Because of the increasing prevalence of obesity and colonic diseases in the world population, the impact of obesity on outcomes of laparoscopic colectomy remains an important subject. The aim of this review was to evaluate the feasibility and safety of laparoscopic colectomy for colorectal diseases in obese patients compared with nonobese patients. METHODS: We conducted a comprehensive review for the years 1983-2010 to retrieve all relevant articles. RESULTS: A total of 33 studies were found to be eligible and included 3 matched case control studies and 1 review article. Obesity, often accompanied by preexisting comorbidities, was associated with longer operative times and higher rates of conversion to open procedures mainly because of the problem of exposure and difficulties in dissection. Although some studies showed obesity was associated with increased postoperative morbidity including cardiopulmonary and systemic complications, or ileus leading to longer hospital stay, there was no evidence about the negative impact of obesity on intraoperative blood loss, perioperative mortality, and reoperation rate. Whether obesity is a risk factor for wound infection after laparoscopic colectomy remains unclear. Though sometimes in obese patients, additional number of ports were necessary to successfully complete the procedure laparoscopically, obesity did not influence the number of dissected lymph nodes in cancer surgery. Lastly, the postoperative recovery of gastrointestinal function was similar between obese and nonobese patients. CONCLUSIONS: Laparoscopic colorectal surgery appears to be a safe and reasonable option in obese patients offering the benefits of a minimally invasive approach, with no evidence for compromise in treatment of disease.

Managing leaks following anterior resections: a new classification system.

BACKGROUND/AIMS: Anastomotic leak rates following rectal resections and anastomosis stand at 2.9-15.3%, with an attendant mortality rate of 6- 39.3%. The aim of our study was to identify those patients who had developed an anastomotic leak, and evaluate the indications for re-exploration as well as study the impact of covering colostomies on the subsequent outcome. METHODOLOGY: We analyzed 266 consecutive anterior resections for rectal cancer performed at a single institution between 1st September 2002 and 31st December 2006. RESULTS: Twenty-one anastomotic leaks were encountered in 266 resections. Covering colostomies were performed in 56% (151/266) of the patients. Out of the 21 patients who developed a leak, 9 had a covering colostomy (42.8%). In this group, 3 of patients (33%) could be managed without surgical re-exploration, while all the 12 patients without a covering colostomy had to undergo a reexploration. With our new classification system for anastomotic dehiscence, the clinical decisions appear to follow a predictable pattern. There were 4 deaths (1.5%). However, the mortality rate in the patients undergoing surgical re-exploration for complications was 16.6% (3/18). CONCLUSIONS: This large study provides an insight into the potential advantages of covering colostomies wherever indicated following anterior resections. With our new and effective classification system for clinical leaks, the management road map can be simplified and standardized.

The evolution of pancreatoduodenectomy.

Till this day, surgery remains the only chance Pancreas of improving long-term survival in patients with periampullary and pancreatic head cancer. The procedure of choice in these cancers is pancreatoduodenectomy (PD). Associated with high morbidity, PD continues to pose a formidable challenge to pancreatic surgeons around the world. The falling mortality seen following the procedure has often been attributed to improvements in perioperative care - critical care, interventional radiology, and higher generation antibiotics. However, it would not be correct to totally ascribe these improvements only to the advancements in medical management. Developments in the understanding of the anatomical and pathophysiological factors that play a role in surgery around the pancreatoduodenal region have led to progressive modifications in the technique of pancreatoduodenectomy since it was first described in 1898. This review aims at highlighting the important milestones in the history of pancreatoduodenectomy leading to its progressive development, whilst providing a scientific basis.