Impact of Helicobacter pylori Status on Postoperative Morbidities After Laparoscopic Sleeve Gastrectomy in an Endemic Region (a Retrospective Multicentric Study).

PURPOSE: Studies are still ongoing to determine whether Helicobacter pylori (HP) may affect the results of laparoscopic sleeve gastrectomy (LSG). The main research objectives were HP prevalence in patients with severe obesity and the effects of HP status on outcomes. PATIENTS AND METHODS: This multicenter retrospective study included patients with severe obesity who had LSG. The patients were grouped into three groups based on the HP status of preoperative endoscopic biopsies and postoperative specimen results: group I (negative HP), group II (eradicated HP), and group III (positive HP). The primary outcome was the overall postoperative morbidities. RESULTS: One thousand six hundred fifteen patients who underwent LSG for severe obesity were included in this study. Seven hundred fifty (46.4%) patients had negative HP, and 637 (39.4%) patients had eradicated HP, whereas 228 (14.1%) patients had positive HP. The antral and gastric body wall thickness was significantly noticed with positive HP. The groups had no significant differences regarding postoperative complication frequency, severity, and hospital mortality. The rates of gastric leakage in the three groups do not differ significantly. BMI > 50, gastropexy, gastric thickness, and antral resection were found to be independent risk factors for the occurrence of postoperative complications after LSG. There was no statistical significance as regards postoperative %TWL and %EWL among the three groups. CONCLUSION: The early results of LSG do not appear to be impacted by HP's status. The early postoperative course is unaffected by HP eradication anymore. Therefore, routine preoperative HP testing may not be as necessary, and management can be finished after LSG.

Prevalence, Predictors, and Management of Gastroesophageal Reflux Disease After Laparoscopic Sleeve Gastrectomy: a Multicenter Cohort Study.

BACKGROUND: One of the most popular bariatric procedures is laparoscopic sleeve gastrectomy (LSG), which can either cause or worsen gastroesophageal reflux disease (GERD). Therefore, the goal of this study was to examine the prevalence, predictors, and management of GERD symptoms after LSG. MATERIALS AND METHODS: From January 2017 to January 2022, we looked at patients who had a primary LSG and developed GERD. Before LSG, all patients underwent a barium meal and upper endoscopy. After LSG, barium meal, endoscopy, esophageal manometry, and 24-h pH measurements were performed for selected patients. The diagnosis of GERD is based on the GERD-HRQL questionnaire and upper endoscopy. RESULTS: The study included 1537 patients (62.5% women and 37.5% men) with a mean age of 34.4 years. The mean % TWL was 40.7% during a mean follow-up period of 15.9 months. A total of 379 patients (24.7%) experienced postoperative GERD, of whom 328 (21.3%) had postoperative de novo GERD symptoms, 25 (1.6%) had worsened preoperative GERD, and 26 (1.7%) had the same preoperative GERD symptoms. Antral preservation and gastropexy were protective factors against the development of GERD after LSG. LSG was converted to LRYGB in 15.8% of the patients with GERD. The response to medical treatment was observed in 300 (79.2%) patients with GERD. CONCLUSION: Post-LSG GERD presented in 379 patients (24.7%). Antral preservation and gastropexy were protective factors for the development of postoperative GERD after LSG. Medical treatment was the main line of treatment for GERD. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT05416645.

Development and Validation of an Artificial Intelligence-Based Model to Predict Gastroesophageal Reflux Disease After Sleeve Gastrectomy.

PURPOSE: Prediction of the onset of de novo gastroesophageal reflux disease (GERD) after sleeve gastrectomy (SG) would be helpful in decision-making and selection of the optimal bariatric procedure for every patient. The present study aimed to develop an artificial intelligence (AI)-based model to predict the onset of GERD after SG to help clinicians and surgeons in decision-making. MATERIALS AND METHODS: A prospectively maintained database of patients with severe obesity who underwent SG was used for the development of the AI model using all the available data points. The dataset was arbitrarily split into two parts: 70% for training and 30% for testing. Then ranking of the variables was performed in two steps. Different learning algorithms were used, and the best model that showed maximum performance was selected for the further steps of machine learning. A multitask AI platform was used to determine the cutoff points for the top numerical predictors of GERD. RESULTS: In total, 441 patients (76.2% female) of a mean age of 43.7 ± 10 years were included. The ensemble model outperformed the other models. The model achieved an AUC of 0.93 (95%CI 0.88-0.99), sensitivity of 79.2% (95% CI 57.9-92.9%), and specificity of 86.1% (95%CI 70.5-95.3%). The top five ranked predictors were age, weight, preoperative GERD, size of orogastric tube, and distance of first stapler firing from the pylorus. CONCLUSION: An AI-based model for the prediction of GERD after SG was developed. The model had excellent accuracy, yet a moderate sensitivity and specificity. Further prospective multicenter trials are needed to externally validate the model developed.

Effect of Altitude Level on Surgical Outcomes of Laparoscopic Sleeve Gastrectomy for Patients With Morbid Obesity: A Multicentre Prospective Study.

BACKGROUND: This study aimed to evaluate the impact of altitude level on surgical outcomes of laparoscopic sleeve gastrectomy (LSG) for patients with morbid obesity. METHODS: At the normal altitude level, 808 patients underwent LSG, and 467 patients underwent LSG in high-altitude regions. The primary outcome was evaluated based on the postoperative morbidity rate. Secondary outcomes were evaluated based on operating time, mortality, hospital stay, percentage of total weight loss (TWL), and comorbidities improvement. RESULTS: No significant differences were noted in-hospital stay, time to start oral intake, gastric leakage, overall complications, and hospital mortality between the 2 groups. Deep vein thrombosis, pulmonary embolism, and mesenteric vascular occlusion were significantly higher in high altitude [11 (1.3%) vs. 14 (3%), P=0.04; 8 (0.7%) vs. 11 (2.4%), P=0.01; 4 (0.5%) vs. 8 (1.7%), P=0.03, respectively]. Patients with normal altitude recorded a better %TWL than those at high altitude after 12 months (41±9 vs. 39±9.6, P=0.002) and after 24 months (41±8 vs. 40±9, P=0.009). In both groups, a significant improvement was noted in comorbidity after LSG. CONCLUSION: The %TWL significantly achieved with LSG in normal and high altitudes. After 12 and 24 months, the %TWL is significantly higher with LSG at normal altitudes. High altitude is associated with a high incidence of deep vein thrombosis, pulmonary embolism, and superior mesenteric vascular occlusion with LSG.

The effect of stoma size on the mid-term weight loss outcome of one anastomosis gastric bypass (OAGB): a single-blinded prospective randomized trial.

BACKGROUND: One anastomosis gastric bypass (OAGB) is gaining wide spread acceptance among bariatric surgeons all over the world because of its technical simplicity and documented efficacy. However, the relation between stoma size in OAGB and magnitude of weight loss has not been addressed. OBJECTIVES: To evaluate the effect of stoma size on the mid-term weight loss outcome for patients with obesity after OAGB. SETTING: University Hospital. MATERIALS AND METHODS: This is a single-blinded prospectively randomized trial. From March 2014 to September 2016, 83 patients, eligible for bariatric surgery, were included in the study. OAGB was carried out with the same technical steps, except for the size of the gastrojejunostomy (GJ). Patients were randomly allocated into two equal groups; narrow GJ group (30 mm) and wide GJ group (45 mm). The percentage of total weight loss (%TWL) and the percentage of excess weight loss (%EWL) were recorded at 6, 12 and 24 months after procedure. RESULTS: At 6 months follow-up, patients with 30 mm GJ had better %EWL (53.3) and %TWL (23.4) than other patients with 45 mm GJ (42.6 and 18.2 respectively). However, at 12 and 24 months the %TWL and %EWL difference between the two groups have disappeared. CONCLUSION: Patients with narrower stoma size (30 mm) of OAGB tend initially to lose more weight than patients with wider stoma (45 mm). However, this difference disappears at mid-term follow-up after 2 years.

Gastric Stenosis After Sleeve Gastrectomy: an Algorithm for Management.

BACKGROUND: Gastric stenosis (GS) is a well-recognized complication after sleeve gastrectomy (SG) with a negative impact on patients' nutritional status and quality of life. There is no consensus on a validated, comprehensive management algorithm for GS. This study evaluates treatment modalities and proposes a management algorithm for obstructive gastric symptoms (OGSs) after SG. METHODS: This is a retrospective cohort study of patients with GS after SG between January 2013 and January 2019. Patients with concomitant GS and staple-line leak were excluded. The primary outcome was the clinical response to treatment. RESULTS: Forty-nine patients presented with OGSs. One patient underwent urgent surgical treatment for acute migration of cardia. Of 42 patients who had evident GS, pneumatic balloon dilatation (PBD) achieved clinical success in 28 (66.7%) patients. Six patients were diagnosed with indolent GS, and four of them improved after empirical PBD. The mean interval from index surgery to PBD was 5.3 (± 4.2) months. Longer duration of PBD session was associated with better clinical outcomes (5.8 ± 3.7 vs. 3.2 ± 1.7 min) (P = 0.017). After failed PBD, endoscopic stenting (n = 2) and revisional surgery (n = 7) were performed with clinical success in all patients. CONCLUSION: PBD using achalasia balloon is the mainstay of treatment with good clinical outcomes. The utility of endoscopic stenting for GS should be different from its use for leakage in aspects of dwelling time and required endoscopic expertise. RYGB is the gold standard revisional procedure due to the high success rate and technical familiarity. Controversial aspects of management require future prospective comparative studies.

Laparoscopic Pancreaticodudenectomy for Periampullary Tumor: Should it be a Routine? A Propensity Score-matched Study.

INTRODUCTION: Laparoscopic pancreaticoduodenectomy (LPD) is a complex and challenging procedure even with experienced surgeons. The aim of this study is to evaluate the feasibility and surgical and oncological outcomes of LPD compared with open pancreaticoduodenectomy (OPD). PATIENTS AND METHOD: This is a propensity score-matched analysis for patients with periampullary tumors who underwent PD. Patients underwent LPD and matched group underwent OPD included in the study. The primary outcome measure was the rate of total postoperative morbidities. Secondary outcomes included operative times, hospital stay, wound length and cosmosis, oncological outcomes, recurrence rate, and survival rate. RESULTS: A total of 111 patients were included in the study (37 LPD and 74 OPD). The conversion rate from LPD to OPD was 4 cases (10.8%). LPD provides significantly shorter hospital stay (7 vs. 10 d; P=0.004), less blood loss (250 vs. 450 mL, P=0.001), less postoperative pain, early oral intake, and better cosmosis. The length of the wound is significantly shorter in LPD. The operative time needed for dissection and reconstruction was significantly longer in LPD group (420 vs. 300 min; P=0.0001). Both groups were comparable as regards lymph node retrieved (15 vs. 14; P=0.21) and R0 rate (86.5% vs. 83.8%; P=0.6). No significant difference was seen as regards postoperative morbidities, re-exploration, readmission, recurrence, and survival rate. CONCLUSIONS: LPD is a feasible procedure; it provided a shorter hospital stay, less blood loss, earlier oral intake, and better cosmosis than OPD. It had the same postoperative complications and oncological outcomes as OPD.

Impact of the Myotomy Extent on Gastric Side on Surgical Outcome After Heller's Cardiomotomy for Achalasia.

BACKGROUND: Laparoscopic Heller cardiomyotomy (LHM) with Dor fundoplication represents the most commonly accepted surgical management for achalasia. The ideal extent of myotomy on the gastric side remains a matter of continuous debate. The aim of this study was to compare the impact of the extent of myotomy on the gastric side on the outcome of LHM. PATIENTS AND METHODS: Patients with achalasia who underwent LHM included in the study. The patients were classified according to the length of the gastric myotomy into 3 groups (group I: <1.5 cm, group II: 1.5 to 2.5 cm, and group III: >2.5 cm). RESULTS: In total, 212 patients (94 males and 118 females) with achalasia treated by LHM and Dor fundoplication included in the study. No statistically significant differences were found among the 3 groups as regards preoperative data, intraoperative mucosal perforation, operative time, blood loss, and hospital stay. The incidence of persistent dysphagia was significantly higher in the group I. Postoperative GERD symptoms were significantly higher in group III (23.3%, P<0.0001). Recurrent achalasia was significantly higher in group I with 11 patients (15.9%), 8 patients in group II (7.1%), and nil in group III (P<0.02). CONCLUSIONS: Longer myotomy on the gastric side (>2.5 cm) ensures complete division of the LES with better outcomes in term of resolution of dysphagia but may be associated with higher postoperative GERD. Therefore, a myotomy length of 1.5 to 2.5 cm on the gastric side provides a balance between relieve of dysphagia and development of postoperative GERD.

Biliary leakage following pancreaticoduodenectomy: Prevalence, risk factors and management.

BACKGROUND: Few studies investigated biliary leakage after pancreaticoduodenectomy (PD) especially when compared to postoperative pancreatic fistula (POPF). This study was to determine the incidence of biliary leakage after PD, predisposing factors of biliary leakage, and its management. METHODS: We retrospectively studied all patients who underwent PD from January 2008 to December 2017 at Gastrointestinal Surgery Center, Mansoura University, Egypt. According to occurrence of postoperative biliary leakage, patients were divided into two groups. Group (1) included patients who developed biliary leakage and group (2) included patients without identified biliary leakage. The preoperative data, operative details, and postoperative morbidity and mortality were analyzed. RESULTS: The study included 555 patients. Forty-four patients (7.9%) developed biliary leakage. Ten patients (1.8%) had concomitant POPF. Multivariate analysis identified obesity and time needed for hepaticojejunostomy reconstruction as independent risk factors of biliary leakage, and no history of preoperative endoscopic retrograde cholangiopancreatiography (ERCP) as protective factor. Biliary leakage from hepaticojejunostomy after PD leads to a significant increase in development of delayed gastric emptying, and wound infection. The median hospital stay and time to resume oral intake were significantly greater in the biliary leakage group. Non-surgical management was needed in 40 patients (90.9%). Only 4 patients (9.1%) required re-exploration due to biliary peritonitis and associated POPF. The mortality rate in the biliary leakage group was significantly higher than that of the non-biliary leakage group (6.8% vs 3.9%, P = 0.05). CONCLUSIONS: Obesity and time needed for hepaticojejunostomy reconstruction are independent risk factors of biliary leakage, and no history of preoperative ERCP is protective factor. Biliary leakage increases the risk of morbidity and mortality especially if concomitant with POPF. However, biliary leakage can be conservatively managed in majority of cases.

Predictors of long-term survival after pancreaticoduodenectomy for peri-ampullary adenocarcinoma: A retrospective study of 5-year survivors.

BACKGROUND: Pancreaticoduodenectomy (PD) is the standard curative treatment for periampullary tumors. The aim of this study is to report the incidence and predictors of long-term survival (≥ 5 years) after PD. METHODS: This study included patients who underwent PD for pathologically proven periampullary adenocarcinomas. Patients were divided into 2 groups: group (I) patients who survived less than 5 years and group (II) patients who survived ≥ 5 years. RESULTS: There were 47 (20.6%) long-term survivors (≥ 5 years) among 228 patients underwent PD for periampullary adenocarcinoma. Patients with ampullary adenocarcinoma represented 31 (66.0%) of the long-term survivors. Primary analysis showed that favourable factors for long-term survival include age < 60 years old, serum CEA < 5 ng/mL, serum CA 19-9 < 37 U/mL, non-cirrhotic liver, tumor size < 2 cm, site of primary tumor, postoperative pancreatic fistula, R0 resection, postoperative chemotherapy, and no recurrence. Multivariate analysis demonstrated that CA 19-9 < 37 U/mL [OR (95% CI) = 1.712 (1.248-2.348), P = 0.001], smaller tumor size [OR (95% CI )= 1.335 (1.032-1.726), P = 0.028] and Ro resection [OR (95% CI) = 3.098 (2.095-4.582), P < 0.001] were independent factors for survival ≥ 5 years. The prognosis was best for ampullary adenocarcinoma, for which the median survival was 54 months and 5-year survival rate was 39.0%, and the poorest was pancreatic head adenocarcinoma, for which the median survival was 27 months and 5-year survival rate was 7%. CONCLUSIONS: The majority of long-term survivors after PD for periampullary adenocarcinoma are patients with ampullary tumor. CA 19-9 < 37 U/mL, smaller tumor size, and R0 resection were found to be independent factors for long-term survival ≥ 5 years.

Open Cholecystectomy Has a Place in the Laparoscopic Era: a Retrospective Cohort Study.

Laparoscopic cholecystectomy (LC) is considered the gold standard for treatment of symptomatic gallbladder stones and has replaced the traditional open cholecystectomy (OC). The aim of this study is to evaluate the proper indications of the primary OC and conversion from LC and their predictive factors. This study includes all patients who underwent cholecystectomy between January 2011 and June 2016, whether open from the start (group A), conversion from laparoscopic approach (group B), or laparoscopic cholecystectomy (group C). There were 3269 patients underwent cholecystectomy. LC was completed in 3117 (95.4%) patients. The overall conversion rate was 83 (2.5%). The main two causes of conversion were adhesion in 35 (42.2%) patients and unclear anatomy in 29 (34.9%) patients. Primary OC was indicated in 69 (2.1%) patients due to previous history of upper abdominal operations in 16 (23.2%) patients and anesthetic problem in 21 (30.4%) patients. Age >60 years, male sex, diabetic patients, history of endoscopic retrograde cholangiopancreatography, dilated common bile duct, gallbladder status, adhesion, and previous upper abdominal operation were demonstrated to be independent risk factors for OC. Open cholecystectomy still has a place in the era of laparoscopy. Conversion should not be a complication, but it represents a valuable choice to avoid an additional risk. Safe OC required training because of the causes of conversion, usually unsafe anatomy, occurrence of complications, or anesthetic problems, in order to prevent disastrous complications.

Surgical outcomes of pancreaticoduodenectomy in young patients: A case series.

BACKGROUND: Pancreaticoduodenectomy (PD) is a complex procedure for management periampullary neoplasms The aim of our work is to report the surgical outcomes after PD in young adult (YA) (<35 years) and to compare it to a adult patients who underwent PD. METHODS: We retrospectively analyzed the data of all patients who underwent PD in the period from January 1993 to December 2016. The primary outcome was the rate of total postoperative complications. Secondary outcomes included postoperative pathology, exocrine and endocrine function and survival rate. RESULTS: 58/975 patients (5.9%) were YA and the majority of them were females. The incidence of post-operative complications in the YA was comparable to that in the adult group. Delayed gastric emptying developed significantly in adult group than YA group (0.008). The overall survival was significantly higher in the YA (P = 0.0001). The most common pathology in the YA was adenocarcinoma (41.4%) and solid pseudopapillary tumor (SPT) (29.3%). No significant difference as regards postoperative pancreatic exocrine and endocrine function in both groups. CONCLUSION: PD in YA when performed in tertiary centers with good surgical experience is safe. The most common pathological diagnosis in the YA was adenocarcinoma followed by SPT.

Cystobiliary communication in hepatic hydatid cyst: predictors and outcome.

BACKGROUND/AIMS: Cystobiliary communication (CBF) with hepatic hydatid disease is responsible for postoperative bile leakage after surgical management. This study aims to detect various predictors of CBF and its outcome after surgical management. MATERIALS AND METHODS: This is a retrospective, cohort study of all patients who underwent surgical management for hydatid disease of the liver. Patient data were recorded on an internal web-based registry system supplemented by paper records. Patients were classified into two groups according to the presence of CBF: group (A) patients with CBF and group (B) patients without CBF. RESULTS: There were 123 patients with a hepatic hydatid cyst with a mean age of 39.92±14.59 years. Patients were classified into group (A), 26 patients (21.1%) with CBF, and group (B), 97 patients (78.9%) without CBF. The age group (p=0.04), presence of jaundice (p=0.001), serum glutamic-pyruvic transaminase (SGPT) (p=0.001), cyst size (p=0.0001), and cyst size group (>10 cm) (p=0.0001) were associated with CBF. That cyst size was the only independent predictor of the occurrence of CBF. Intraoperative suturing and the T tube led to complete healing of CBF, and postoperative endoscopic retrograde cholangio-pancreatography (ERCP) and tubal drainage led to a rapid reduction in the bile output and the healing of the fistulas after 9±2.6 days. CONCLUSION: That cyst size was the only independent predictor for the occurrence of CBF. Management is related to the size of the fistula, the site of the cyst, and the experience of the hepatobiliary surgeon. ERCP is an important option for the management of CBF.

Delayed gastric emptying after pancreaticoduodenectomy. Risk factors, predictors of severity and outcome. A single center experience of 588 cases.

BACKGROUND: Delayed gastric emptying (DGE) is a common complication after pancreaticoduodenectomy (PD). This study was designed to evaluate perioperative risk variables for DGE after PD and analyze the factors that predict its severity. PATIENTS AND METHOD: Demographic data, preoperative, intraoperative, and postoperative variables were collected. RESULTS: A total of 588 consecutive patients underwent PD. One hundred and five patients (17.9 %) developed DGE of any type. Forty-three patients (7.3 %) had a type A, 53 patients (9.01 %) had DGE type B, and the remaining nine patients (1.5 %) had DGE type C. BMI > 25, diabetes mellitus (DM), preoperative biliary drainage, retrocolic reconstruction, type of pancreatic reconstruction, presence of complications, postoperative pancreatic fistula (POPF), and bile leaks were significantly associated with a higher incidence of DGE. Thirty-three (31.4 %) patients were diagnosed as primary DGE, while 72 (68.5 %) patients had DGE secondary to concomitant complications. Type B and C DGE were significantly noticed in secondary DGE (P = 0.04). Hospital stay was significantly shorter in primary DGE. CONCLUSION: Retrocolic GJ, DM, presence of complications, type of pancreatic reconstruction, and severity of POPF were independent significant risk factors for development of DGE. Type B and C DGE were significantly more in secondary DGE.

Endoscopic ultrasound of isolated gastric corrosive stricture mimicking linitis plastica.

Isolated gastric outlet obstruction after 1 month of asymptomatic ingestion of corrosive is a rare phenomenon and rarely reported. In this type of cases, diagnosis is very difficult due to no symptoms at the time of poisoning, and biased history. We report a case of a young male presented with isolated gastric outlet obstruction after 1 month of asymptomatic ingestion of toilet cleaner, which was known to us later, mimicking linitis plastica. On upper endoscopy, the stomach was grossly edematous, antrum edematous and inflamed with reduced distensibility and narrow pyloric canal. Endoscopic ultrasound of the stomach revealed diffuse thickening of the gastric wall, mainly the antrum, involving submucosa and muscularis propria. We propose corrosive injury to be in the differential diagnosis of gastric linitis plastica.

The effect of residual gastric antrum size on the outcome of laparoscopic sleeve gastrectomy: a prospective randomized trial.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is gaining popularity worldwide as a definitive bariatric procedure. However, there are still some controversial issues associated with the technique, one of which is the size of the residual antrum. OBJECTIVES: The aim of this prospective randomized trial is to study the effect of the size of the residual gastric antrum on the outcome of LSG. SETTINGS: University-affiliated hospital. METHODS: Between November 2009 and August 2013, 113 morbidly obese patients submitted for LSG were randomized into 2 groups, namely antral preserving-LSG (AP-LSG) and antral resecting-LSG (AR-LSG), depending on the distance from the pylorus at which gastric division begins. In the AP-LSG group, the distance was 6 cm from the pylorus and included 58 patients, whereas the distance was 2 cm in the AR-LSG group and included 55 patients. The follow-up period was at least 12 months. Baseline and 6 and 12 month outcomes were analyzed including assessments of the percent excess weight lost (%EWL), reduction in BMI, morbidity, mortality, reoperations, quality of life, and co-morbidities. RESULTS: Both groups were comparable regarding age, gender, body mass index (BMI), and co-morbidities. There was one 30-day mortality, and there was no significant difference in the complication rate or early reoperations between the 2 groups. Weight loss was significant in both groups at 6 and 12 months. At 12 months, weight loss was greater in the AR-LSG than in the AP-LSG group, but with was no significant difference between the 2 groups at 12 months (%EWL was 64.2% in the AP-LSG group and 67.6% in the AR-LSG group; p>.05). The resolution/improvement of co-morbidities, quality of life outcome and the overall prevalence of co-morbidities were similar. CONCLUSIONS: LSG with or without antral preservation produces significant weight loss after surgery. The 2 procedures are equally effective regarding %EWL, morbidity, quality of life, and amelioration of co-morbidities.

Prognostic factors affecting survival after pancreaticoduodenectomy for pancreatic adenocarcinoma (single center experience).

BACKGROUND: Pancreatic cancer is considered to have the worst prognosis of the periampullary carcinomas. This retrospective study was to determine prognostic factors for survival after pancreaticoduodenectomy in patients had pancreatic carcinoma. METHODS: We retrospectively studied all patients who underwent PD for pancreatic adenocarcinoma originating from the head, neck or uncinate process from January 1996 to January 2011 in our center. Preoperative variables, intraoperative variables and postoperative variables were collected. RESULTS: The study included 480 patients (282 males and 198 females with a median age of 53 years. At the time of analysis, 180 (37.5%) patients were still alive. The median survival was 19 months. This corresponded to a 1-, 3-, and 5-year actuarial survival of 44 %, 20%, and 15% respectively. Mass size less than 2 cm (P=0.0001), lymph node ratio (P=0.0001), safety margin (P=0.0001), perineural, perivascular infiltration, age above 60 years (P=0.03), gender, preoperative bilirubin, SGPT, liver status, pre and postoperative CEA, CA19- 9 (P=0.0001) were significant predictors of survival. CONCLUSION: Mass size less than 2 cm, lymph node ratio, safety margin, perineural, perivascular infiltration, age above 60 years, gender, liver status, pre and postoperative CEA, CA19-9 are important predictors of survival in patients undergoing PD for pancreatic cancer.

Post-splenectomy splenosis presenting as hepatocellular carcinoma in the left lateral section of the liver: A case report.

INTRODUCTION: Defined as heterotrophic autotransplantation of splenic tissue after splenic trauma or surgery. PRESENTATION OF CASE: We present a case of 45 years old female patient with past history of splenectomy for haemolyticanaemia. Complaining of abdominal pain the patient was investigated by abdominal CT scan which revealed a focal lesion in the left lateral section of the liver suspicious to be hepatocellular carcinoma and gall bladder stones. Serum α-fetoprotein was within normal range. Exploration revealed a well encapsulated lesion completely separable from the liver and the diaphragm. Histopathological examination confirmed the diagnosis of splenosis. Although it is a rare condition, we recommend that the diagnosis of splenosis should be put in consideration in every patient with past history of splenectomy for proper management. DISCUSSION: Although several cases of hepatic splenosis have been reported in the literature, supra-hepatic splenosis as our case has been rarely described. CONCLUSION: Considering patients past history of splenectomy or splenic trauma should add splenosis to the list of possible differential diagnosis to avoid unnecessary surgical intervention.

Hilar cholangiocarcinoma in cirrhotic liver: a case-control study.

BACKGROUND: Surgical resection is the only hope for patients with cholangiocarcinoma (CC). This study is designed to assess the impact of cirrhosis on the outcome of surgical management for CC. PATIENT AND METHODS: We retrospectively studied all patients who underwent surgical resection for hilar CC. Group I (patients with cirrhotic liver) and Group II (patients with non-cirrhotic liver). Preoperative demographic data, intra-operative data, and postoperative details were collected. RESULTS: Only 102/243 patients (41.9%) had cirrhotic liver. Caudate lobe resection was more frequently performed in the non-cirrhotic group (P = <0.001). There was no difference between both groups regarding intraoperative blood loss and the need for blood transfusion. The median postoperative stay was higher in the cirrhotic group (P = 0.063). The incidence of early postoperative liver cell failure was significantly higher in the cirrhotic group (P = <0.001). Cirrhosis was associated with significantly lower overall survival (P = <0.001). CONCLUSION: Patients with concomitant liver cirrhosis and hilar CC should not be precluded from surgical resection and should be considered for resection at high volume centers with expertise available to manage liver cirrhosis. The incidence of early postoperative liver cell failure was significantly higher in the cirrhotic group.