Gastroduodenal Artery Pseudoaneurysm Causing Obstructive Jaundice.

Background: Visceral artery aneurysms and pseudoaneurysms are uncommon phenomena with a high mortality rate in cases of rupture. These rare vascular pathologies are usually asymptomatic and are therefore generally discovered incidentally on computed tomography or magnetic resonance imaging examination. Current therapeutic options have trended toward a minimally invasive approach because of evolving endovascular treatment options, with open operations typically reserved for cases of intraabdominal hemorrhage. Case Report: We describe a case of gastroduodenal artery pseudoaneurysm manifesting as obstructive jaundice and pancreatitis because of extrahepatic compression of the common bile duct and pancreatic duct by mass effect. Open repair was ultimately required secondary to arterial anatomy that was not amenable to any endovascular treatment approach. Conclusion: While endovascular options are the preferred treatment modality for visceral artery aneurysms and pseudo-aneurysms, some cases require definitive open repair for a variety of reasons, including unsuitable anatomy.

The Role of Venous and Arterial Resection in Pancreatic Cancer Surgery.

Pancreatic cancer continues to carry a dismal prognosis with the majority of patients presenting at advanced stages of disease. Complete surgical resection remains essential for prolonging survival and increasing the possibility of cure. However, few patients will be resectable at diagnosis, with a significant portion presenting with borderline or locally advanced disease. The addition of vascular resection and reconstruction at the time of pancreatectomy enables expansion of the patient population able to undergo resection with curative intent and achieve tumor-free margins. This review provides an overview of the literature regarding the role of venous and arterial resection in the treatment of pancreatic cancer, with a focus on outcomes including survival, morbidity, and mortality.

Intrahepatic stones from congenital biliary dilatation.

BACKGROUND: Congenital or primary intrahepatic bile duct (IHBD) dilatation is a rare disorder with symptoms of abdominal pain and hepatomegaly that usually presents in childhood and adolescence. Recurrent cholangitis, liver abscesses, septicemia, and biliary cirrhosis may result secondary to biliary sludge and hepatolithiasis. CASE REPORT: We present a case of IHBD dilatation with hepatolithiasis cured with surgical resection and discuss the management of this disease. CONCLUSION: IHBD dilatation should be treated, as chronic biliary stasis and hepatolithiasis can lead to infection and recurrent cholangitis that can progress to cholangiocarcinoma. Treatment for IHBD dilatation usually involves multiple modalities including medical therapy, but ultimately resection of the diseased segments or lobes is required given the increased risk of malignancy.

Intracystic Biopsy and Diagnosis of Intraductal Papillary Mucinous Neoplasm via SpyGlass Pancreatoscopy.

BACKGROUND: Intraductal papillary mucinous neoplasm (IPMN) of the pancreas carries a risk of malignancy ranging from 15%-60%, depending on certain high-risk features. Diagnostic efforts often include radiographic imaging with computed tomography, magnetic resonance imaging, magnetic resonance cholangiopancreatography, and endoscopic ultrasound. Once IPMN has been diagnosed, the proposed indications for cyst resection are based primarily on size, main duct involvement, symptoms, and the presence of mural nodules. Diagnostic difficulty still remains, however, in patients with small lesions and with normal carcinoembryonic antigen levels, so alternative endoscopic modalities are needed. CASE REPORT: We report a case of intracystic SpyGlass Direct Visualization System (Boston Scientific) evaluation and biopsy of an IPMN in a 74-year-old male patient who presented to our surgical clinic with a history of chronic pancreatitis and significant weight loss during the last 2½ years. CONCLUSION: In difficult diagnostic cases, SpyGlass pancreatoscopy can be quite useful because the device allows direct endoscopic visualization of the pancreaticobiliary ducts. Ductal pathology, including stones, strictures, and proliferative epithelial abnormalities, can be observed and even directly biopsied. Early experience in applying this technology to pancreatic cyst evaluation has indicated improved diagnostic accuracy.

Postgastrectomy syndromes.

The first postgastrectomy syndrome was noted not long after the first gastrectomy was performed. The indications for gastric resection have changed dramatically over the past 4 decades, and the overall incidence of gastric resection has decreased. This article focuses on the small proportion of patients with severe, debilitating symptoms; these symptoms can challenge the acumen of the surgeon who is providing the patient's long-term follow-up and care. The article does not deal with the sequelae of bariatric surgery.

Small bowel adenocarcinoma: understaged and undertreated?

BACKGROUND: Primary small bowel adenocarcinoma (SBA) is a rare, chemoresistant tumor with an aggressive clinical nature. Surgery is the mainstay of therapy, but the extent of lymph node (LN) recovery necessary for optimal care of jejunoileal SBA is unknown. MATERIALS AND METHODS: The SEER database was queried to identify patients whose primary jejunoileal SBA was diagnosed between 1995 and 2005. Patients were grouped by AJCC stage and number of LNs recovered from the surgical specimen. RESULTS: Of 1444 patients with primary SBA, 93 (6.4%), 529 (36.6%), 356 (24.7%), and 466 (32.3%) were initially diagnosed with stage I, II, III, and IV disease, respectively. Five-year overall survival (OS) rate was 59.8%, 39.5%, 27.0%, and 3.2% for patients with stage I, II, III, and IV SBA, respectively. When ≥10 nodes were recovered, OS rate increased nonsignificantly in stage I (73.2% vs. 55.6%) and significantly in stage II (61.8% vs. 32.9%, P < .001) but was unchanged in stage III (27.4% vs. 27.3%, P = .13). Recovery of ≥10 nodes occurred in 26.9%, 23.6%, and 42.1% of patients with stage I, II, and III SBA, respectively. Multivariate analysis identified age, AJCC stage, site of primary tumor, recovery of ≥10 LNs, and number of positive nodes as significant for OS. CONCLUSIONS: We have found SBA staging is largely inadequate. Our results suggest recovery of ≥10 LNs ensures accurate staging. Improvement in stage II SBA OS after adequate LN may reflect a high degree of understaging in this dataset rather than a therapeutic effect of LAD.

Does specialized surgical training increase lymph node yield in colon cancer?

Most colon cancer resections do not meet the 12-lymph node minimum recommended in 2001 National Cancer Institute (NCI) panel guidelines. Previous reports suggest surgical training influences lymph node recovery. We hypothesized that recent trends show improved results for lymphadenectomy regardless of specialty. The cancer registry database at a large community hospital with an academic surgical oncology training program was queried to identify resections performed for colon cancer before (1995 to 2000) and after (2001 to 2006) NCI guideline publication. There were no changes in pathology procedures between 374 early and 411 later procedures. The later period brought increases in mean total lymph nodes (15.4 vs 10.4, P < 0.0001), total positive nodes (1.8 vs 1.2, P = 0.005), and the percentage of procedures yielding 12 or more nodes (overall: 65.9 vs 36.0%, P < 0.0001; Stage II and III disease: 73.0 vs 41.4%, P < 0.003). In addition, mean nodal yield increased (P < 0.0001) for fellowship-trained surgeons (16.7 vs 11.2) and nonfellowship-trained surgeons (14.9 vs 10.2). Single-registry data show that since 2001, most colon resections exceed minimum recommendations for lymph node recovery regardless of surgical training. The increased rate of adequate lymphadenectomy for Stage II and III disease is encouraging because this patient population will benefit most by accurate staging of colon cancer.

Age-related lymphatic dysfunction in melanoma patients.

BACKGROUND: Age-related outcomes have become increasingly common in evaluating patients with melanoma. For instance, as age increases, sentinel node (SN) nonidentification increases and SN positivity decreases. Furthermore, advanced age is a risk factor for in-transit disease. We hypothesized that increasing age is accompanied by alterations in lymphatic function, possibly explaining these findings. METHODS: Our center's melanoma database was queried to identify patients who underwent successful sentinel node biopsy after lymphoscintigraphy. Records of those treated between 2000 and 2005 were reviewed for age, sex, drainage basin, intraoperative radioactivity, and SN pathology. RESULTS: The 858 patients had a mean age of 55 years; 59% were men. Mean radioactivity in the hottest SN was 5232 counts per second; 179 patients (21%) had SN metastases. SN count rates were significantly and inversely related to age (P < .001 by Pearson correlation, analysis of variance, and chi(2) test). Mean counts per second were 6105, 5883, and 2720 for axillary, inguinal, and cervical basins, respectively (P < .01), and count rates in these basins were consistently lower with increasing age (neck and axilla, P < .001; groin, P = .060; Pearson correlation). Multivariate analysis confirmed an independent inverse association between age and count rates (P < .001), overall and within each primary tumor site. CONCLUSIONS: Lymphatic function, as assessed by radiocolloid transit to and uptake within the SN, declines with age. Altered lymphatic function in older patients may modify metastatic patterns; knowledge of this may help clarify findings of reduced nodal positivity and increased in-transit disease in this population.