Outcome of the pancreatic remnant following segmental pancreatectomy for non-invasive intraductal papillary mucinous neoplasm

OBJECTIVES

Intraductual papillary mucinous neoplasms (IPMNs) are often multifocal and involve the entire pancreas. Because of the morbidity associated with total pancreatectomy, surgeons will perform segmental pancreatectomy, resecting only the most 'threatening' IPMN lesion(s). We sought to determine whether the presence of residual IPMN following segmental pancreatectomy for non-invasive IPMN increases the risk for subsequent development of invasive pancreatic cancer and decreases survival.

METHODS

Data on patients undergoing segmental resection of non-invasive IPMN during the period 1991-2010 at a high-volume academic institution were prospectively accrued.

RESULTS

Of 243 patients who underwent segmental resection for IPMN, 191 (79%) demonstrated non-invasive pathology. Of these, 153 (80%) showed the absence and 38 (20%) the presence of residual IPMN at the initial operation. Of the 38 patients with residual IPMN, eight had positive IPMN margins, 23 had radiographic evidence of IPMN, and seven had both. During a mean follow-up of 73 months, 31 (20%) of 153 patients without residual IPMN developed a new radiographic lesion consistent with IPMN and, of these, three (10%) were found to represent invasive cancer. One (3%) of 38 patients with residual IPMN developed invasive cancer. In summary, in 191 initially non-invasive cases of IPMN, four invasive cancers (2%) developed during follow-up. The mean progression-free interval in these four patients was 54 months (range: 20-99 months).

CONCLUSIONS

Compared with patients undergoing complete operative IPMN clearance, patients with residual IPMN after segmental pancreatectomy do not demonstrate increased risk for the development of invasive disease or reduced survival. In patients without residual IPMN who later develop new IPMN, the risk for invasive IPMN is increased.

Laparoscopic lymphatic roadmapping with blue dye and radioisotope in colon cancer

Lymphatic mapping (LM) and sentinel lymph node (SLN) identification by blue dye in colon cancer is a procedure feasible during minimally invasive surgery, with good specificity, but still a low sensitivity (78% in our series). These results are in accordance with the literature and have limited more widespread diffusion of the method, both as a tool for upstaging and more controversially, as a potential roadmap to a tailored lymphadenectomy. It is possible to improve the results of LM with careful selection of patients and by the use of an intraoperative gamma camera. The preliminary results of intra-operative lymphoscintigraphy are promising in a well-selected small group of patients, with high levels of sensitivity and specificity. If these results are confirmed in further prospective analyses, it may be possible to undertake selected, tailored lymphadenectomy.

A case of obstruction due to jejunoileal diverticula

OBJECTIVE

The objective of this study is to discuss the presentation and diagnosis of a complicated jejunoileal diverticuli.

CASE REPORT

The case of a 94-year-old woman with small bowel obstruction secondary to an impacted enterolith from a jejunoileal diverticulum is presented to illustrate the clinical picture and radiographic findings of complicated small bowel diverticula.

Future perspectives in robotic surgery

• Robotics of the current day have advanced significantly from early computer-aided design/manufacturing systems to modern master-slave robotic systems that replicate the surgeon's exact movements onto robotic instruments in the patient. • Globally >300,000 robotic procedures were completed in 2010, including ≈98,000 robot-assisted radical prostatectomies. • Broadening applications of robotics for urological procedures are being investigated in both adult and paediatric urology. • The use of the current robotic system continues to be further refined. Increasing experience has optimized port placement reducing arm collisions to allow for more expedient surgery. Improved three-dimensional camera magnification provides improved intraoperative identification of structures. • Robotics has probably improved the learning curve of laparoscopic surgery while still maintaining its patient recovery advantages and outcomes. • The future of robotic surgery will take this current platform forward by improving haptic (touch) feedback, improving vision beyond even the magnified eye, improving robot accessibility with a reduction of entry ports and miniaturizing the slave robot. • Here, we focus on the possible advancements that may change the future landscape of robotic surgery.

Extracorporeal shock wave lithotripsy for pancreatic and large common bile duct stones

Extraction of large pancreatic and common bile duct (CBD) calculi has always challenged the therapeutic endoscopist. Extracorporeal shockwave lithotripsy (ESWL) is an excellent tool for patients with large pancreatic and CBD calculi that are not amenable to routine endotherapy. Pancreatic calculi in the head and body are targeted by ESWL, with an aim to fragment them to < 3 mm diameter so that they can be extracted by subsequent endoscopic retrograde cholangiopancreatography (ERCP). In our experience, complete clearance of the pancreatic duct was achieved in 76% and partial clearance in 17% of 1006 patients. Short-term pain relief with reduction in the number of analgesics ingested was seen in 84% of these patients. For large CBD calculi, a nasobiliary tube is placed to help target the calculi, as well as bathe the calculi in saline - a simple maneuver which helps to facilitate fragmentation. The aim is to fragment calculi to < 5 mm size and clear the same during ERCP. Complete clearance of the CBD was achieved in 84.4% of and partial clearance in 12.3% of 283 patients. More than 90% of the patients with pancreatic and biliary calculi needed three or fewer sessions of ESWL with 5000 shocks being delivered at each session. The use of epidural anesthesia helped in reducing patient movement. This, together with the better focus achieved with newer third-generation lithotripters, prevents collateral tissue damage and minimizes the complications. Complications in our experience with nearly 1300 patients were minimal, and no extension of hospital stay was required. Similar rates of clearance of pancreatic and biliary calculi with minimal adverse effects have been reported from the centers where ESWL is performed regularly. In view of its high efficiency, non-invasive nature and low complication rates, ESWL can be offered as the first-line therapy for selected patients with large pancreatic and CBD calculi.

Current status of immunomodulatory and cellular therapies in preclinical and clinical islet transplantation

Clinical islet transplantation is a β-cell replacement strategy that represents a possible definitive intervention for patients with type 1 diabetes, offering substantial benefits in terms of lowering daily insulin requirements and reducing incidences of debilitating hypoglycemic episodes and unawareness. Despite impressive advances in this field, a limiting supply of islets, inadequate means for preventing islet rejection, and the deleterious diabetogenic and nephrotoxic side effects associated with chronic immunosuppressive therapy preclude its wide-spread applicability. Islet transplantation however allows a window of opportunity for attempting various therapeutic manipulations of islets prior to transplantation aimed at achieving superior transplant outcomes. In this paper, we will focus on the current status of various immunosuppressive and cellular therapies that promote graft function and survival in preclinical and clinical islet transplantation with special emphasis on the tolerance-inducing capacity of regulatory T cells as well as the β-cells regenerative capacity of stem cells.

Adjuvant radiotherapy in the treatment of invasive intraductal papillary mucinous neoplasm of the pancreas: an analysis of the surveillance, epidemiology, and end results registry

BACKGROUND

Management and outcomes of patients with invasive intraductal papillary mucinous neoplasm (IPMN) of the pancreas are not well established. We investigated whether adjuvant radiotherapy (RT) improved cancer-specific survival (CSS) and overall survival (OS) among patients undergoing surgical resection for invasive IPMN.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) registry was used in this retrospective cohort study. All adult patients with resection of invasive IPMN from 1988 to 2007 were included. CSS and OS were analyzed using Kaplan-Meier curves. Unadjusted and propensity-score-adjusted Cox proportional-hazards modeling were used for subgroup analyses.

RESULTS

972 patients were included. Adjuvant RT was administered to 31.8% (n=309) of patients. There was no difference in overall median CSS or OS in patients who received adjuvant RT (5-year CSS: 26.5 months; 5-year OS: 23.5 months) versus those who did not (CSS: 28.5 months, P=0.17; OS: 23.5 months, P=0.23). Univariate predictors of survival were lymph node (LN) involvement, T4-classified tumors, and poorly differentiated tumor grade (all P<0.05). In the propensity-score-adjusted analysis, adjuvant RT was associated with improved 5-year CSS [hazard ratio (HR): 0.67, P=0.004] and 5-year OS (HR: 0.73, P=0.014) among all patients with LN involvement, though further analysis by T-classification demonstrated no survival differences among patients with T1/T2 disease; patients with T3/T4-classified tumors had improved CSS (HR: 0.71, P=0.022) but no difference in OS (HR: 0.76, P=0.06).

CONCLUSION

On propensity-score-adjusted analysis, adjuvant RT was associated with improved survival in selected subsets of patients with invasive IPMN, particularly those with T3/T4 tumors and LN involvement.

Evolution of β-Cell Replacement Therapy in Diabetes Mellitus: Islet Cell Transplantation

Diabetes mellitus remains one of the leading causes of morbidity and mortality worldwide. According to the Centers for Disease Control and Prevention, approximately 23.6 million people in the United States are affected. Of these individuals, 5 to 10% have been diagnosed with Type 1 diabetes mellitus (T1DM), an autoimmune disease. Although it often appears in childhood, T1DM may manifest at any age, leading to significant morbidity and decreased quality of life. Since the 1960s, the surgical treatment for diabetes mellitus has evolved to become a viable alternative to insulin administration, beginning with pancreatic transplantation. While islet cell transplantation has emerged as another potential alternative, its role in the treatment of T1DM remains to be solidified as research continues to establish it as a truly viable alternative for achieving insulin independence. In this paper, the historical evolution, procurement, current status, benefits, risks, and ongoing research of islet cell transplantation are explored.

Comparison of laparoscopic and open surgery for pyogenic liver abscess with biliary pathology

AIM: To investigate the feasibility and therapeutic effect of laparoscopic surgery for pyogenic liver abscess (PLA) with biliary pathology.

METHODS: From January 2004 to October 2010, 31 patients with PLA combined with biliary pathology meeting entry criteria received surgical management in our hospital. Of the 31 patients, 13 underwent laparoscopic surgery (LS group) and 18 underwent open surgery (OS group). Clinical data including operation time, intraoperative blood loss, postoperative complication rate, length of postoperative hospital stay, and abscess recurrence rate were retrospectively analyzed and compared between the two groups.

RESULTS: All patients received systemic antibiotic therapy. Four patients underwent ultrasound-guided percutaneous catheter drainage before operation. Postoperative complications occurred in 5 patients (16.1%, 5/31) including 2 in the LS group and 3 in the OS group. One patient had retained calculus in the common bile duct and another had liver abscess recurrence in the OS group. No retained calculus and liver abscess recurrence occurred in the LS group. In the two groups, there was no mortality during the perioperative period. There were no significant differences in operation time, intraoperative blood loss and transfusion, postoperative complication rate and abscess recurrence rate between the two groups. Oral intake was earlier (1.9 ± 0.4 d vs 3.1 ± 0.7 d, P < 0.05) and length of postoperative hospital stay was shorter (11.3 ± 2.9 d vs 14.5 ± 3.7 d, P < 0.05) in the LS group than in the OS group.

CONCLUSION: Laparoscopic surgery for simultaneous treatment of PLA and biliary pathology is feasible in selected patients and the therapeutic effect is similar to that of open surgery.

Robotic-assisted colon and rectal surgery: a systematic review

BACKGROUND

Colorectal surgery is one of the most common procedures performed by general surgeons, with an increasing number being performed laparoscopically. Robotic technology is emerging in the ongoing evolution in minimally invasive surgery. This study systematically reviews the literature regarding the safety and feasibility of robotic-assisted colorectal surgery.

METHODS

A comprehensive search of electronic databases was completed for the period 2000 to 2010. Two independent reviewers assessed the studies for relevance and inclusion, and extracted data.

RESULTS

After an initial screen of 347 titles, 20 studies met the inclusion criteria. A total of 854 patients were included with a mean age of 61 years and a body mass index of 25.5 kg/m(2) . Major complications included 27 anastamotic leaks (27/766 = 3.5%), 10 post-operative bleeds (1.1%) and 14 post-operative infections (1.6%). There were no mortalities reported.

CONCLUSIONS

This systematic review demonstrates that robotic-assisted colorectal surgery is emerging as a safe and feasible option in colorectal surgery.

Reducing preoperative fasting in elective adult surgical patients: a case-control study

BACKGROUND

The practice of fasting from midnight prior to surgery is an outdated one.

AIMS

The aim of this study was to assess the impact of an evidence-based protocol for reduced preoperative fasting on fasting times, patient safety, and comfort.

METHODS

A non-randomised case-control study of preoperative fasting times among adult surgical patients undergoing elective procedures was conducted. Consecutive patients were allocated to a reduced preoperative fasting protocol allowing fluids and solids up to 2 and 6 h prior to anaesthesia, respectively (n = 21). These were compared to control patients identified from an historic study of preoperative fasting times who followed the traditional fast from midnight (n = 29). Fasting times and details of patients' subjective comfort were collected using an interview-assisted questionnaire. Incidence of intraoperative aspirations was obtained from anaesthetic records.

RESULTS

Significant reductions in fasting times for fluids (p = 0.000) and solids (p = 0.000) were achieved following implementation of the fasting protocol. Less preoperative thirst (0.000), headache (0.012) and nausea (0.015) were reported by those who had a shorter fast. Intraoperative aspiration did not occur in either group.

CONCLUSION

Implementation of this protocol for reduced preoperative fasting achieved an appreciable reduction in fasting times and enhanced patient comfort. Patient safety was not compromised. Further modifications of our protocols are necessary to meet the international best practice. We recommend its implementation across all surgical groups in our institution.

Sentinel lymph node biopsy for gastric cancer: Where do we stand?

Development of sentinel node navigation surgery (SNNS) and advances in minimally invasive surgical techniques have greatly shaped the modern day approach to gastric cancer surgery. An extensive body of knowledge now exists on this type of clinical application but is principally composed of single institute studies. Certain dye tracers, such as isosulfan blue or patent blue violet, have been widely utilized with a notable amount of success; however, indocyanine green is gaining popularity. The double tracer method, a synchronized use of dye and radio-isotope tracers, appears to be superior to any of the dyes alone. In the meantime, the concepts of infrared ray electronic endoscopy, florescence imaging, nanoparticles and near-infrared technology are emerging as particularly promising alternative techniques. Hematoxylin and eosin staining remains the main method for the detection of sentinel lymph node (SLN) metastases. Several specialized centers have begun to employ immunohistochemical staining for this type of clinical analysis but the equipment costs involving the associated ultra-rapid processing systems is limiting its widespread application. Laparoscopic function-preserving resection of primary tumor from the stomach in conjunction with lymphatic basin dissection navigated by SLN identification represents the current paramount of SNNS for early gastric cancer. Patients with cT3 stage or higher still require standard D₂ dissection.

Light Sources for Single-Access Surgery

Background. Minimally invasive surgical techniques such as single access and natural orifice translumenal endoscopic surgery (NOTES) aim to reduce the number of external scars on the patient but impose restrictions on the space available for the light source within the endoscope and, therefore, the size of the field of view that can be sufficiently illuminated. Materials and Methods. This article presents and compares a number of illumination methods (xenon, light-emitting diodes, laser/phosphor, supercontinuum laser) that could be applied in single-access, robotic, and NOTES procedures. The luminance, spectral content, and intensity profile of each source was measured. Standardized images of each illuminating an abdominal simulator were assessed by a group of surgeons to provide an initial clinical impression. Results. The xenon source was found to have the highest luminance when used with a standard laparoscopic light cable, but this was significantly reduced when used with a small cable suitable for single-access applications. The supercontinuum laser–based light source had brightness comparable to the xenon, which was supported by the surgical test group observations. Conclusions. The supercontinuum fiber probe is a potential alternative to xenon light sources for use in single-access surgery with its comparable luminance, small diameter, flexibility, and even illumination. An initial in vivo test is described, providing a guide for future development.

Aquaporin-3 positively regulates matrix metalloproteinases via PI3K/AKT signal pathway in human gastric carcinoma SGC7901 cells

BACKGROUND

matrix metalloproteinases (MMPs) are produced by tumor cells, so they may be associated with tumor progression including invasion, migration, angiogenesis and metastasis. Aquaporin-3 (AQP3) also plays a critical role in gastric cancer cell migration and proliferation.

METHODS

In this study, AQP3 was silenced or over-expressed in SGC7901 cells.

RESULTS

We found a significant decrease in MT1-MMP, MMP-2, and MMP-9 expression after AQP3 knockdown, and a significant increase in MT1-MMP, MMP-2, and MMP-9 expression after AQP3 over-expression in SGC7901 cells. We also found that AQP3 silence led to a significant decrease of phosphorylation of ser473 in AKT in SGC7901 cells.

CONCLUSION

Our findings showed that AQP3 might positively regulate MMPs proteins expression through PI3K/AKT signal pathway in human gastric carcinoma SGC7901 cells.

Pancreas procurement and preservation for islet transplantation: personal considerations

Pancreatic islet transplantation is a promising option for the treatment of type 1 diabetic patients. After the successful demonstration of the Edmonton protocol, islet transplantation has advanced significantly on several fronts, including improved pancreas procurement and preservation systems. Since we frequently use pancreata from donors after cardiac death in Japan,we have applied the in situ regional organ cooling system for pancreas procurement to reduce the warm ischemic time. To reduce the apoptosis of pancreatic tissue during cold preservation, we have applied the ductal injection of preservation solution. For pancreas preservation, we use modified Kyoto solution, which is advantageous at trypsin inhibition and less collagenase inhibition. In this paper, we show pancreas procurement and preservation in our group for islet transplantation.

Robust spectral analysis of videocapsule images acquired from celiac disease patients

Background

Dominant frequency (DF) analysis of videocapsule endoscopy images is a new method to detect small intestinal periodicities that may result from mechanical rhythms such as peristalsis. Longer periodicity is related to greater image texture at areas of villous atrophy in celiac disease. However, extraneous features and spatiotemporal phase shift may mask DF rhythms.

Method

The robustness of Fourier and ensemble averaging spectral analysis to compute DF was tested. Videocapsule images from the distal duodenum of 11 celiac patients (frame rate 2/s and pixel resolution 576 × 576) were analyzed. For patients 1, 2, ... 11, respectively, a total of 10, 11, ..., 20 sequential images were extracted from a randomly selected time epoch. Each image sequence was artificially repeated to 200 frames, simulating periodicities of 0.2, 0.18, ..., 0.1Hz, respectively. Random white noise at four different levels, spatiotemporal phase shift, and frames with air bubbles were added. Power spectra were constructed pixel-wise over 200 frames, and an average spectrum was computed from the 576 × 576 individual spectra. The largest spectral peak in the average spectrum was the estimated DF. Error was defined as the absolute difference between actual DF and estimated DF.

Results

For Fourier analysis, the mean absolute error between estimated and actual DF was 0.032 ± 0.052Hz. Error increased with greater degree of random noise imposed. In contrast, all ensemble average estimates precisely predicted the simulated DF.

Conclusions

The ensemble average DF estimate of videocapsule images with simulated periodicity is robust to noise and spatiotemporal phase shift as compared with Fourier analysis. Accurate estimation of DF eliminates the need to impose complex masking, extraction, and/or corrective preprocessing measures.

Is pyogenic liver abscess associated with recurrent pyogenic cholangitis a distinct clinical entity? A retrospective analysis over a 10-year period in a regional hospital

BACKGROUND

Recurrent pyogenic cholangitis (RPC) is recognized as an important cause of pyogenic liver abscesses (PLA). Although it is endemic to Southeast Asia, it is seen increasing in the west mainly owing to immigration. The aim of this study is to compare the clinical characteristics of PLA in patients with RPC and without RPC.

METHODS

We performed a retrospective analysis involving patients with PLA. The demographic, clinical features, laboratory and imaging findings, management strategy, and outcome of patients with and without RPC were studied.

RESULTS

From January 2000 to December 2009 inclusive, 319 patients (27 with RPC and 292 without RPC) had PLA. Patients with RPC had higher mean age (71.7 vs. 64.9 years; P=0.03) and tended to have more acute onset of presentation than it did in those without RPC. The common clinical features of the two groups were fever, chill, and right upper quadrant pain. Patients without RPC tended to have more respiratory symptoms and signs. The laboratory abnormalities of both groups shared common features such as anemia, leukocytosis, high erythrocyte sedimentation rate and C-reactive protein, hypoalbuminemia, elevated total bilirubin, and alanine aminotransferase. Left lobe was predominantly involved in patients with RPC (51.9% vs. 23.6%; P<0.01) whereas those without RPC usually had PLA at right lobe (67.5 vs. 40.7%; P<0.01). Both groups also shared common radiological features such as hypoechoic in ultrasonograpphy, rim enhancement and septal lobulation in computed tomography. However, aerobila was found more in patients with RPC than those without RPC (25.9 vs. 5.5%; P<0.01) and the latter tended to have more abscess ruptures. The biliary tract disorder was the most common cause of the disease in the two groups. The microorganisms involved had distinct patterns between these two groups. Patients with RPC tended to have fewer complications than patients without RPC as there were fewer occurrences in metastatic infections, disseminated intravascular coagulation, and acute renal and respiratory failure. PLA in patients with RPC had higher recurrence rate than those without RPC (37 vs. 2.4%; P<0.01). The odds ratio of local recurrence between RPC and non-RPC group was 23.95 (95% confidence interval, 8.11-70.72). However, both were effectively managed by the combination of antibiotic and image-guided aspiration with/without drainage, and their mortality rates are comparable with each other.

CONCLUSION

PLA associated with RPC tends to have distinct clinical syndrome in regards to different extent of clinical manifestations, radiological and microbiological features, and complications. Its recurrent rate is higher than that of non-RPC type. However, both can be effectively treated with a combination of antibiotic and image-guided aspiration with/without drainage.

Abdominal-pelvic actinomycosis mimicking malignant neoplasm

Abdominal-pelvic actinomycosis is often mistaken for other conditions, presenting a preoperative diagnostic challenge. In a 46-year-old female, computed tomography showed an abdominal-pelvic retroperitoneal mass extending from the lower pole of the right kidney to the lower pelvis. The patient had a 3-year history of intrauterine device. The mass appeared to involve the ascending colon, cecum, distal ileum, right Fallopian tube and ovary, and ureter anteriorly and the psoas muscle posteriorly. The resection of retroperitoneal mass, distal ileum appendicectomy, right hemicolectomy, and right salpingo-oophorectomy was performed. The postoperative period was uneventful. Penicillin therapy was given for six months without any complication. The retroperitoneal mass measured 4.5 × 3.5 × 3 cm, surrounded adjacent organs and histologically showed inflammatory granulomatous tissue, agglomeration of filaments, and sulfur granules of Actinomyces, with positive reaction with periodic acid Schiff. Right tubo-ovarian abscess was present. Abdominalpelvic actinomycosis should always be considered in patients with a pelvic mass especially in ones using intrauterine device.

Malignant peritoneal mesothelioma presenting with persistent high fever

Malignant peritoneal mesothelioma (MPM) is a rare tumor that develops in the peritoneum. In this paper, we describe an extremely rare case of MPM metastasizing to the appendix in a 48-year-old female who initially presented with a persistent high fever. The woman reported a slight lower abdominal discomfort which had been relieved by urination for four months. She had lost 5 kg of weight. There was no nausea, vomiting, diarrhea, abdominal pain, or abdominal distension. Many broad spectrum antibiotics were given without relief of fever. Computed tomography (CT) scans revealed a thickened omentum majus and diffused multiple omental nodules. An omentectomy, appendectomy, and adnexectomy were carried out. A gross pathologic specimen of omentum tissue revealed a firm gray-white mass. Microscopic and immunohistochemical examinations confirmed the diagnosis of appendiceal and bilateral adnexal metastases of an MPM. These results suggest that MPM should be considered in the differential diagnosis of unexplained persistent high fever. Awareness of such atypical presentations of mesothelioma may help to make a correct diagnosis.

Diagnosis and management of cystic lesions of the pancreas

Pancreatic cysts are challenging lesions to diagnose and to treat. Determining which of the five most common diagnoses—pancreatic pseudocyst, serous cystic neoplasm (SCN), solid pseudopapillary neoplasm (SPN), mucinous cystic neoplasm (MCN), and intraductal mucinous papillary neoplasm (IPMN)—is likely the correct one requires the careful integration of many historical, radiographic, laboratory, and other factors, and management is markedly different depending on the type of cystic lesion of the pancreas. Pseudocysts are generally distinguishable based on historical, clinical and radiographic characteristics, and among the others, the most important differentiation is between the mucin-producing MCN and IPMN (high risk for cancer) versus the serous SCN and SPN (low risk for cancer). EUS with FNA and cyst-fluid analysis will continue to play an important role in diagnosis. Among mucinous lesions, those that require treatment (resection currently) are any MCN, any MD IPMN, and BD IPMN larger than 3 cm, symptomatic, or with an associated mass, with the understanding that SCN or pseudocysts may be removed inadvertently due to diagnostic inaccuracy, and that a certain proportion of SPN will indeed be malignant at the time of removal. The role of ethanol ablation is under investigation as an alternative to resection in selected patients.

Jejunal Diverticular Perforation due to Enterolith

Jejunal diverticulosis is a rare entity with variable clinical and anatomical presentations. Although there is no consensus on the management of asymptomatic jejunal diverticular disease, some complications are potentially life-threatening and require early surgical treatment. Small bowel perforation secondary to jejunal diverticulitis by enteroliths is rare. The aim of this study was to report a case of small intestinal perforation caused by a large jejunal enterolith. An 86-year-old woman was admitted with signs of diffuse peritonitis. After initial fluid recovery the patient underwent emergency laparotomy. The surgery showed that she had small bowel diverticular disease, mainly localized in the proximal jejunum. The peritonitis was due to intestinal perforation caused by an enterolith 12 cm in length, localized inside one of these diverticula. The intestinal segment containing the perforated diverticulum with the enterolith was removed and an end-to-end anastomosis was done to reconstruct the intestinal transit. The patient recovered well and was discharged from hospital on the 5th postoperative day. There were no signs of abdominal pain 1 year after the surgical procedure. Although jejunal diverticular disease with its complications, such as formation of enteroliths, is difficult to suspect in patients with peritonitis, it should be considered as a possible source of abdominal infection in the elderly patient when more common diagnoses have been excluded.

Progress in research of intraductal papillary mucinous neoplasms

Intraductal papillary mucinous neoplasms (IPMNs) represent a spectrum of neoplasms arising from the main pancreatic duct or branch ducts and producing mucin and can be regarded as a type of precancerous lesions. Thanks to improvements in endoscopy and imaging techniques, IPMNs are being diagnosed with increasing frequency. However, there are currently no highly sensitive and specific preoperative criteria available to distinguish benign IPMNs from malignant ones. What's more, the necessity for EUS and ERCP in the diagnosis of IPMNs is still under debate. Here, we review recent advances in research of IPMNs and summarize potential differences between benign and malignant IPMNs.

Hepatic flow optimization in full right split liver transplantation

Split liver transplantation for two adults offers a valuable opportunity to expand the donor pool for adult recipients. However, its application is mainly hampered by the physiological limits of these partial grafts. Small for size syndrome is a major concern during transplantation with partial graft and different techniques have been developed in living donor liver transplantation to prevent the graft dysfunction. Herein, we report the first application of synergic approaches to optimise the hepatic hemodynamic in a split liver graft for two adults. A Caucasian woman underwent liver transplantation for alcoholic cirrhosis (MELD 21) with a full right liver graft (S5-S8) without middle hepatic vein. Minor and accessory inferior hepatic veins were preserved by splitting the vena cava; V5 and V8 were anastomosed with a donor venous iliac patch. After implantation, a 16G catheter was advanced in the main portal trunk. Inflow modulation was achieved by splenic artery ligation. Intraportal infusion of PGE1 was started intraoperatively and discontinued after 5 d. Graft function was immediate with normalization of liver test after 7 d. Nineteen months after transplantation, liver function is normal and graft volume is 110% of the recipient standard liver volume. Optimisation of the venous outflow, inflow modulation and intraportal infusion of PGE1 may represent a valuable synergic strategy to prevent the graft dysfunction and it may increase the safety of split liver graft for two adults.

Acute liver failure

PURPOSE OF REVIEW

Acute liver failure (ALF) results in a multitude of serious complications that often lead to multi-organ failure. This brief review focuses on the pathophysiological processes in ALF and how to manage these.

RECENT FINDINGS

The clinical presentation in ALF ranges from slightly altered conscious level with profound coagulopathy to coma with a catastrophic failure of multiple organs, including uncontrollable cerebral edema and brain death, which is rarely seen in decompensated cirrhosis. Interestingly, ALF patients who recover as the liver is regenerating, usually do not suffer from hepatic or extrahepatic sequelae. In contrast patients surviving acute-on-chronic liver failure will return to a state with incompensated cirrhosis, and eventually need transplantation for survival.In the management of ALF, the use of noradrenalin in combination with continuous high-dose renal replacement therapy, terlipressin, hypertonic sodium chloride, and mannitol can ameliorate systemic vasodilation and attenuate brain edema. Furthermore, liver assist devices seem to improve extrahepatic organ dysfunction and survival.

SUMMARY

Insight into the of pathopysiological mechanisms of ALF that lead to cardiovascular instability, brain edema and development of multiorgan failure has advanced and resulted in improved survival. The role of liver assisting is still unknown but preliminary results indicate a positive effect on survival.

Acute-on-chronic liver failure: extracorporeal liver assist devices

PURPOSE OF REVIEW

Acute-on-chronic liver failure (ACLF), a syndrome precipitated by acute liver injury in patients with advanced cirrhosis, is associated with multiorgan dysfunction and high rates of mortality. Liver support systems have been developed in an attempt to improve survival of patients with ACLF by providing a bridge until recovery of the native liver function.

RECENT FINDINGS

Nonbiological devices such as molecular adsorbent recirculating system (MARS) and fractionated plasma separation and adsorption (Prometheus) are effective in improving severe hepatic encephalopathy and cholestasis, have good safety and tolerability profiles and are frequently employed in patients with ACLD; however, randomized controlled trials (RCTs) failed to show improvement in survival. Biologic devices that incorporate hepatic cells in bioreactors are also under development. Recent data from pilot studies suggested improvement in survival rates in some groups of patients with ACLF; however, their effect on patient survival in RCT is still unknown.

SUMMARY

Liver support systems are safe and well tolerated when used in management of patients with ACLF. Their use should continue in controlled clinical trials to explore their role in bridging patients to liver transplantation or recovery in well defined patient groups.

Intraductal papillary mucinous neoplasm

Intraductal papillary mucinous neoplasm (IPMN) is a grossly visible (≥1 cm), mucin-producing neoplasm that arises in the main pancreatic duct and/or its branches. Patients with intraductal papillary mucinous neoplasm can present with symptoms caused by obstruction of the pancreatic duct system, or they can be asymptomatic. There are 3 clinical subtypes of intraductal papillary mucinous neoplasm: main duct, branch duct, and mixed. Five histologic types of intraductal papillary mucinous neoplasm are recognized: gastric foveolar type, intestinal type, pancreatobiliary type, intraductal oncocytic papillary neoplasm, and intraductal tubulopapillary neoplasm. Noninvasive intraductal papillary mucinous neoplasms are classified into 3 grades based on the degree of cytoarchitectural atypia: low-, intermediate-, and high-grade dysplasia. The most important prognosticator, however, is the presence or absence of an associated invasive carcinoma. Some main duct-intraductal papillary mucinous neoplasms progress into invasive carcinoma, mainly tubular adenocarcinoma (conventional pancreatic ductal adenocarcinoma) and colloid carcinoma. Branch duct-intraductal papillary mucinous neoplasms have a low risk for malignant transformation. Preoperative prediction of the malignant potential of an intraductal papillary mucinous neoplasm is of growing importance because pancreatic surgery has its complications, and many small intraductal papillary mucinous neoplasms, especially branch duct-intraductal papillary mucinous neoplasms, have an extremely low risk of progressing to an invasive cancer. Although most clinical decision making relies on imaging, a better understanding of the molecular genetics of intraductal papillary mucinous neoplasm could help identify molecular markers of high-risk lesions. When surgery is performed, intraoperative frozen section assessment of the pancreatic resection margin can guide the extent of resection. Intraductal papillary mucinous neoplasms are often multifocal, and surgically resected patients should be followed for metachronous disease.

Management of early gastrointestinal neuroendocrine neoplasms

Neuroendocrine neoplasms (NENs) of the stomach, duodenum, appendix or rectum that are small (≤ 1 cm) and well differentiated can be considered “early” tumors, since they generally have a (very) good prognosis. In the new WHO classification of 2010, these neoplasms are called neuroendocrine tumors/ carcinoids (NETs), grade (G) 1 or 2, and distinguished from poorly differentiated neuroendocrine carcinomas (NECs), G3. NETs are increasing, with a rise in the age-adjusted incidence in the U.S.A. by about 700 % in the last 35 years. Improved early detection seems to be the main reason for these epidemiological changes. Both the better general availability of endoscopy, and imaging techniques, have led to a shift in the discovery of smaller-sized (≤ 10-20 mm) intestinal NETs/carcinoids and earlier tumor stages at diagnosis. Endoscopic screening is therefore effective in the early diagnosis, not only of colorectal adenocarcinomas, but also of NETs/carcinoids. Endoscopic removal, followed up with endoscopic surveillance is the treatment of choice in NETs/carcinoids of the stomach, duodenum and rectum that are ≤ 10 mm in size, have a low proliferative activity (G1), do not infiltrate the muscular layer and show no angioinvasion. In all the other intestinal NENs, optimal treatment generally needs surgery and/or medical therapy depending on type, biology and stage of the tumor, as well as the individual situation of the patient.

"Nil per oral after midnight": Is it necessary for clear fluids?

Fasting before general anaesthesia aims to reduce the volume and acidity of stomach contents, thus reducing the risk of regurgitation and aspiration. Recent guidelines have recommended a shift in fasting policies from the standard ‘nil per oral from midnight’ to a more relaxed policy of clear fluid intake a few hours before surgery. The effect of preoperative oral administration of 150 ml of water 2 h prior to surgery was studied prospectively in 100 ASA I and II patients, for elective surgery. Patients were randomly assigned to two groups. Group I (n = 50) was fasting overnight while Group II (n = 50) was given 150 ml of water 2 h prior to surgery. A nasogastric tube was inserted after intubation and gastric aspirate was collected for volume and pH. The gastric fluid volume was found to be lesser in Group II (5.5 ± 3.70 ml) than Group I (17.1 ± 8.2 ml) which was statistically significant. The mean pH values for both groups were similar. Hence, we conclude that patients not at risk for aspiration can be allowed to ingest 150 ml water 2 h prior to surgery.

Disinfection of the Access Orifice in NOTES: Evaluation of the Evidence Base

Introduction. Appropriate prevention of infection is a key area of research in natural orifice translumenal endoscopic surgery (NOTES), as identified by the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR). Methods. A review of the literature was conducted evaluating the evidence base for access orifice preparation/treatment in NOTES procedures in the context of infectious complications. Recommendations based on the Oxford Centre for Evidence-Based Medicine guidelines were made. Results. The most robust evidence includes several experimental randomised controlled trials assessing infectious complications in the transgastric approach to NOTES. Transvaginal procedures are long established for accessing the peritoneal cavity following disinfection with antiseptic. Only experimental case series for transcolonic and transvesical approaches are described. Conclusion. Grade C recommendation requiring no preoperative preparation can be made for the transgastric approach. Antiseptic irrigation is recommended for transvaginal (grade C) NOTES access, as is current practice. Further human trials need to be conducted to corroborate the current evidence base for transgastric closure. It is important that future trials are conducted in a methodologically robust fashion, with emphasis on clinical outcomes and standardisation of enterotomy closure and postoperative therapy.

Metastases to the pancreas: the experience of a high volume center and a review of the literature

BACKGROUND

Metastasis to the pancreas (PM) is uncommon. Several types of cancers were reported to metastasize to the pancreas. Surgery is advocated in selected patients when technically feasible and if the patient can be rendered disease free.

METHODS

A retrospective review of PM patients at the University of Cincinnati Pancreas Database was performed over a 7-year time period.

RESULTS

Twenty patients with a median age of 62.5 years were identified. Fifteen patients (75%) were males and (50%) presented with abdominal pain. Nine patients (45.0%) were offered surgical resection, distal pancreatectomy was the most common procedure (n = 4, 44.4%). The commonest pathology was RCC (60%), followed by lung (20%), colon (15%), and breast (5%). Median disease free interval (DFI) was 96 months for RCC, 7 months for other pathologies. Median survival was 19 months for RCC, 8.5 months for other pathologies. Based on DFI, short DFI patients (≤12 months) had worse prognosis (2-year survival of 40%), as opposed to (2-year survival of 80%) in longer DFI patients (P = 0.01). RCC patients with a DFI longer than 94 months had a better survival (P = 0.01). Survival of resected PM tended to be longer than non-resected PM (P = 0.11).

CONCLUSIONS

PM from RCC carries a consistently favorable prognosis compared to other pathologies. Surgical resection of PM is a safe and viable option, and, in selected patients, may improve survival. However, a period of expectant management in patients with short DFI may be considered.

Metastasis to the pancreas and the spleen: an increasing diagnostic and therapeutic challenge

We have reviewed the electronic biopsies database files of the Department of Surgical Pathology, Fundación Jiménez Díaz in Madrid (Spain). In this time period (1998–2010) we have found 3 pancreatic metastasis and 5 splenic metastasis. Two of the pancreatic metastases were originated in clear cell renal cell carcinomas. The last pancreatic metastasis was from a malignant cutaneous melanoma diagnosed and treated 8 years before. As for splenic metastasis, three of them were diagnosed during the abdominal surgery for primary therapy of the tumour (2 ovaries and one endometrium), while the remaining 2 corresponded to metastasis from a lung primary diagnosed 1 year before and a colonic primary diagnosed 6 years before. The patients with splenic metastasis died on the short term with progression of the disease despite resection of the splenic lesions, while the patients with pancreatic metastasis have survived longer.

Review of histopathological and molecular prognostic features in colorectal cancer

Prediction of prognosis in colorectal cancer is vital for the choice of therapeutic options. Histopathological factors remain paramount in this respect. Factors such as tumor size, histological type and subtype, presence of signet ring morphology and the degree of differentiation as well as the presence of lymphovascular invasion and lymph node involvement are well known factors that influence outcome. Our understanding of these factors has improved in the past few years with factors such as tumor budding, lymphocytic infiltration being recognized as important. Likewise the prognostic significance of resection margins, particularly circumferential margins has been appreciated in the last two decades. A number of molecular and genetic markers such as KRAS, BRAF and microsatellite instability are also important and correlate with histological features in some patients. This review summarizes our current understanding of the main histopathological factors that affect prognosis of colorectal cancer.

[Gastric neuroendocrine tumors. Endoscopic and surgical treatment]

Neuroendocrine tumors (NETs) of the stomach are the most frequent among all neuroendocrine neoplasms in the digestive tract. The diagnosis and classification are complicated by the fact that these tumors have to be categorized not only by common staging and grading but also according to their pathophysiological background (types). The types differ in their biological behaviour (aggressiveness) which influences therapeutic concepts. This article explains and summarizes the etiology and classification of gastric NETs and offers a precise concept for diagnosis and treatment to improve clinical outcome.

[Surgical infections as patient safety problems]

Surgical infections are severe complications of surgical interventions and one of the most important patient safety issues. These are associated with increased morbidity, mortality, costs and decreased quality of life. Prevention of infections is essential, while one has to consider pre-, intra- and postoperative factors and procedures in the clinical practice. In this article we summarize the latest recommendations for clinicians based on the relevant published literature.

Nonalcoholic steatohepatitis (NASH) after pancreaticoduodenectomy: association of pancreatic exocrine deficiency and infection

Previous clinical study has demonstrated that 30-40% of patients undergoing pancreaticoduodenectomy (PD) developed hepatic steatosis. However, nonalcoholic steatohepatitis (NASH) is a little-known complication after PD. Recently we encountered two patients with PD who later developed NASH diagnosed by liver biopsy. Case 1 was a 79-year-old woman who underwent PD for intraductal papillary mucinous neoplasm (IPMN). She had postoperative severe diarrhea due to pseudomembranous enterocolitis. Severe liver dysfunction was observed on the 31st postoperative day. Abdominal computed tomography (CT) on the 32nd day showed remarkably decreased hepatic CT value of 6 HU. Immediate liver biopsy revealed NASH (Brunt criteria: grade 2, stage 2). Case 2 was a 71-year-old woman who underwent PD for IPMN. Liver biopsy on 70th postoperative day, which was performed for assessment of moderate liver dysfunction and decreased hepatic CT value of 44 HU, demonstrated simple steatosis. In the 21st postoperative month, she developed severe urinary tract infection together with marked liver dysfunction. Immediate liver biopsy revealed NASH (Brunt criteria: grade 1, stage 1). For each patient, treatment of infection and high-dose pancreatic enzyme supplements improved liver dysfunction and liver steatosis. Clinical features of our cases seem to support the current leading hypothesis of the pathogenesis of NASH, i.e., the two-hit theory.

Role of living donor liver transplantation in the treatment of hepatitis C virus infection

Hepatitis C virus (HCV) infection is one of the most common indications for liver transplantation worldwide. Because of the existing organ shortage, adult-to-adult living donor liver transplantation (LDLT) has become an important method of expanding the donor pool to meet the ever-increasing need. However, despite advantages such as the quality of the hepatic graft and the timing of the transplant, the exact role of LDLT in the treatment of HCV is still unclear. In this review, we aim to address some of these issues in an effort to highlight both the advantages and disadvantages, as well as to identify the main challenges, of using LDLT for treating patients with HCV infection.

Review of screening for pancreatic cancer in high risk individuals

Pancreatic cancer is difficult to diagnose at an early stage and is associated with a very poor survival. Ten percent of pancreatic cancers result from genetic susceptibility and/or familial aggregation. Individuals from families with multiple affected first-degree relatives and those with a known cancer-causing genetic mutation have been shown to be at much higher risk of developing pancreatic cancer. Recent efforts have focused on detecting disease at an earlier stage to improve survival in these high-risk groups. This article reviews high-risk groups, screening methods, and current screening programs and their results.

A natural orifice transrectal approach for oncologic resection of the rectosigmoid: an experimental study and comparison with conventional laparoscopy

BACKGROUND

A transrectal (TR) approach for natural orifice translumenal endoscopic surgery (NOTES) makes sense for colorectal surgery because the colotomy can be incorporated into subsequent anastomosis. Because cancer is a primary indication for left-sided colon resection, oncologic standards will have to be met by a NOTES procedure. This study aimed to assess whether pure TR rectosigmoidectomy can be performed with strict adherence to oncologic principles compared with a conventional laparoscopically assisted approach (LAP).

METHODS

Human male cadavers were allocated to either TR (n = 4) or LAP (n = 2). A simulated sigmoid lesion was created at 25 cm. Transrectal retrograde mobilization of the rectosigmoid was performed using conventional transanal endoscopic microsurgery (TEM) instrumentation. After ligation of the superior hemorrhoidal artery and further mobilization, the specimen was delivered transanally and divided extracorporeally. Using a circular stapler, NOTES colorectal anastomosis was performed. Lymph node yield, adequate resection margins, and operative time were compared with LAP.

RESULTS

Transrectal retrograde rectosigmoid dissection was achieved in all attempts (4/4) and showed numbers of lymph nodes (median, 5; range, 3-6) similar to the LAP group (median, 4.5; range, 2-7). One pure TR approach failed to resect the lesion. Three TR procedures required additional mobilization via an abdominal approach to provide adequate margins. The mean length of TR specimens was 16 ± 4 cm compared with 31 ± 9 cm achieved by LAP (p < 0.01). The TR operative time was significantly longer (247 ± 15 vs 110 ± 14 min).

CONCLUSION

Lymph node yield during TR rectosigmoidectomy was similar to that achieved by the LAP approach. However, conventional TEM instrumentation alone did not permit adequate colon mobilization. This indicates a need for flexible instrumentation or other technical solutions to perform true NOTES colectomies.