A rational approach to postoperative surveillance for resected non-functional pancreatic neuro-endocrine tumours.

BACKGROUND: Non-functional pancreatic neuroendocrine tumours (NF-PNETs) are rare and have highly variable outcomes. Current guidelines recommend surveillance for NF-PNETs <2 cm. Patients who ultimately have surgical resection are at risk of disease recurrence, and data to support postoperative surveillance protocols are lacking. The aims of this study were to i) identify post-operative predictors of recurrence and ii) risk stratify patients at risk of recurrence. METHODS: Consecutive patients who underwent surgery for NF-PNETs between 2002 and 2015 were identified retrospectively. Data were collected on demographics, pre-operative laboratory results and histopathological tumour characteristics. Statistical analyses were based on penalised Cox-regression modelling and a decision-tree model. Comparison of the variables identified was performed using ROC curves to identify the most sensitive and specific variable associated with disease recurrence. RESULTS: We identified 73 patients (38 males) with a median age of 61.5 years (range: 31-79). The median period of follow-up was 49 months (5-131). During follow up, 10 deaths (13.9%) were recorded and disease recurrence occurred in 12 patients (16.4%). The Kaplan-Meier predicted 1-,3- and 5-year recurrence-free survival rates were 98.6% (95% CI = 95.9, 100%), 85.4% (76.9-94.8%) and 72% (58.7-88.2%) respectively. Cox multivariate analysis identified poor tumour differentiation (WHO G3 grade) and lymph node ratio (LNR) as independent predictors for recurrence (p < 0.05). A simple criterion of 'tumour grade G3 or LNR ≥0.1' was found to be sensitive and specific in detecting disease recurrence. CONCLUSION: Our results have identified a simple and sensitive criterion for risk stratifying post-resection surveillance. Prospective validation in larger patient cohort is now warranted.

Comparative study of magnetic resonance defaecography and evacuation proctography in the evaluation of obstructed defaecation.

AIM: Obstructed defaecation syndrome is a common condition of multifactorial aetiology and requires specialized evaluation. Accurate and reproducible pelvic floor imaging is imperative for multidisciplinary decision-making. Evacuation proctography (EP) and magnetic resonance defaecography (MRD) are the main imaging modalities used to assess dynamic pelvic floor function. The aim of this prospective study was to compare the findings and acceptability of MRD and EP in the same cohort of patients. METHOD: This was a prospective comparative study of MRD vs EP in 55 patients with obstructed defaecation syndrome in a single National Health Service Foundation Trust. RESULTS: Fifty-five patients were recruited and underwent both EP and MRD. Detection rates for rectocoele were similar (82% vs 73%, P = 0.227), but EP revealed a significantly higher number of trapping rectocoeles compared to MRD (75% vs 31%, P < 0.001). EP detected more rectal intussusceptions than MRD (56% vs 35%, P = 0.023). MRD appeared to underestimate the size of the identified rectocoele, although it detected a significant number of anatomical abnormalities in the middle and anterior pelvic compartment not seen on EP (1.8% enterocoele, 9% peritoneocoele and 20% cystocoele). Patients achieved higher rates of expulsion of rectal contrast during EP compared to MRD, but this difference was not significant (76% vs 64% in MRD, P = 0.092). Of the two studies, patients preferred MRD. CONCLUSIONS: MRD provides a global assessment of pelvic floor function and anatomical abnormality. MRD is better tolerated by patients but it is not as sensitive as EP in detecting trapping rectocoeles and intussusceptions.

Biliary cooling during radiofrequency ablation of liver tumours close to central biliary tree: A systematic review and pooled analysis.

INTRODUCTION: Biliary cooling during radiofrequency ablation (RFA) of liver tumour has been proposed as a protective measure for RFA-related biliary complications in cases whereby the RFA site is close to central biliary tree. This systematic review aims to assess the effect of biliary cooling during RFA on: 1) the development of biliary complications and 2) tumour recurrence rates at ablation site. METHODOLOGY: A systematic literature search was performed using the PubMed/EMBASE databases using PRISMA methodology (2000-2019). The initial search yielded 75 reports which were potentially suitable for inclusion. Studies reporting at least one outcome of interest were considered to be suitable for inclusion. Conference abstracts, case reports and animal studies were excluded. Data was retrieved from each study on patient demographics, tumour characteristics, method of cooling, biliary complications, local tumour recurrence and duration of follow-up. RESULTS: The final number of studies which met the inclusion criteria was 7, involving 100 patients. There were no randomized controlled trials identified after the literature search. The mean age of the patients included was 65 years. Biliary cooling was performed with the use of a nasobiliary tube in 4 out of 7 studies, via a choledochal incision in 2 out of 7 studies and through the cystic duct in a single study. The overall biliary stricture rate was 2% and the overall tumour recurrence rate at RFA treated site was 14.5%. CONCLUSION: Biliary complications appear to be low after biliary cooling during RFA close to central biliary tree. More evidence is required to assess the tumour recurrence rates.

Preoperative diagnosis of intraductal papillary neoplasm of the bile duct with endoscopic ultrasound.

Intraductal papillary mucinous neoplasm of the bile duct is a rare tumour only recently classified as a distinct pathological entity. These neoplasms, rarely encountered in clinical practice in the UK, are now considered to be important precursors for the development of cholangiocarcinoma. We present a histologically confirmed case of intraductal papillary neoplasm of the bile duct in a male patient and discuss the main radiographic manifestations of this rare condition across multiple imaging modalities, with an emphasis on the imaging features of endoscopic ultrasonography and its role in establishing the diagnosis.

Elective "True Day Case" Laparoscopic Inguinal Hernia Repair in a District General Hospital: Lessons Learned from 1000 Consecutive Cases.

INTRODUCTION: Laparoscopic inguinal hernia repair (LIHR) is ideal for day case surgery. It is recommended that at least 70% should be day cases as a measure of cost-effectiveness. The aims of this study were to (i) assess the rate of true day case (TDC) surgery and (ii) identify predictors associated with unexpected overnight stay (UOS). METHODS: Data was collected prospectively on 1000 consecutive elective LIHR performed in a District General Hospital (DGH) over a 7-year period. Data was collected on baseline patient demographics, ASA grade, and intraoperative details. A multivariate analysis was performed in order to identify predictors of UOS. RESULTS: 1000 patients (927 males) underwent elective LIHR. Mean age was 57.3±15.2 years. 915 patients were planned as day case procedures. 822/915 day cases (89.8%) were discharged on the same day and 93 (10.2%) stayed overnight unexpectedly. Patient age, duration of procedure, and patient slot in the operating list were found to be independent predictors (p<0.05) of UOS. CONCLUSION: Our results demonstrate that LIHR is a "true" day case procedure in a DGH. Although some factors associated with UOS cannot be altered, careful patient selection and operating list planning are of paramount importance in order to minimise the burden on healthcare resources.

Postoperative Ascites of Unknown Origin following Laparoscopic Appendicectomy: An Unusual Complication of Laparoscopic Surgery.

Postoperative ascites is a very rare complication of laparoscopic surgery. Significant iatrogenic injuries to the bowel, the urinary tract, and the lymphatic system should be excluded promptly to avoid devastating results for the patient. In some cases, in spite of investigating patients extensively, no definitive causative factor for the accumulation of fluid can be identified. In such cases, idiopathic allergic or inflammatory reaction of the peritoneum may be responsible for the development of ascites. We present a case of ascites of an unknown origin in a young female patient following a laparoscopic appendicectomy.

Comparison of external and endonasal dacryocystorhinostomy.

INTRODUCTION: External dacryocystorhinostomy has been the treatment for nasolacrimal duct obstruction for more than a century. More recently, nasal endoscopy has allowed this procedure to be carried out endonasally. AIM: The aim of this postal questionnaire study was to compare the health status of patients treated for epiphora by external versus endonasal non-laser dacryocystorhinostomy. METHOD: The Glasgow benefit inventory questionnaire, along with an additional, department-based symptomatic questionnaire, was distributed to all patients fitting our criteria. RESULTS: Satisfactorily completed questionnaires were received from 64 out of 90 patients in the external group and from 30 of 41 patients in the endonasal group. Results indicated positive scores for both groups for all four subscales of the Glasgow benefit inventory. There were no statistically significant differences between results for the external and endonasal procedures. The ocular symptomatology questionnaire results indicated better scores for the external procedure, but this difference did not reach statistical significance.