Laparoscopic transversus abdominis plane block reduces postoperative opioid requirements after laparoscopic cholecystectomy.

BACKGROUND: Surgeons directly contribute to the over-prescription of opioids. Alternative postoperative pain management strategies are necessary to reduce opioid dispensation and combat the opioid epidemic. We set out to examine the effectiveness of a laparoscopic transversus abdominis plane block on reducing opioid requirements after laparoscopic cholecystectomy. METHODS: In a retrospective cohort analysis, we compared opioid naïve patients who underwent an elective, outpatient laparoscopic cholecystectomy with a transversus abdominis plane block with patients who underwent a laparoscopic cholecystectomy alone between January 2018 and June 2021 at a single institution. Patient characteristics, perioperative pain scores, and postoperative analgesic requirements were compared between cohorts. RESULTS: There were 200 patients included in the study (laparoscopic cholecystectomy with a transversus abdominis plane block, n = 100; laparoscopic cholecystectomy alone, n = 100). The average postoperative pain scores in the postanesthesia care unit were equivalent between the groups (laparoscopic cholecystectomy with a transversus abdominis plane block = 3.39 versus laparoscopic cholecystectomy alone = 4.17, P = .12), with the mean postanesthesia care unit opioid requirements significantly lower in patients receiving laparoscopic cholecystectomy with a transversus abdominis plane block (12.1 vs 20.4 oral morphine equivalents, P < .001). Patients receiving laparoscopic cholecystectomy with a transversus abdominis plane block were prescribed fewer opioids on discharge (mean 77.5 vs 92.9 oral morphine equivalents, P < .05) and reported using a lower proportion of their opioid prescription at follow-up (83.2% vs 100%, P < .001). Of the patients receiving laparoscopic cholecystectomy with a transversus abdominis plane block, 65% reported using over-the-counter pain medications compared with 82% of patients receiving laparoscopic cholecystectomy alone (P < .001). CONCLUSION: Performing a laparoscopic transversus abdominis plane block during elective laparoscopic cholecystectomy is a safe and effective strategy to reduce postoperative opioid requirements for the treatment of acute postoperative pain.

Neoadjuvant chemoradiation is associated with decreased lymph node ratio in borderline resectable pancreatic cancer: A propensity score matched analysis.

BACKGROUND: Lymph node ratio (LNR) and margin status have prognostic significance in pancreatic cancer. Herein we examined the pathologic and clinical outcomes in patients with borderline resectable pancreatic cancer (BRPC) following neoadjuvant therapy (NAT) and pancreaticoduodenectomy. METHODS: Patients who underwent treatment between January 1, 2012 and June 30, 2017 were included. Sequential patients in the BRPC group were compared to a propensity score matched cohort of patients with radiographically resectable pancreatic cancer who underwent upfront surgical resection. The BRPC group was also compared to sequential patients with radiographically resectable pancreatic cancer who required vein resection (VR) during upfront surgery. RESULTS: There were 50 patients in the BRPC group, 50 patients in the matched control group, and 38 patients in the VR group. Negative margins (R0) were seen in 72%, 64%, and 34% of the BRPC, control, and VR groups, respectively (P = 0.521 for BRPC vs. control; P = 0.002 for BRPC vs. VR), with 24% of the BRPC group requiring a vascular resection. Nodal stage was N0 in 64%, 20%, and 18% of the BRPC, control, and VR groups, respectively (P < 0.001 for BRPC vs. control or VR). When nodal status was stratified into four groups (N0, or LNR ≤ 0.2, 0.2-0.4, ≥ 0.4), the BRPC group had a more favorable distribution (P < 0.001). The median overall survival were 28.8, 38.6, and 19.0 months for the BRPC, control, and VR groups, respectively (log-rank P = 0.096). CONCLUSIONS: NAT in BRPC was associated with more R0 and N0 resections and lower LNR compared to patients undergoing upfront resection for resectable disease.

Incidental Diagnosis of Pseudomyxoma Peritonei After Emergent Splenectomy.

Pseudomyxoma peritonei (PMP) is a rare disease associated with mucinous ascites. Pseudomyxoma peritonei has a low incidence and is difficult to diagnose. Pseudomyxoma peritonei usually presents with vague abdominal pain after significant progression. Computed tomography imaging is the most common modality for diagnosis; however, diagnosis as a result of surgical intervention in cases of acute abdomen has become increasingly common. We present a unique case of a 66-year-old man who was incidentally diagnosed with PMP after undergoing an emergent splenectomy for presumed blunt trauma. The patient presented to the emergency room with abdominal pain, shortness of breath, and diaphoresis. Computed tomography imaging revealed a splenic hematoma with suspicion of extravasation and a moderate amount of free intraperitoneal fluid consistent with blood. The patient was taken to the operating room emergently for an emergent splenectomy where splenic laceration was noted, as were multiple areas of nodularity in the omentum and cecum. Histologic evaluation of these lesions led to the diagnosis of PMP. After recovery from his initial splenectomy, the patient underwent exploratory laparotomy, cytoreductive surgery, cholecystectomy, removal of appendiceal mucocele, and hyperthermic intraperitoneal chemotherapy without complication. Final pathology was consistent with PMP and primary mucinous appendiceal adenocarcinoma. This case highlights an unusual presentation of PMP for a patient who was undergoing surgery for presumed splenic trauma. Surgeons must maintain a high index of suspicion and should perform histological evaluation when such unexpected findings are encountered.

Comparison of pancreas-sparing duodenectomy (PSD) and pancreatoduodenectomy (PD) for the management of duodenal polyposis syndromes.

BACKGROUND: Familial adenomatous polyposis affects primarily the colon but can also involve other locations within the gastrointestinal tract, including the duodenum. The aim of this study was to describe a single center experience with pancreas-sparing duodenectomy for familial adenomatous polyposis and to compare outcomes with pancreatoduodenectomy performed for duodenal polyp disease. PATIENTS AND METHODS: A retrospective review of a prospectively maintained database identified patients who had undergone pancreas-sparing duodenectomy during the period 2001 to 2016. This population was matched 1:1 with a cohort of patients undergoing pancreatoduodenectomy for duodenal adenomas, both sporadic and familial, during the same time period. Baseline demographics and perioperative (short- and long-term) outcomes were compared. RESULTS: A total of 88 patients were included; 44 in each group. The pancreas-sparing duodenectomy cohort was younger (52.6 vs 64.3 years; P < .001) and more patients had undergone prior colectomy (100% vs 32%; P < .001) or additional prior abdominal surgery (27% vs 9% (P < .001). Median operative times were greater for pancreatoduodenectomy (391 vs 460 min; P = .002). There was no difference in any of the early postoperative complications. There was 1 30-day mortality in the pancreatoduodenectomy group secondary to aspiration. Late acute pancreatitis was more common after pancreas-sparing duodenectomy (16% vs 0%; P = .012) and exocrine pancreatic insufficiency was more common after pancreatoduodenectomy (30% vs 11%; P = .034). CONCLUSION: Pancreas-sparing duodenectomy is a reasonable option for duodenal cancer prophylaxis in familial adenomatous polyposis with high-risk features. The perioperative safety profile is comparable to pancreatoduodenectomy done for similar indications, and pancreas-sparing duodenectomy has a favorable long-term with a lesser incidence of exocrine impairment.

Diagnostic Laparoscopy Prior to Neoadjuvant Therapy in Pancreatic Cancer Is High Yield: an Analysis of Outcomes and Costs.

BACKGROUND: There is currently no standardized regimen for management of borderline resectable pancreatic cancer (BRPC), and treatment includes varying sequences of surgery, chemotherapy, and/or radiation. This study examines the diagnostic yield and cost of performing staging diagnostic laparoscopy (SDL) prior to neoadjuvant therapy (NAT) in BRPC. METHODS: Sequential patients treated for BRPC between January 2010 and October 2013 were included. SDL was adopted in a staged fashion due to surgeon preference, and included biopsy of visible lesions and washings for cytology. Cost ratios (CRs) were calculated to compare the direct cost of the SDL versus no-SDL groups and to compare patients with positive versus negative SDL. RESULTS: Of 116 patients evaluated for BRPC, 75 patients underwent SDL and 19 (25%) revealed occult metastatic disease. Sixteen patients had a positive biopsy and three had positive cytology alone. There was no difference in overall treatment cost (CR 0.95, 95% CI 0.62-1.37), oncologic treatment (CR 0.66, 95% CI 0.32-1.23), or remaining surgical treatment (CR 1.14, 95% CI 0.77-1.71) for patients who underwent SDL compared to those who did not. Patients with a positive SDL incurred lower overall cost compared to those with a negative SDL (CR 0.23, 95% CI 0.16-0.32) due to lack of further surgery or radiation, and less intensive chemotherapy regimens. CONCLUSIONS: SDL prior to NAT is a useful adjunct to CT to diagnose occult metastatic disease in BRPC.

Rate of growth of pancreatic serous cystadenoma as an indication for resection.

BACKGROUND: The purpose of this study was to examine the natural history and growth rate of pancreatic serous cystadenomas (SCAs) to determine which factors lead to resection for these benign neoplasms. METHODS: We reviewed retrospectively a prospectively maintained database, identifying patients diagnosed with SCAs of the pancreas. The diagnosis was made via a combination of classic imaging features with or without cyst aspiration results consistent with SCA. To determine growth rates, gamma regression models were used and the average was modeled using the log function. RESULTS: A prospectively maintained database of 1,241 pancreatic cystic neoplasms was queried from 1998 to 2010. A total of 219 patients (18%) were diagnosed with SCA, 194 in the surveillance group and 25 in the resection group. Twenty patients underwent resection after initial imaging principally for presence of symptoms and indeterminate diagnosis, and 5 underwent resection after surveillance for development of symptoms and/or rapid rate of growth. Rate of growth increased at a steady state over time, with an estimated doubling time of 12 years (95% confidence interval, 7.8-21.5). CONCLUSION: This study shows that growth patterns are similar for SCAs of the pancreas regardless of initial size. When doubling time is faster than 12 years, resection should be considered.

Laparoscopic median arcuate ligament release: are we improving symptoms?

BACKGROUND: Median arcuate ligament syndrome is a rare disorder characterized by postprandial abdominal pain, weight loss, and celiac stenosis. We report our experience using a laparoscopic approach for this uncommon diagnosis. STUDY DESIGN: This is an IRB-approved, prospectively collected retrospective analysis of patients treated with laparoscopic median arcuate ligament release at our institution. Data collected included patient demographics, preoperative symptoms, operative approach, and postoperative outcomes. Ultimately, patients were contacted to complete a postoperative survey aimed at assessing resolution of symptoms and overall satisfaction. RESULTS: A total of 15 patients underwent laparoscopic median arcuate ligament release from March 2007 to January 2012. Mean age was 34 years (range 17 to 68 years) and 93% were female. Mean preoperative celiac velocity was 380 cm/s (range 210 to 600 cm/s). Fourteen patients had laparoscopic median arcuate ligament release and 1 patient had robotic-assisted laparoscopic release. Mean operative time was 179 minutes (range 79 to 473 minutes) and there was 1 conversion to laparotomy. Twelve of 15 patients had a postoperative celiac axis ultrasonography. Celiac occlusion occurred in 2 patients (present in 1 patient preoperatively). In the remaining 10 there was a statistically significant decrease in celiac velocity to 215 cm/s (range 135 to 306 cm/s; p = 0.005). Survey response rate was 86% at a mean follow-up of 15.4 months (range 2.8 to 32.6 months), and all but 1 patient reported having resolution of pain. CONCLUSIONS: Laparoscopic release of the median arcuate ligament is a safe, feasible, and effective means of managing median arcuate ligament syndrome. Postoperative symptomatic relief is seen in the vast majority of patients undergoing this procedure.

Biologic prosthetic materials for hernia repairs.

Herniorrhaphy continues to be one of the most commonly performed operations worldwide. As the literature shows, there is a clear advantage to tension-free mesh reinforcement versus primary suture repair alone in most settings. The choice of medical implant is based on many factors, including type and location of hernia, host environment, efficacy with product utilization, and total cost. The use of prosthetic implants has evolved over the years from "first-generation" synthetic materials to "third-generation" biologic grafts. In this review, we report on various biologic materials used in the repair of ventral, inguinal, and hiatal hernias. Despite an ever-expanding selection of products, there is currently no consensus on when or how to use them, and no long-term data exist regarding the effect of implantation. The goal of this study is to highlight the current indications for bioprosthetic materials used in hernia repair, as well as the reported short- and long-term effects of implantation.