Short-term outcomes after minimally invasive oesophagectomy.

INTRODUCTION: Minimally invasive oesophagectomy (MIO) has gained increasing popularity. This study reports the results of the first patients operated using this technique at our department. METHODS: All procedures were prospectively registered in a database. Patients were followed until death, two years after surgery or 1 January 2019. RESULTS: A total of 150 procedures were performed (from 23 November 2015 to 27 February 2018). The median proced-ure time decreased from 350 minutes for the initial 75 pa-tients to 320 minutes for the final 75 patients (p < 0.05). Blood loss decreased from 200 ml to 100 ml (p < 0.05), respectively. The conversion rate for the abdominal procedure was 7% for the initial 75 patients and 8% for the final 75 patients (not significant (NS)). For the thoracic procedure, the corresponding figures were 11% and 7% (NS), respectively. Anastomotic leakage was seen in 17% (initial patients) and 11% (final patients) (NS); however, less than 20% of the leakages needed surgical treatment. The median length of post-operative stay was nine days for both groups. For all 150 patients, pulmonary complications were observed in 18% and cardiac complications in 11%. The 30-day mortality rate was 2% and the one-year survival rate was 86% (124 registered patients). CONCLUSIONS: MIO was introduced at our department with acceptable morbidity and mortality rates and the short-term oncological result was not compromised. FUNDING: none. TRIAL REGISTRATION: The study was approved as a quality project by the Region of Southern Denmark (18/37355).

[Metastasis from a malignant melanoma presenting as a gall bladder polyp].

Gall bladder polyps larger than 10 mm hold an increased risk of malignancy. In this case report, a metastasis from a superficial spreading malignant melanoma level IV presented as a large gall bladder polyp in a 52-year-old woman. The melanoma had been surgically resected eight years earlier. The most frequent distant metastatic sites of malignant melanoma are soft tissue, lung, liver, skin and brain, but metastasis to the gallbladder is rare. It is important to refer patients with large gall bladder polyps to centres with expertise in liver surgery.

[Palliative treatment of malignant gastric outlet obstruction].

In gastric outlet obstruction (GOO) the passage from the stomach to the intestine is obstructed. The condition is referred to as malignant GOO if cancer is the reason. Self-expanding metal stents (SEMS) and gastrojejunostomy (GEA) are the therapeutic options for palliation, with SEMS often being recommended as first choice. However, no major difference in terms of clinical success has been shown between SEMS and GEA in comparative studies. Thus, the choice between SEMS and GEA should be made on an individual basis. If SEMS is chosen, covered and uncovered stents offer equal success rates.

Ten years of experience with transgastric necrosectomy for walled-off necrosis in acute pancreatitis.

INTRODUCTION: The aim of this study was to report our results with open transgastric necrosectomy for walled-off necrosis in acute pancreatitis over a period of ten years. METHODS: Patients operated at the department from 2003 until 2012 were studied retrospectively. RESULTS: A total of 50 patients had surgery. The median age was 55 years (range: 17-79 years). The presumed aetiologies were: gallstones (n = 28), alcohol (n = 8) and other causes (n = 14). The median preoperative stay at hospital was 50 days (range: 2-150 days). Bacterial culture from the necrotic tissue was positive in 26 patients (52%), negative in 15 patients (30%); and in nine patients, no information on this was available. In all, 22 patients (44%) had one or more incidents (i.e. abdominal compartment syndrome, bleeding, new abscess, pleural effusion or delayed gastric emptying) where additional invasive therapy was needed. Ten patients (20%) died during their admission to our department. In total, 18 (45%) patients developed late complications defined as endocrine and/or exocrine malfunction of the pancreas (diabetes (n = 10), exocrine insufficiency (n = 4), both diabetes and exocrine insufficiency (n = 4)). CONCLUSION: Acute pancreatitis with walled-off necrosis has a high mortality rate. Need for additional therapy following necrosectomy was associated with fatal outcome. Endocrine and exocrine insufficiency was often seen at follow-up. FUNDING: none. TRIAL REGISTRATION: The study was approved by the Danish Data Protection Agency via Region of Southern Denmark (case no. 13/29319).

Endoscopic ultrasonography is a valuable diagnostic tool in patients with incidental findings in the pancreas or bile ducts.

INTRODUCTION: Incidental findings are often seen at computed tomographies (CT). This study describes patients who had an endoscopic ultrasonography (EUS) because of an incidental finding in the pancreas/bile duct. METHODS: Patients referred for EUS between September 2012 and September 2013 because of an incidental finding in the pancreas/bile duct at a CT were prospectively enrolled. After EUS, the findings of this procedure were noted together with the plan for further diagnostic work-up or therapy. A follow-up was made after 6 months and 1 year after EUS was performed. RESULTS: A total of 47 patients (24 women, 23 men) were registered with an incidental finding. The median age was 69 years (range: 45-83 years). Diagnoses after performing EUS were: normal findings (n = 16), cystic lesion (n = 16), mass lesion (n = 6), inconclusive (n = 6) and other specified (n = 3). The plan after EUS was: no further evaluation (n = 27), referred for new EUS or other imaging procedures (n = 14) and referred for surgery/endoscopic retrograde cholangiopancreatography (n = 6). In total, 6 patients proved to have neoplastic diseases in the pancreas. None of the patients who were stopped from further evaluation following EUS later proved to have a malignant disease in the pancreas. CONCLUSION: EUS is a valuable diagnostic tool in patients with incidental findings in the pancreas/bile duct noted at a CT. Many patients can be stopped from further diagnostic work-up after EUS with a minimal risk of overlooking a malignant disease. FUNDING: not relevant. TRIAL REGISTRATION: The study was approved by the Danish Data Protection Agency via Region of Southern Denmark (case no. 13/27,321).

[Malignant lymphoma perforating the small intestine].

A rare cause of acute abdominal pain: lymphoma making its debut by perforation of the small intestine. Lymphomas localised to the gastrointestinal tract are rare. A case is presented where the initial symptom of the disease was acute abdominal pain because of perforation of one of the lymphomas in the small intestine. The diagnostic and therapeutic options in such emergency cases are discussed.

[Diagnostic workup for incidentally found thickening of the stomach wall]. / Udredning af tilfældigt opdaget fortykkelse af ventriklens væg.

Thickened stomach wall is sometimes found incidentally in abdominal CT scans. A review of the literature supports our general perception that normal findings or benign diseases are found in the majority of the cases. Gastroscopy seems to be sufficient for making the diagnosis in most patients; and endoscopic ultrasonograhy is only indicated for those patients in whom malignant diseases or benign submucosal lesions with need for therapy are still suspected after standard upper endoscopy has been performed.

Potential impact of adding endoscopic ultrasound to standard imaging procedures in the preoperative assessment of resectability in patients with liver tumors.

OBJECTIVE: The value of endoscopic ultrasonography (EUS) in patients with liver diseases is limitedly described. The aim of this study was to evaluate the potential impact of adding EUS to standard imaging procedures in the evaluation of resectability in patients with liver tumors. MATERIAL AND METHODS: Patients who, based on the findings of CT and/or MRI, had been referred for curative resection of liver tumours were studied. Each patient underwent EUS before the final assessment of resectability, which was done by laparoscopic ultrasound or laparotomy. RESULTS: Sixty-four patients were included. Intended curative resection was performed in 19 (30%) patients. Thirty-five (55%) patients were considered to have non-curative malignant disease. In 10 (15%) patients, the tumor was judged to be benign and surgery was not performed. There were no complications related to EUS. The sensitivity, specificity, positive predictive value, and negative predictive value of EUS regarding prediction of non-resectability were 0.24, 0.94, 0.80 and 0.56 (tumor in right lobe), 0.50, 1.0, 1.0 and 0.75 (tumor in left lobe), and 0.60, 0.67, 0.86 and 0.33 (tumors in both lobes), respectively. Sixteen patients (25%) would have had changed their further management, if decision regarding non-resectability had been taken after EUS. DISCUSSION: Addition of EUS to a standard imaging set-up based on CT and/or MRI would have changed the management in 25% of the patients otherwise scheduled for resection of suspected liver tumors.

Cholecystectomy in children.

INTRODUCTION: It is recommended that children with typical clinical signs of biliary colic should be offered surgery if gallstones are present. The aim of this study was to describe a population of children having undergone cholecystectomy. MATERIAL AND METHODS: A retrospective study of all children (aged less than 15 years) who had a cholecystectomy at the Department of Surgery, Odense University Hospital, during a ten-year period (2000-2009). RESULTS: Thirteen patients (ten girls and three boys) were operated. The median age was nine years and eight months (range: three years and two months to 14 years 11 and months). The indications for cholecystectomy were: recurrent abdominal pain and known gall bladder stones (n = 11), recurrent abdominal pain and thickening of the gall bladder wall as verified by ultrasonography (n = 2). Ten children had no known predisposing factor for development of gallstones. Among the remaining three, one had hereditary spherocytosis, one was obese and one had a bowel resection performed as a newborn because of necrotising enterocolitis. Laparoscopic cholecystectomy was performed in nine patients; open cholecystectomy in three and in one, the operation was initiated laparoscopically but converted into an open procedure. There were no postoperative complications. The median postoperative stay was one day (range: 1-7 days). Only one patient underwent subsequent diagnostic work-up for recurrent abdominal pain. CONCLUSION: Cholecystectomy is rarely performed in children and when so, it is mostly performed in otherwise healthy children. The surgical techniques deployed and the duration of the postoperative stay are very similar to those observed for adults.

Indications for and clinical impact of repeat endoscopic ultrasound.

OBJECTIVE: The value of repeating endoscopic ultrasound (EUS) is seldom described. This study evaluates a patient population in which EUS was repeated. MATERIAL AND METHODS: This was a retrospective study of patients who between January 2002 and December 2006 had an EUS scan performed; this EUS scan (re-EUS) was the second or more EUS scan performed. RESULTS: Over the study period, the department performed 3024 EUS procedures, of which 561 investigations were defined as re-EUS. According to defined exclusion criteria, 244 procedures were not analyzed further. The study group thus consisted of 317 procedures (242 patients). In 163 cases (126 patients), re-EUS was planned by the endosonographer for control of an undetermined lesion. The first re-EUS scan performed changed the further management in 91 of 126 patients (72%). Sensitivity and specificity of re-EUS regarding pancreatic cancer were 0.65 and 1.00, respectively. Re-EUS was performed in 82 cases (77 patients) where no re-investigation had been planned at the initial EUS scan but worsening of symptoms or new findings of other imaging procedures had led to an additional EUS scan. Thirteen of these patients (17%) proved to have pancreatic cancer. In 62 cases (57 patients) re-EUS and EUS-guided fine-needle aspiration (FNA) had been planed in order to confirm the suspicion of malignant disease. Following re-EUS and EUS-FNA, 40 of these patients could be referred for either oncology or surgery. In the remaining 10 cases, re-EUS was performed for miscellaneous indications. CONCLUSION: Re-EUS has a substantial clinical impact on the further management of the patient.

[Routinely performed endoscopic retrograde cholangiopancreatography should not be recommended for gallstone-induced acute pancreatitis]. / Rutinemaessig endoskopisk retrograd kolangiopankreatikografi kan ikke anbefales ved galdestenspankreatitis.

Danish guidelines recommend that patients with presumed severe gallstone-induced acute pancreatitis (GAP) should receive endoscopic retrograde cholangiopancreatography (ERCP) within 72 hours. The results of a newly performed meta-analysis show that acute ERCP in patients with GAP does not reduce the risk of complications, and ERCP is therefore not to be used routinely in GAP patients. The possible benefits of replacing ERCP with either endoscopic ultrasonography or magnetic resonance cholangiopancreatograhy have yet to be demonstrated.

[Endoscopic ultrasonography in patients suspected of neuroendocrine tumours]. / Endoskopisk ultralydskanning af patienter, hos hvem der er mistanke om neuroendokrine tumorer.

BACKGROUND: Endoscopic ultrasonography (EUS) is a valuable diagnostic tool for evaluating pathologies in or in relation to the upper gastrointestinal tract. The aim of this study was to evaluate the diagnostic yield of EUS in patients suspected of neuroendocrine tumours (NETs). MATERIALS AND METHODS: Retrospective analysis of data from the department's local EUS database and from hospital records. RESULTS: From November 2001 to December 2006, 21 patients were referred for EUS due to suspected neuroendocrine tumour. 17 patients were females and 4 were males. The median age was 48 years (range 14-93 years). 13 patients had symptoms (hypoglycaemia) suggesting that an insulinoma could be present. The remaining 8 patients had different kinds of symptoms including patients whose tumour was found by chance by another imaging modality. In 8 patients, EUS did not show any pathology. At follow-up, 6 of these were without any symptoms. One patient had died and one patient had subsequent surgery for intestinal obstruction due to a neuroendocrine carcinoma in the ileum and liver metastases. EUS revealed a mass lesion in 13 patients. 7 of these have had a CT scan which showed normal findings in 4. External ultrasound had been performed in 8 of the 13 patients, and showed normal findings in 4 out of the 8. All 13 patients with mass lesions had subsequent surgery showing different kinds of NETs in 11 patients, adenocarcinoma of the pancreas in one patient, and normal findings in one case. CONCLUSION: EUS may detect NETs which have not being visualised by other imaging modalities. EUS should be performed early in the diagnostic work up if a NET is suspected.