Staple line reinforcement in laparoscopic bariatric surgery: does it actually make a difference? A systematic review and meta-analysis.

BACKGROUND: Staple line leaks represent a major concern in all laparoscopic operations but are particularly important in bariatric surgery, where leak complications carry significant morbidity and mortality. Therefore, several means of staple line reinforcement have been described, but none is totally accepted. In this study, we attempt to illuminate any clear benefit of staple line reinforcement through a systematic review and meta-analysis of reported articles. METHODS: Two major databases (PubMed and Cochrane) were searched and assessed by two reviewers. Inclusion criteria were: detailed description of operative technique, especially concerning staple line reinforcement, and possible existence of proven staple line leak. Selected studies were evaluated by systematic review and meta-analysis according to their eligibility. The study population was finally divided into two groups: reinforcement (of any type) and no reinforcement. RESULTS: In the initial search, 126 studies were obtained. Then, 17 full papers, both randomised controlled trials (RCTs) and non-RCTs, were included in the systematic review. Seven studies, comprising 3,299 patients, were examined for evaluation of population odds of leak (7.69), which was considered clinically significant. Meta-analysis of three studies comprising 1,899 patients revealed no clear benefit of reinforcement group, though with marginal significance. CONCLUSIONS: Although several drawbacks exist, this study illustrates two important aspects: that current staplers may not be uniformly reliable, and that staple line reinforcement does not seem to have any clear benefit, at least concerning leak rate.

Successful pancreaticoduodenectomy with immediate vascular reconstruction in a patient with cancer of the pancreatic head and celiac artery stenosis. A case report.

CONTEXT: Celiac artery stenosis is observed in a significant percentage of individuals in the general population. Although usually clinically silent and insignificant, due to the presence of extensive collaterals between the celiac artery and the superior mesenteric artery, celiac artery stenosis may be associated with potentially catastrophic ischemic complications in patients undergoing pancreaticoduodenectomy, due to the abrupt interruption of the collateral pathways. Therefore, revascularization may be indicated in selected patients with celiac artery stenosis undergoing a PD. CASE REPORT: We present a patient with celiac artery stenosis diagnosed intraoperatively during a PD, who underwent vascular reconstruction at the time of the PD. In the immediate postoperative period, he developed hepatic ischemia due to stenosis at the anastomosis of the stent with the hepatic artery. He was subsequently treated successfully with the endovascular placement of a stent. In retrospect, a careful reevaluation of the preoperative abdominal CT scan showed the stenosis at the origin of celiac artery. CONCLUSION: A careful evaluation of abdominal CT scan is required to preoperatively identify this not uncommon vascular obstructive disease, especially in asymptomatic patients. Otherwise, the astute surgeon should suspect celiac artery stenosis based on intraoperative findings/changes immediately following ligation of the gastroduodenal artery during a PD.

Large somatostatin-producing endocrine carcinoma of the ampulla of vater in association with GIST in a patient with von Recklinghausen's disease. Case report and review of the literature.

CONTEXT: Somatostatin-producing endocrine tumors of the duodenum are very rare neoplasms of the gastrointestinal tract. These tumors may be associated with von Recklinghausen's disease. CASE REPORT: We present the case of a 49-year-old female patient with von Recklinghausen's disease and an incidentally diagnosed ampullary neoplasm. The patient was treated with a classical pancreaticoduodenectomy. At surgery, a mass was found in the greater curve of the stomach which was resected using the classic Whipple procedure. Histology and immunohistochemistry showed that the duodenal tumor was an ampullary somatostatin-producing endocrine carcinoma while the gastric tumor was a gastrointestinal stromal tumor (GIST). The postoperative course was uneventful and the patient is alive, without tumor recurrence, six years after surgery. CONCLUSION: Somatostatin-producing endocrine tumors of the duodenum are rare tumors, often associated with von Recklinghausen's disease; these neoplasms should be treated aggressively using radical surgical resection. Although local resection may be appropriate for small duodenal somatostatin-producing tumors, a pancreaticoduodenectomy is usually required for larger tumors.

Good results after major pancreatic resections in a middle-volume center.

OBJECTIVES: Recently, hospital and surgeon volume is widely discussed as a prognostic factor after major pancreatic surgery. We present our experience regarding major pancreatectomy in a middle-volume center. METHODS: During the last 11 years, 66 patients underwent major pancreatectomy (pancreaticoduodenectomy [n = 52], distal pancreatectomy with splenectomy [n = 13], and central pancreatectomy [n = 1]). Postoperative course and long-term outcome were recorded and analyzed. RESULTS: One patient died after pancreaticoduodenectomy for ampullary cancer (total mortality of approximately 1.5% for the whole group of patients or 1.9% for the group of patients who underwent pancreatoduodenectomy). None of our patients was reoperated on. Transient pancreatic fistula was observed in 46 patients (36 patients after pancreatoduodenectomy [69%] and 10 patients after distal pancreatectomy [77%]). Two patients required percutaneous computed tomography-guided drainage of fluid collections, whereas in another one, a tube thoracostomy was performed to drain a pleuritic fluid collection. Delayed gastric emptying was observed in 6 patients after pancreatoduodenectomy. Median survival for the whole group of patients was 17 months. CONCLUSIONS: Major pancreatic resections can be performed safely, with acceptable morbidity and mortality and good long-term results, even in middle-volume centers. However, experience is required from the part of the operating surgeon. ABBREVIATIONS: PD - pancreatoduodenectomy, DP - distal pancreatectomy, PPPD - pylorus-preserving pancreatoduodenectomy.

Angiomyofibroblastoma of the spermatic cord: a case report.

INTRODUCTION: Angiomyofibroblastoma is a benign soft tissue tumor with tendency to arise in the vulva. CASE PRESENTATION: We report a 36-year-old Greek Caucasian man presenting with a left inguinal painless mass. This is the second case of angiomyofibroblastoma of the spermatic cord. At operation, a 4.5 cm well-circumscribed solid tumor was found adherent to the spermatic cord. The tumor consisted of spindle-shaped cells proliferating in short fascicles between numerous medium-sized blood vessels with thin and hyalinized walls. Neoplastic cells had eosinophilic cytoplasm with neither mitotic figures nor nuclear atypia. The stroma included abundant mast cells and few mature lypocytes. Immunostaining showed positivity for vimentin, CD34, desmin and smooth muscle actin. Our patient was treated by simple excision and was followed up for five years with clinical examination and ultrasonography, revealing no evidence of local recurrence or metastasis. CONCLUSION: This unusual neoplasm should be distinguished from aggressive angiomyxoma and other myxoid malignant tumors with widespread metastatic potential.

Non-operative management of blunt abdominal trauma. Is it safe and feasible in a district general hospital?

BACKGROUND: To evaluate the feasibility and safety of non-operative management (NOM) of blunt abdominal trauma in a district general hospital with middle volume trauma case load. METHODS: Prospective protocol-driven study including 30 consecutive patients who have been treated in our Department during a 30-month-period. Demographic, medical and trauma characteristics, type of treatment and outcome were examined. Patients were divided in 3 groups: those who underwent immediate laparotomy (OP group), those who had a successful NOM (NOM-S group) and those with a NOM failure (NOM-F group). RESULTS: NOM was applied in 73.3% (22 patients) of all blunt abdominal injuries with a failure rate of 13.6% (3 patients). Injury severity score (ISS), admission hematocrit, hemodynamic status and need for transfusion were significantly different between NOM and OP group. NOM failure occurred mainly in patients with splenic trauma. CONCLUSION: According to our experience, the hemodynamically stable or easily stabilized trauma patient can be admitted in a non-ICU ward with the provision of close monitoring. Splenic injury, especially with multiple-site free intra-abdominal fluid in abdominal computed tomography, carries a high risk for NOM failure. In this series, the main criterion for a laparotomy in a NOM patient was hemodynamic deterioration after a second rapid fluid load.