Learning Curves of Minimally Invasive Distal Pancreatectomy in Experienced Pancreatic Centers

Importance

Understanding the learning curve of a new complex surgical technique helps to reduce potential patient harm. Current series on the learning curve of minimally invasive distal pancreatectomy (MIDP) are mostly small, single-center series, thus providing limited data.

Objective

To evaluate the length of pooled learning curves of MIDP in experienced centers.

Design, Setting, and Participants

This international, multicenter, retrospective cohort study included MIDP procedures performed from January 1, 2006, through June 30, 2019, in 26 European centers from 8 countries that each performed more than 15 distal pancreatectomies annually, with an overall experience exceeding 50 MIDP procedures. Consecutive patients who underwent elective laparoscopic or robotic distal pancreatectomy for all indications were included. Data were analyzed between September 1, 2021, and May 1, 2022.

Exposures

The learning curve for MIDP was estimated by pooling data from all centers.

Main Outcomes and Measures

The learning curve was assessed for the primary textbook outcome (TBO), which is a composite measure that reflects optimal outcome, and for surgical mastery. Generalized additive models and a 2-piece linear model with a break point were used to estimate the learning curve length of MIDP. Case mix-expected probabilities were plotted and compared with observed outcomes to assess the association of changing case mix with outcomes. The learning curve also was assessed for the secondary outcomes of operation time, intraoperative blood loss, conversion to open rate, and postoperative pancreatic fistula grade B/C.

Results

From a total of 2610 MIDP procedures, the learning curve analysis was conducted on 2041 procedures (mean [SD] patient age, 58 [15.3] years; among 2040 with reported sex, 1249 were female [61.2%] and 791 male [38.8%]). The 2-piece model showed an increase and eventually a break point for TBO at 85 procedures (95% CI, 13-157 procedures), with a plateau TBO rate at 70%. The learning-associated loss of TBO rate was estimated at 3.3%. For conversion, a break point was estimated at 40 procedures (95% CI, 11-68 procedures); for operation time, at 56 procedures (95% CI, 35-77 procedures); and for intraoperative blood loss, at 71 procedures (95% CI, 28-114 procedures). For postoperative pancreatic fistula, no break point could be estimated.

Conclusion and Relevance

In experienced international centers, the learning curve length of MIDP for TBO was considerable with 85 procedures. These findings suggest that although learning curves for conversion, operation time, and intraoperative blood loss are completed earlier, extensive experience may be needed to master the learning curve of MIDP.

Oncological outcomes after pancreatoduodenectomy for pancreatic ductal adenocarcinoma in octogenarians: case-control study

BACKGROUND

By the end of this decade, 70 per cent of all diagnosed pancreatic ductal adenocarcinomas will be in the elderly. Surgical resection is the only curative option. In the elderly perioperative mortality is higher, while controversy still exists as to whether aggressive treatment offers any survival benefit. This study aimed to assess the oncological benefit of pancreatoduodenectomy in octogenarians with pancreatic ductal adenocarcinoma.

METHOD

Retrospective multicentre case-control study of octogenarians and younger controls who underwent pancreatoduodenectomy for pancreatic ductal adenocarcinoma between 2008 and 2017. The primary endpoint was overall survival and the secondary endpoint was disease-free survival.

RESULTS

Overall, 220 patients were included. Although the Charlson co-morbidity index was higher in octogenerians, Eastern Cooperative Oncology Group performance status, ASA and pathological parameters were comparable. Adjuvant therapy was more frequently delivered in the younger group (n = 80, 73 per cent versus n = 58, 53 per cent, P = 0.006). There was no significant difference between octogenarians and controls in overall survival (20 versus 29 months, P = 0.095) or disease-free survival (19 versus 22 months, P = 0.742). On multivariable analysis, age was not an independent predictor of either oncological outcome measured.

CONCLUSION

Octogenarians with pancreatic ductal adenocarcinoma of the head and uncinate process may benefit from comparable oncological outcomes to younger patients with surgical treatment. Due to the age- and disease-related frailty and co-morbidities, careful preoperative assessment and patient selection is of paramount importance.

Surgical outcomes of gallbladder cancer: the OMEGA retrospective, multicentre, international cohort study

Background

Gallbladder cancer (GBC) is rare but aggressive. The extent of surgical intervention for different GBC stages is non-uniform, ranging from cholecystectomy alone to extended resections including major hepatectomy, resection of adjacent organs and routine extrahepatic bile duct resection (EBDR). Robust evidence here is lacking, however, and survival benefit poorly defined. This study assesses factors associated with recurrence-free survival (RFS), overall survival (OS) and morbidity and mortality following GBC surgery in high income countries (HIC) and low and middle income countries (LMIC).

Methods

The multicentre, retrospective Operative Management of Gallbladder Cancer (OMEGA) cohort study included all patients who underwent GBC resection across 133 centres between 1st January 2010 and 31st December 2020. Regression analyses assessed factors associated with OS, RFS and morbidity.

Findings

On multivariable analysis of all 3676 patients, wedge resection and segment IVb/V resection failed to improve RFS (HR 1.04 [0.84-1.29], p = 0.711 and HR 1.18 [0.95-1.46], p = 0.13 respectively) or OS (HR 0.96 [0.79-1.17], p = 0.67 and HR 1.48 [1.16-1.88], p = 0.49 respectively), while major hepatectomy was associated with worse RFS (HR 1.33 [1.02-1.74], p = 0.037) and OS (HR 1.26 [1.03-1.53], p = 0.022). Furthermore, EBDR (OR 2.86 [2.3-3.52], p < 0.0010), resection of additional organs (OR 2.22 [1.62-3.02], p < 0.0010) and major hepatectomy (OR 3.81 [2.55-5.73], p < 0.0010) were all associated with increased morbidity and mortality. Compared to LMIC, patients in HIC were associated with poorer RFS (HR 1.18 [1.02-1.37], p = 0.031) but not OS (HR 1.05 [0.91-1.22], p = 0.48). Adjuvant and neoadjuvant treatments were infrequently used.

Interpretation

In this large, multicentre analysis of GBC surgical outcomes, liver resection was not conclusively associated with improved survival, and extended resections were associated with greater morbidity and mortality without oncological benefit. Aggressive upfront resections do not benefit higher stage GBC, and international collaborations are needed to develop evidence-based neoadjuvant and adjuvant treatment strategies to minimise surgical morbidity and prioritise prognostic benefit.

Funding

Cambridge Hepatopancreatobiliary Department Research Fund.

Robot-Assisted Versus Laparoscopic Distal Pancreatectomy in Patients with Resectable Pancreatic Cancer: An International, Retrospective, Cohort Study

BACKGROUND

Robot-assisted distal pancreatectomy (RDP) is increasingly used as an alternative to laparoscopic distal pancreatectomy (LDP) in patients with resectable pancreatic cancer but comparative multicenter studies confirming the safety and efficacy of RDP are lacking.

METHODS

An international, multicenter, retrospective, cohort study, including consecutive patients undergoing RDP and LDP for resectable pancreatic cancer in 33 experienced centers from 11 countries (2010-2019). The primary outcome was R0-resection. Secondary outcomes included lymph node yield, major complications, conversion rate, and overall survival.

RESULTS

In total, 542 patients after minimally invasive distal pancreatectomy were included: 103 RDP (19%) and 439 LDP (81%). The R0-resection rate was comparable (75.7% RDP vs. 69.3% LDP, p = 0.404). RDP was associated with longer operative time (290 vs. 240 min, p < 0.001), more vascular resections (7.6% vs. 2.7%, p = 0.030), lower conversion rate (4.9% vs. 17.3%, p = 0.001), more major complications (26.2% vs. 16.3%, p = 0.019), improved lymph node yield (18 vs. 16, p = 0.021), and longer hospital stay (10 vs. 8 days, p = 0.001). The 90-day mortality (1.9% vs. 0.7%, p = 0.268) and overall survival (median 28 vs. 31 months, p = 0.599) did not differ significantly between RDP and LDP, respectively.

CONCLUSIONS

In selected patients with resectable pancreatic cancer, RDP and LDP provide a comparable R0-resection rate and overall survival in experienced centers. Although the lymph node yield and conversion rate appeared favorable after RDP, LDP was associated with shorter operating time, less major complications, and shorter hospital stay. The specific benefits associated with each approach should be confirmed by multicenter, randomized trials.

Benchmarking of robotic and laparoscopic spleen-preserving distal pancreatectomy by using two different methods

BACKGROUND

Benchmarking is an important tool for quality comparison and improvement. However, no benchmark values are available for minimally invasive spleen-preserving distal pancreatectomy, either laparoscopically or robotically assisted. The aim of this study was to establish benchmarks for these techniques using two different methods.

METHODS

Data from patients undergoing laparoscopically or robotically assisted spleen-preserving distal pancreatectomy were extracted from a multicentre database (2006-2019). Benchmarks for 10 outcomes were calculated using the Achievable Benchmark of Care (ABC) and best-patient-in-best-centre methods.

RESULTS

Overall, 951 laparoscopically assisted (77.3 per cent) and 279 robotically assisted (22.7 per cent) procedures were included. Using the ABC method, the benchmarks for laparoscopically assisted and robotically assisted spleen-preserving distal pancreatectomy respectively were: 150 and 207 min for duration of operation, 55 and 100 ml for blood loss, 3.5 and 1.7 per cent for conversion, 0 and 1.7 per cent for failure to preserve the spleen, 27.3 and 34.0 per cent for overall morbidity, 5.1 and 3.3 per cent for major morbidity, 3.6 and 7.1 per cent for pancreatic fistula grade B/C, 5 and 6 days for duration of hospital stay, 2.9 and 5.4 per cent for readmissions, and 0 and 0 per cent for 90-day mortality. Best-patient-in-best-centre methodology revealed milder benchmark cut-offs for laparoscopically and robotically assisted procedures, with operating times of 254 and 262.5 min, blood loss of 150 and 195 ml, conversion rates of 5.8 and 8.2 per cent, rates of failure to salvage spleen of 29.9 and 27.3 per cent, overall morbidity rates of 62.7 and 55.7 per cent, major morbidity rates of 20.4 and 14 per cent, POPF B/C rates of 23.8 and 24.2 per cent, duration of hospital stay of 8 and 8 days, readmission rates of 20 and 15.1 per cent, and 90-day mortality rates of 0 and 0 per cent respectively.

CONCLUSION

Two benchmark methods for minimally invasive distal pancreatectomy produced different values, and should be interpreted and applied differently.

HPB P03 Oncological outcomes are comparable between octogenarians and younger patients after pancreatoduodenectomy for pancreatic ductal adenocarcinoma

Background

Oncological outcomes are comparable between octogenarians and younger patients after pancreatoduodenectomy for pancreatic ductal adenocarcinoma

Methods

A multicentre case-control study of octogenarians matched on complexity of surgery with consecutive younger controls who underwent PD for PDAC (2008–2017).

Results

Some 220 patients were included, 110 octogenarians (age 81 (80–83)) and 110 controls (age 69 (62–74)). Charlson Comorbidity Index score was higher in octogenarians than controls (7 (6–8) vs 5 (4–6)), p&lt;0.0001) but Eastern Cooperative Oncology Group performance status (Groups 0–1: 99 vs 98; 2–3: 5 vs 4, p=0.756) and ASA (ASA 1–2: 72 vs 77; 3–4: 20 vs 18; p=0.635) were comparable. Adjuvant therapy was delivered more commonly in the younger cohort (76.2 vs 58.0%, p= 0.007). Tumour stage, lymph node ratio and resection margin status were comparable between groups. There was no difference between octogenarians and controls in OS (20 (14–26) vs 29, (24–24) months p=0.095) or DFS (19,(13–24) vs 22,(15–29) months p=0.742). On multivariate analysis, age was not a risk predictor.

Conclusions

In selected fit octogenarians, equivalent survival is achievable. Centralisation and multimodal therapy are key. Pre-operative risk stratification using at ECOG and albumin level can be used to identify an appropriate population.

Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

Benchmarking of minimally invasive distal pancreatectomy with splenectomy: European multicentre study

Background

Benchmarking is the process to used assess the best achievable results and compare outcomes with that standard. This study aimed to assess best achievable outcomes in minimally invasive distal pancreatectomy with splenectomy (MIDPS).

Methods

This retrospective study included consecutive patients undergoing MIDPS for any indication, between 2003 and 2019, in 31 European centres. Benchmarks of the main clinical outcomes were calculated according to the Achievable Benchmark of Care (ABC™) method. After identifying independent risk factors for severe morbidity and conversion, risk-adjusted ABCs were calculated for each subgroup of patients at risk.

Results

A total of 1595 patients were included. The ABC was 2.5 per cent for conversion and 8.4 per cent for severe morbidity. ABC values were 160 min for duration of operation time, 8.3 per cent for POPF, 1.8 per cent for reoperation, and 0 per cent for mortality. Multivariable analysis showed that conversion was associated with male sex (OR 1.48), BMI exceeding 30 kg/m2 (OR 2.42), multivisceral resection (OR 3.04), and laparoscopy (OR 2.24). Increased risk of severe morbidity was associated with ASA fitness grade above II (OR 1.60), multivisceral resection (OR 1.88), and robotic approach (OR 1.87).

Conclusion

The benchmark values obtained using the ABC method represent optimal outcomes from best achievable care, including low complication rates and zero mortality. These benchmarks should be used to set standards to improve patient outcomes.

Number of Worrisome Features and Risk of Malignancy in Intraductal Papillary Mucinous Neoplasm

BACKGROUND

The 2017 revised International Association of Pancreatology guidelines for management of intraductal papillary mucinous neoplasm (IPMN) describe worrisome features (WF) and high-risk stigmata (HRS), recommending resection in the latter and further work-up and close surveillance for patients with WF. The effect of multiple WF on the likelihood of malignancy has not been evaluated.

STUDY DESIGN

Eight hundred ten patients who underwent pancreatic resection for IPMN in 2 tertiary referral centers were identified from prospective institutional databases. Patients were retrospectively categorized into subgroups according to the number of WF or HRS and presence of malignancy, defined as high-grade dysplasia (HGD) or invasive cancer on final pathology.

RESULTS

Three hundred seventy-nine (47%) patients had HRS, 370 (46%) had 1 or more WF, and 61 patients (7%) had neither. Malignancy was present in 70% (n = 267) of patients with HRS and in 30% (n = 127) of those with WF. Only 3 of 61 patients without WF/HRS had malignancy, and all only in the form of HGD. The risk of malignancy increased in a stepwise fashion with the number of WF, to 22%, 34%, and 59% with 1, 2, and 3 WF, respectively (p = 0.001), and reached 100% in patients with 4 or more WF. Although the relative risks differed for particular WF, the areas under the curve were not statistically different.

CONCLUSION

We confirm that presence of HRS in IPMN is associated with a very high likelihood of malignancy. The presence of a single WF has a malignancy risk of 22%, and additional WF increase this risk significantly. When 3 or more WF are present, the risk is similar to that of HRS.

ABO blood group distribution and risk of malignancy in patients undergoing resection for intraductal papillary mucinous neoplasm (IPMN)

BACKGROUND

The ABO blood type has been associated with risk of development of several malignancies, including pancreatic cancer. Data regarding IPMN is equivocal. To investigate this further, we analyzed the association between the ABO blood group and the presence of malignancy in a large cohort of resected IPMN and its influence in survival.

METHODS

819 patients who underwent pancreatic resection for IPMN in the Massachusetts General Hospital (MGH) and Cambridge University Hospitals NHS Foundation Trust (CUH) from January 1993 to December 2020 were identified from prospective institutional databases. Pathological characteristics and blood type were correlated.

RESULTS

The distribution of blood types A, B, AB and O was 384 (47%), 92 (11%), 44 (5%) and 299 (37%), respectively. This blood type distribution was different than the reference population of the MGH and the CUH, which is 55% non-O blood group, and 45% type O. There was a significant predominance of non-O blood types when compared with O-blood type in patients with malignant IPMN (i.e. patients with high-grade dysplasia and invasive cancer) (67% vs 33%, OR 1.31 95%CI: 0.98-1.75, p = 0.069). The association was stronger for IPMN with invasive cancer (OR 1.43 95%CI: 1.01-2.02, p = 0.039). Blood group did not influence survival.

CONCLUSION

Non-O blood type is associated with need for resection in IPMN and with presence of invasive carcinoma.

P-O05 Deconstructing Operations to Improve Recording of Surgical Training Experience

Background

A new outcomes-based curriculum is soon to be implemented for UK surgical trainees. Performance will be evaluated against the standard expected of a new consultant. Accurate recording of operative experience and performance will therefore be crucial to demonstrate achievement of this standard. The current eLogbook system for recording surgical experience has many benefits including simplicity and accessibility, but may misrepresent actual experience because most operations are considered as a whole; unlike some colorectal operations, involvement in steps within many upper gastrointestinal (UGI) operations cannot be recorded.

Methods

Impact on training by the COVID-19 pandemic led to discussion and identification of cultural and logistical barriers to accurate recording of experience. To address these, a modification to enhance the current eLogbook system was developed by trainees and trainers at a university teaching hospital. An existing typology was used to deconstruct common UGI operations into their component steps, which can be recorded at this more detailed level. 

Results

The modified deconstructed logbook concept is described using a worked example, which can be applied to any operation. We also describe the integration of a component-based training discussion into the surgical team brief and debrief; this complements the deconstructed logbook by promoting a training culture.

Conclusions

Using the described techniques, trainees of all levels can comprehensively and accurately describe their surgical experience. Senior trainees will benefit from recording complex operations which they are not expected to complete in their entirety, whilst less experienced trainees will benefit from the ability to record their involvement in more basic parts of operations. The suggested approach will reduce misrepresentation of experience, encourage proactive planning of training opportunities, and reduce the impact of crises such as pandemics on surgical training.

Short-term outcomes after pancreatoduodenectomy in octogenarians: multicentre case-control study

BACKGROUND

Pancreatoduodenectomy (PD) is frequently the surgical treatment indicated for a number of pathologies. Elderly patients may be denied surgery because of concerns over poor perioperative outcomes. The aim of this study was to evaluate postoperative clinical outcomes and provide evidence on current UK practice in the elderly population after PD.

METHODS

This was a multicentre retrospective case-control study of octogenarians undergoing PD between January 2008 and December 2017, matched with younger controls from seven specialist centres in the UK. The primary endpoint was 90-day mortality. Secondary endpoints were index admission mortality, postoperative complications, and 30-day readmission rates.

RESULTS

In total, 235 octogenarians (median age 81 (range 80-90) years) and 235 controls (age 67 (31-79) years) were included in the study. Eastern Cooperative Oncology Group performance status (median 0 (range 0-3) versus 0 (0-2); P = 0.010) and Charlson Co-morbidity Index score (7 (6-11) versus 5 (2-9); P = 0.001) were higher for octogenarians than controls. Postoperative complication and 30-day readmission rates were comparable. The 90-day mortality rate was higher among octogenarians (9 versus 3 per cent; P = 0.030). Index admission mortality rates were comparable (4 versus 2 per cent; P = 0.160), indicating that the difference in mortality was related to deaths after hospital discharge. Despite the higher 90-day mortality rate in the octogenarian population, multivariable Cox regression analysis did not identify age as an independent predictor of postoperative mortality.

CONCLUSION

Despite careful patient selection and comparable index admission mortality, 90-day and, particularly, out-of-hospital mortality rates were higher in octogenarians.

EP.TH.1043Outcomes of liver resections by trainee surgeons versus consultant surgeon – a single centre experience

Introduction

Liver resection is a most effective treatment for patients with operable primary or secondary cancer deposits. The role of trainee as a lead surgeon versus consultant surgeon performing liver resections and its impact on surgical outcomes had never been reported.

Methods and Materials

This study was aimed to assess the liver resection outcomes including operative time, acute kidney injury (AKI), bile leak, sepsis, mortality and hospital readmission within 3 months. A total of 320 liver resections from Addenbookes Hospital at Cambridge between 2015 to 2017 were included in this study.

All liver resections were performed under supervision of the consultant surgeon who is either scrubbed or unscrubbed in theatre. Trainee surgeons have performed 116 of 320 as lead surgeon and the consultant surgeons performed the remaining 204.

Results

The mean operative time was 413±129 versus 383±118 (P = 0.41) minutes in trainee surgeons and consultant surgeons respectively. The incidence of postoperative AKI were similar in between the groups (5/116 versus 11/204;P=0.79). Although the bile leak was numerically high in the trainee group, did not reach statistical difference (13/116 versus 12/204;P=0.12); similar results noted in the incidence of sepsis too (3/116 versus 4/204;P=070). Mortality, hospital readmission at 3 months were (1/204 versus 1/116;P=1) and (2/116 versus 4/204;P=1) respectively. No significant difference was observed.

Conclusion

Liver resections performed by the trainee surgeons under supervision appeared to be safe without increasing the operative time, morbidity, mortality and hospital readmission at 90 days. Further multicentre prospective study with long-term follow up is recommended.

EP.TH.603Hypofractionated radiotherapy for resectable pancreatic ductal adenocarcinoma: a world first in response to COVID19

Introduction

COVID-19 has challenged healthcare systems across the world, restricting resources for major hepato-pancreato-biliary resections. We report the experience of a unique temporising measure to overcome unavailability of upfront surgery, for select patients with resectable pancreatic ductal adenocarcinoma (rPDAC) during the pandemic.

Methods

Select patients with rPDAC who were assessed to be unsuitable for, or declined, upfront systemic chemotherapy, were considered for hypofractionated radiotherapy (hypoRT) as bridging therapy to Whipple’s pancreaticoduodenectomy.

Results

Three patients with EUS-biopsy confirmed rPDAC with no vascular involvement received 5 fractions of hypoRT followed by Whipple’s resection. Median patient age was 68 (range 63-77). All patients successfully completed hypoRT, with one case of transient grade 2 anorexia. Median interval from hypoRT to resection was 75 days (range 41-95 days), with median operative time including anaesthesia of 573 minutes (range 496-661 minutes). R0 resection was achieved in two cases, including one requiring portal vein resection. R1 resection was seen in one patient who required superior mesenteric vein resection. One patient experienced complication in the form of delayed gastric emptying. Median length of stay was 11 days (range 11-58 days). No patient experienced post-operative pancreatic fistula, and no patient has evidence of recurrence on 30-day follow up imaging.

Conclusion

This report provides initial experience for hypoRT in select patients with rPDAC prior to resection. Further work is required to quantify outcomes and long-term safety profile of this novel approach. The hypoRT programme allowed select patients to obtain treatment whilst awaiting availability of surgical resources.

Patient-reported outcomes after minimally invasive retroperitoneal pancreatic necrosectomy to treat acute pancreatitis: An exploratory study

OBJECTIVE

The aim of this study (abbreviated as QUANTUM) was to assess the quality of life (QoL) of patients who underwent minimally invasive retroperitoneal pancreatic necrosectomy (MIRPN) for acute pancreatic necrosis with or without infection of necrotic tissue collections after discharge and to compare the patient-reported outcomes (PRO) in these patients with published data in normative population.

METHODS

Patients with acute pancreatitis who underwent MIRPN between January 2010 and December 2016 were identified and invited to complete the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and EORTC PAN28(CP) questionnaires. PRO were compared using Pearson correlation coefficient and ANOVA (significance P < 0.01) with an age- and sex-matched normative population of western Europe, stratified by age, and also the time duration after MIRPN (<3 y and >3 y). A change >15 points in the PRO score was taken as clinically important.

RESULTS

Among 52 eligible patients identified, 46 (88%) agreed to participate, 74% returned questionnaires. After the MIRPN all patients had worse physical and social functioning scores with a clinically important (>15 points) reduction in those ≤50 years; while fatigue, pain and insomnia symptom scales had the highest scores (42, 26 and 30 points, respectively). Patients <3 years after MIRPN had similar scores for all functional scales and global health-related quality of life (HRQoL) compared to the normative population. However, over time their global HRQoL deteriorated and after 3 years their scores for functioning and symptoms were statistically (P < 0.0001) and clinically (>15 points) worse than those in age-matched controls.

CONCLUSIONS

During the first 3 years after the MIRPN patients have a relatively high QoL but report worse fatigue than the normative population. However, patients should be informed that their HRQoL deteriorates with time, often due to chronic pancreatitis and pancreatic insufficiency. This study supports the use of MIRPN and prospective studies of HRQoL in this setting are indicated.

Preclinical evaluation of the versius surgical system, a new robot-assisted surgical device for use in minimal access general and colorectal procedures

OBJECTIVE

To evaluate the utility of a new robot-assisted surgical system (the Versius Surgical System, CMR Surgical, Cambridge, UK) for use in minimal access general and colorectal surgery, in a preclinical setting. Robot-assisted laparoscopy has been developed to overcome some of the important limitations of conventional laparoscopy. The new system is designed to assist surgeons in performing minimal access surgery and overcome some of the challenges associated with currently available surgical robots.

METHODS

Cadaveric sessions were conducted to evaluate the ability of the system to provide adequate surgical access and reach required to complete a range of general and colorectal procedures. Port and bedside unit positions were recorded, and surgical access and reach were evaluated by the lead surgeon using a visual analogue scale. A live animal (porcine) model was used to assess the surgical device's safety in performing cholecystectomy or small bowel enterotomy.

RESULTS

Nine types of procedure were performed in cadavers by nine lead surgeons; 35/38 procedures were completed successfully. The positioning of ports and bedside units reflected the lead surgeons' preferred laparoscopic set-up and enabled good surgical access and reach. Cholecystectomy (n = 6) and small bowel enterotomy (n = 5) procedures performed in pigs were all completed successfully by two surgeons. There were no device-related intra-operative complications.

CONCLUSIONS

This preclinical study of a new robot-assisted surgical system for minimal access general and colorectal surgery demonstrated the safety and effectiveness of the system in cadaver and porcine models. Further studies are required to assess its clinical utility.

Colorectal liver metastases: Current management and future perspectives

The liver is the commonest site of metastatic disease for patients with colorectal cancer, with at least 25% developing colorectal liver metastases (CRLM) during the course of their illness. The management of CRLM has evolved into a complex field requiring input from experienced members of a multi-disciplinary team involving radiology (cross sectional, nuclear medicine and interventional), Oncology, Liver surgery, Colorectal surgery, and Histopathology. Patient management is based on assessment of sophisticated clinical, radiological and biomarker information. Despite incomplete evidence in this very heterogeneous patient group, maximising resection of CRLM using all available techniques remains a key objective and provides the best chance of long-term survival and cure. To this end, liver resection is maximised by the use of downsizing chemotherapy, optimisation of liver remnant by portal vein embolization, associating liver partition and portal vein ligation for staged hepatectomy, and combining resection with ablation, in the context of improvements in the functional assessment of the future remnant liver. Liver resection may safely be carried out laparoscopically or open, and synchronously with, or before, colorectal surgery in selected patients. For unresectable patients, treatment options including systemic chemotherapy, targeted biological agents, intra-arterial infusion or bead delivered chemotherapy, tumour ablation, stereotactic radiotherapy, and selective internal radiotherapy contribute to improve survival and may convert initially unresectable patients to operability. Currently evolving areas include biomarker characterisation of tumours, the development of novel systemic agents targeting specific oncogenic pathways, and the potential re-emergence of radical surgical options such as liver transplantation.

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.

Minimally invasive pancreatic necrosectomy; a technical pictorial review

Necrotizing pancreatitis is the most severe form of acute pancreatitis, which is associated with significant mortality and morbidity. Open necrosectomy has been one of the treatment modalities; however, it has been associated with high mortality rates and alternative minimally invasive procedures such as minimal invasive pancreatic necrosectomy (MIPN) were developed to improve on the outcomes. While current clinical evidence on MIPN showed significant advantages in terms of incidence of multiple organ failure, incisional hernias and new-onset diabetes there were no differences in terms of mortality rate. In this pictorial review we are presenting the technical details of MIPN as a minimally invasive procedure for the debridement of the necrotic pancreatic tissue and we will discuss the current evidence around the use of this procedure for the management of pancreatic necrosis.

Surgical management of hepato-pancreatic metastasis from renal cell carcinoma

AIM

To investigate the outcomes of liver and pancreatic resections for renal cell carcinoma (RCC) metastatic disease.

METHODS

This is a retrospective, single centre review of liver and/or pancreatic resections for RCC metastases between January 2003 and December 2015. Descriptive statistical analysis and survival analysis using the Kaplan-Meier estimation were performed.

RESULTS

Thirteen patients had 7 pancreatic and 7 liver resections, with median follow-up 33 mo (range: 3-98). Postoperative complications were recorded in 5 cases, with no postoperative mortality. Three patients after hepatic and 5 after pancreatic resection developed recurrent disease. Median overall survival was 94 mo (range: 23-94) after liver and 98 mo (range: 3-98) after pancreatic resection. Disease-free survival was 10 mo (range 3-55) after liver and 28 mo (range 3-53) after pancreatic resection.

CONCLUSION

Our study shows that despite the high incidence of recurrence, long term survival can be achieved with resection of hepatic and pancreatic RCC metastases in selected cases and should be considered as a management option in patients with oligometastatic disease.

Incidental non-benign gallbladder histopathology after cholecystectomy in an United Kingdom population: Need for routine histological analysis?

AIM

To analyse the range of histopathology detected in the largest published United Kingdom series of cholecystectomy specimens and to evaluate the rational for selective histopathological analysis.

METHODS

Incidental gallbladder malignancy is rare in the United Kingdom with recent literature supporting selective histological assessment of gallbladders after routine cholecystectomy. All cholecystectomy gallbladder specimens examined by the histopathology department at our hospital during a five year period between March 2008 and March 2013 were retrospectively analysed. Further data was collected on all specimens demonstrating carcinoma, dysplasia and polypoid growths.

RESULTS

The study included 4027 patients. The majority (97%) of specimens exhibited gallstone or cholecystitis related disease. Polyps were demonstrated in 44 (1.09%), the majority of which were cholesterol based (41/44). Dysplasia, ranging from low to multifocal high-grade was demonstrated in 55 (1.37%). Incidental primary gallbladder adenocarcinoma was detected in 6 specimens (0.15%, 5 female and 1 male), and a single gallbladder revealed carcinoma in situ (0.02%). This large single centre study demonstrated a full range of gallbladder disease from cholecystectomy specimens, including more than 1% neoplastic histology and two cases of macroscopically occult gallbladder malignancies.

CONCLUSION

Routine histological evaluation of all elective and emergency cholecystectomies is justified in a United Kingdom population as selective analysis has potential to miss potentially curable life threatening pathology.

Spontaneous diaphragmatic rupture following robotic prostatectomy

Robotic surgery is an established therapy for localised prostate cancer and is replacing conventional laparoscopic prostatectomy in developed countries. Port-site hernia is a recognised, albeit small, risk following laparoscopic or robotic surgery. We report a case of spontaneous rupture of the right hemidiaphragm following robotic prostatectomy.

Successful surgical management of ruptured umbilical hernias in cirrhotic patients

Acute umbilical hernia rupture in patients with hepatic cirrhosis and ascites is an unusual, but potentially life-threatening complication, with postoperative morbidity about 70% and mortality between 60%-80% after supportive care and 6%-20% after urgent surgical repair. Management options include primary surgical repair with or without concomitant portal venous system decompression for the control of the ascites. We present a retrospective analysis of our centre’s experience over the last 6 years. Our cohort consisted of 11 consecutive patients (median age: 53 years, range: 36-63 years) with advanced hepatic cirrhosis and refractory ascites. Appropriate patient resuscitation and optimisation with intravenous fluids, prophylactic antibiotics and local measures was instituted. One failed attempt for conservative management was followed by a successful primary repair. In all cases, with one exception, a primary repair with non-absorbable Nylon, interrupted sutures, without mesh, was performed. The perioperative complication rate was 25% and the recurrence rate 8.3%. No mortality was recorded. Median length of hospital stay was 14 d (range: 4-31 d). Based on our experience, the management of ruptured umbilical hernias in patients with advanced hepatic cirrhosis and refractory ascites is feasible without the use of transjugular intrahepatic portosystemic shunt routinely in the preoperative period, provided that meticulous patient optimisation is performed.

Salvage pancreaticoduodenectomy after complete response to chemoradiotherapy for a previously unresectable pancreatic adenosquamous carcinoma: a case report

Pancreatic cancer is known for its typically late presentation and poor survival rates, with overall 5-year survival of less than 5%. The role of chemotherapy alone or with radiotherapy in the management of locally advanced tumors continues to be an area of debate.We report a case of locally advanced, pancreatic adenosquamous carcinoma that was initially deemed unresectable intraoperatively. Nonetheless, the tumor was resected after radiological response to gemcitabine-capecitabine chemoradiotherapy regimen similar to the Selective Chemoradiation in Advanced LOcalised Pancreatic cancer trial. Histological examination revealed complete pathological response with extensive fibrosis (ypT0 N0). On 12-month follow-up CT, a single liver lesion in the left lateral segment was identified and confirmed to be a metastasis with cytological diagnosis via EUS and FNA. The disease remained stable and confined to the solitary hepatic metastasis after further gemcitabine chemotherapy. Therefore, a further successful resection was performed.The 2 main strategies for the management of locally advanced unresectable pancreatic cancer are chemotherapy induction followed by consolidation chemoradiotherapy or chemotherapy alone, with conflicting published evidence. Evidence for the optimal management of the rare histological type of adenosquamous carcinoma is scant. We present a case of such tumor with a complete pathological response to chemoradiotherapy. The results of future studies in the area are eagerly awaited.

Negative predictive value of drain amylase concentration for development of pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

Post-operative pancreatic fistula (POPF) is the major source of morbidity following pancreaticoduodenectomy. A predictive indicator would be highly advantageous. One potential marker is drain amylase concentration (DAC). However, its predictive value has not been fully established.

METHODS

405 patients undergoing pancreaticoduodenectomy at our centre over a 10 year period were reviewed to determine the value of DAC as a predictive indicator for the development of POPF.

RESULTS

POPF developed in 58 patients (14%). These patients suffered greater morbidity. Overall 30-day mortality was 1.5%. Male gender (OR: 5.1; p = 0.0082) and age > 70 (OR 2; p = 0.0372) were independent risk factors for POPF, whilst Type 2 diabetes (OR: 0.2321; p = 0.0090) and pancreatic ductal-adenocarcinoma (OR: 0.3721; p = 0.0039) decreased POPF risk. The DACs post-operatively were significantly higher in those developing POPF, but with significant overlap. ROC curves revealed optimal threshold values for differentiating POPF and non-POPF patients. A DAC°<°1400 U/ml on day 1 and <768 U/ml on day 2, although having a poor positive predictive value (32-44%), had a very strong negative predictive value (97-99%).

CONCLUSION

Our data suggest that post-operative DAC below the determined optimal threshold values on day 1 and 2 following pancreaticoduodenectomy carries high negative predictive value for POPF development and identifies patients in whom early drain removal, and enhanced recovery may be considered, with simultaneous assessment of operative and clinical factors.

Delayed dynamic abdominal wall closure following multi-visceral transplantation

INTRODUCTION

Primary closure of the abdominal wall following intestinal transplantation or multivisceral transplantation could become a challenging problem in a significant number of patients.

PRESENTATION OF CASE

A 38-year-old woman with familial adenomatous polyposis (FAP) underwent a multi-visceral transplantation for short gut syndrome. She subsequently developed acute graft rejection that proved resistant to conventional treatment. She was relisted and underwent re-transplantation along with kidney transplantation. Abdominal wall closure could not be achieved because of the large size of the graft and bowel oedema. The wound was initially managed with laparostomy followed by insertion of the delayed dynamic abdominal closure (DDAC) device (Abdominal Retraction Anchor – ABRA^® system). Continuous dynamic traction to the wound edges resulted in gradual approximation and complete closure of the abdominal wound was achieved within 3 weeks.

DISCUSSION

Successful abdominal closure after multivisceral transplantation or isolated intestinal transplantation often requires biological mesh, vascularised flaps or abdominal wall transplantation. DDAC eliminated the need for a prosthetic mesh or skin graft and provided an excellent cosmetic result. Adjustment of the dynamic traction at the bedside minimised the need for multiple returns to the operating theatre. It resulted in a well-healed linear scar without a hernia.

CONCLUSION

Dynamic traction allows delayed closure of laparotomy resulting in strong and cosmetically sound wound healing with native tissue.

Outcomes following liver trauma in equestrian accidents

Background

Equestrian sports are common outdoor activities that may carry a risk of liver injury. Due to the relative infrequency of equestrian accidents the injury patterns and outcomes associated with liver trauma in these patients have not been well characterized.

Methods

We examined our experience of the management of equestrian liver trauma in our regional hepatopancreaticobiliary unit at a tertiary referral center. The medical records of patients who sustained liver trauma secondary to equestrian activities were analysed for parameters such as demographic data, liver function tests, patterns of injury, radiological findings, the need for intervention and outcomes.

Results

20 patients sustained liver trauma after falling from or being kicked by a horse. The majority of patients were haemodynamically stable on admission. Alanine transaminase (ALT) levels were elevated in all patients and right-sided rib fractures were a frequently associated finding. CT demonstrated laceration of the liver in 12 patients, contusion in 3 and subcapsular haematoma in 2. The right lobe of the liver was most commonly affected. Only two patients required laparotomy and liver resection; the remaining 18 were successfully managed conservatively.

Conclusions

The risk of liver injury following a horse kick or falling off a horse should not be overlooked. Early CT imaging is advised in these patients, particularly in the presence of high ALT levels and concomitant chest injuries such as rib fractures. Despite significant liver trauma, conservative management in the form of close observation, ideally in a high-dependency setting, is often sufficient. Laparotomy is only rarely warranted and associated with a significantly higher risk of post-operative bile leaks.

Improved long-term survival after resection of colorectal liver metastases following staging with FDG positron emission tomography

BACKGROUND AND OBJECTIVES

Actual long-term survival of patients with colorectal liver metastases staged by PET CT has not been reported. Objectives were to investigate whether PET CT staging results in actual improved long-term survival, to examine outcome in patients with 'equivocal' PET CT scans, and those excluded from hepatectomy by PET CT.

METHODS

A retrospective analysis of patients undergoing hepatectomy for colorectal liver metastases between March 1998 and September 2008.

RESULTS

Overall 5- and 10-year survival was 44.8% and 23.9%. PET CT staging resulted in management changes in 23% of patients. PET CT staged patients showed significantly better survival than those staged by CT alone at 3 years (79.8% vs. 54.1%) and at 5 years (54.1% vs. 37.3%) with median survivals of 6.4 years versus 3.9 years (log rank P = 0.018). Patients with equivocal PET CT scans showed worse median survival than those with favourable PET CT (log rank P = 0.002), but may include a subpopulation whose prognosis trends towards a more favourable outcome than those excluded from liver resection by PET CT, whose median survival remains limited to 21 months.

CONCLUSIONS

Staging of patients with colorectal liver metastases by PET CT is associated with significantly improved actual long-term survival, and provides valuable prognostic information which guides surgical and oncological treatments.

Colonic and anal metastases from pancreato-biliary malignancies

Pancreato-biliary malignancies often present with locally advanced or metastatic disease. Surgery is the mainstay of treatment although less than 20% of tumours are suitable for resection at presentation. Common sites for metastases are liver, lungs, lymph nodes and peritoneal cavity. Metastatic disease carries poor prognosis, with median survival of less than 3 mo. We report two cases where metastases from pancreato-biliary cancers were identified in the colon and anal canal. In both cases specific immunohistochemical staining was utilised in the diagnosis. In the first case, the presenting complaint was obstructive jaundice due to an ampullary tumour for which a pancreato-duodenectomy was carried out. However, the patient re-presented 4 wk later with an atypical anal fissure which was found to be metastatic deposit from the primary ampullary adenocarcinoma. In the second case, the patient presented with obstructive jaundice due to a biliary stricture. Subsequent imaging revealed sigmoid thickening, which was confirmed to be a metastatic deposit. Distal colonic and anorectal metastases from pancreato-biliary cancers are rare and can masquerade as primary colorectal tumours. The key to the diagnosis is the specific immunohistochemical profile of the intestinal lesion biopsies.

Extra-hepatic portal vein aneurysm: A case report, overview of the literature and suggested management algorithm

INTRODUCTION

Portal venous aneurysms are a rare finding. The reported incidence is on the rise with increasing use of modern imaging techniques in clinical practice. However, there is still much to be elicited regarding their aetiology, natural history, and management.

PRESENTATION OF CASE

An 80-year-old woman presented with abdominal pain and nausea. Investigations showed a hypoechoic area in the region of the head of pancreas on ultrasound, which was found to be a portal venous aneurysm on CT. In view of her multiple comorbidities, a conservative approach was taken.

DISCUSSION

Portal venous aneurysms represent approximately 3% of all venous aneurysms with a reported prevalence of 0.43%. They may be congenital, due to failure of complete regression of the right vitelline vein, or acquired secondary to portal hypertension. The primary presentation of portal vein aneurysm is abdominal pain, followed by incidental detection on imaging, with a minority of patients presenting with gastrointestinal bleeding. Complications of PVA include thrombosis, biliary tract obstruction, inferior vena cava obstruction, and duodenal compression. On the whole PVAs are stable and have a low risk of complications with 88% of patients showing no progression of aneurysm size or complications on subsequent follow up scans.

CONCLUSION

We recommend that portal venous aneurysms be assessed using colour Doppler ultrasonography in the first instance with CT scans reserved for indeterminate cases or symptomatic patients. Due to the slow progression of such aneurysms, surgery is recommended only for symptomatic patients or those with complications secondary to portal venous aneurysms.

Direct histological processing of EUS biopsies enables rapid molecular biomarker analysis for interventional pancreatic cancer trials

OBJECTIVE

Current practice to diagnose pancreatic cancer is accomplished by endoscopic ultrasound guided fine needle aspiration (EUS-FNA) using a cytological approach. This method is time consuming and often fails to provide suitable specimens for modern molecular analyses. Here, we compare the cytological approach with direct formalin fixation of pancreatic EUS-FNA micro-cores and evaluate the potential to perform molecular biomarker analysis on these specimen.

METHODS

130 specimens obtained by EUS-FNA with a 22G needle were processed by the standard cytological approach and compared to a separate cohort of 130 specimens that were immediately formalin fixed to preserve micro-cores of tissue prior to routine histological processing.

RESULTS

We found that direct formalin fixation significantly shortened the time required for diagnosis from 3.6 days to 2.9 days (p<0.05) by reducing the average time (140 vs 33 min/case) and number of slides (9.65 vs 4.67 slides/case) for histopathological processing. Specificity and sensitivity yielded comparable results between the two approaches (82.3% vs 77% and 90.9% vs 100%). Importantly, EUS-FNA histology preserved the tumour tissue architecture with neoplastic glands embedded in stroma in 67.89% of diagnostic cases compared to 27.55% with the standard cytological approach (p < 0.001). Furthermore, micro-core samples were suitable for molecular studies including the immunohistochemical detection of intranuclear Hes1 in malignant cells, and the laser-capture microdissection-mediated measurement of Gli-1 mRNA in tumour stromal myofibroblasts.

CONCLUSIONS

Direct formalin fixation of pancreatic EUS-FNA micro-cores demonstrates superiority regarding diagnostic delay, costs, and specimen suitability for molecular studies. We advocate this approach for future investigational trials in pancreatic cancer patients.

A rare cause of duodenal stricture

The authors report the case of a 62-year-old lady who had never lived overseas and who presented with symptoms of gastric outflow obstruction with weight loss. Endoscopic investigation demonstrated a tight, impassable stricture in the second part of the duodenum, with CT demonstrating a mass and surrounding lymphadenopathy. Extrinsic compression at this site in UK residents in late middle age usually heralds a diagnosis of pancreatic malignancy. In this case, investigation by endoscopic ultrasound with sampling of an otherwise inaccessible lymph node to obtain 'micro biopsies' by fine needle aspiration allowed a diagnosis of duodenal tuberculosis. The patient has responded to appropriate antibiotic therapy and is now well.

Acute sigmoid volvulus in a West African population

BACKGROUND

Acute sigmoid volvulus is one of the commonest causes of benign large bowel obstruction. Its incidence varies considerably from one geographic area to another.

OBJECTIVE

To review the management of acute sigmoid volvulus in a relatively high prevalence area.

METHODS

All adult patients with acute sigmoid volvulus seen at the Royal Victoria Teaching Hospital (RVTH) Banjul, between September 2000 and January 2005 were studied. Information obtained for analysis from the records included age, sex, clinical features, test results, and outcomes.

RESULTS

A total of 48 patients, 45 (93.8%) males and three (6.3%) females, with a male: female ratio of 14.3:1, age range of 19 to 78 years and mean age of 45.8 +17.6 years, underwent treatment for acute sigmoid volvulus. Twenty-one (43.8%) of the patients were aged 40 to 59 years. Two (4.2%) had rectal tube detortion followed by elective sigmoidectomy and primary anastomosis on the same admission, while 24 (50%) had emergency laparotomy at which bowel decompression, one-stage resection and primary anastomosis without on-table lavage was done. The rest of the patients, 22 (45.8%) had gangrenous sigmoid colons at laparotomy and consequently had Hartmann's procedure done. Fourteen patients (29.1%) developed wound infection and five (10.4%) had prolonged ileus that was managed conservatively. There was no anastomotic leak. The mean hospital stay was 11.1 days. There were five deaths giving a mortality rate of 10.4%.

CONCLUSION

Acute sigmoid volvulus in the Gambia is almost exclusively a male disease. Sigmoid colectomy and primary anastomosis can be carried out safely in those with viable colon without on-table colonic lavage.

Adrenocortical oncocytoma: Review of imaging and histopathological implications

Oncocytomas are rare tumours of the adrenal glands whose malignant potential is difficult to assess with certainty. We report a case of an adrenal oncocytoma and present a review of the literature particularly with regards to the radiological and histopathological features and their impact on the management.Adrenal oncocytomas are usually identified incidentally on imaging and can achieve large sizes. They should be considered in the differential diagnosis of any large upper abdominal lesion including those apparently arising from the liver as in this case report. MRI scan appears to be the ideal imaging modality to characterise such lesions. There seems to be little benefit in biopsying these masses and surgery remains the most optimal management. It remains difficult to predict metastatic behaviour based on histological findings and so long term surveillance is advisable.

Impact of pancreatic leaks on survival following pancreaticoduodenectomy

CONTEXT

Pancreatic leak following pancreaticoduodenectomy has a major impact on postoperative mortality. However, it is not clear whether pancreatic leaks affect long term survival in patients with pancreatic ductal adenocarcinoma.

OBJECTIVE

The aim of this study is to compare the long term outcome in patients who underwent pancreaticoduodenectomy, with and without postoperative pancreatic leak.

PATIENTS

All 133 patients who underwent a pancreaticoduodenectomy at the HepatoPancreatoBiliary Unit, Addenbrooke's Hospital, Cambridge, between June 2002 and June 2007 were identified from a prospectively held database. The study was restricted to 47 patients who had a confirmed diagnosis of pancreatic ductal adenocarcinoma.

SETTING

Pancreatic leak was defined as drain fluid amylase more than three times the serum level for more than 3 days post operatively.

MAIN OUTCOME MEASURE

Long term survival of patients with and without leaks were compared using Kaplan-Meier curves and significance was measured using the log-rank test.

RESULTS

Median follow-up was 30.8 months. The median actuarial survival of all ductal adenocarcinoma patients was 19 months. Pancreatic leaks occurred in 9 patients (19.1%). There were no significant differences in the overall survival or presence of recurrence between the two groups.

CONCLUSIONS

Pancreatic leak following pancreaticoduodenectomy does not appear to impact on long-term outcome of patients with pancreatic ductal adenocarcinoma.

Cutaneous metastases from cholangiocarcinoma following percutaneous transhepatic biliary drainage: Case report and literature review

Percutaneous transhepatic biliary drainage (PTBD) is commonly used in the management of cholangiocarcioma. Major and minor complications of PTBD such as cholangitis, haemorrhage and catheter dislocation are well documented. A lesser reported complication are cutaneous metastases following PTBD for cholangiocarcinoma.

We report a case of a 79 year old man who presented with right upper quadrant pain, jaundice and weight loss, with dilated intra-hepatic bile ducts on imaging. The cytology results from a sample taken during endoscopic retrograde cholangiopancreatography were highly suspicious of cholangiocarcioma. A PTBD was subsequently performed and bilateral metal biliary stents were placed without external drainage. Five months after the PTBD he was found to have a hard nodule under the PTBD puncture site. The nodule was excised and the histology confirmed a cholangiocarcinoma metastasis.

A review of the literature identified twelve cases of cutaneous metastases from cholangiocarcinoma, following PTBD. In addition, tumour seeding along the catheter tract following PTBD, with metastatic deposits on the abdominal wall, peritoneoum, chest wall, pleural space, and liver parenchyma have also been reported.

Health care professionals should be aware of this rare complication and offer appropriate management options to patients.

The implications of the presence of an aberrant right hepatic artery in patients undergoing a pancreaticoduodenectomy

PURPOSE

An aberrant right hepatic artery (ARHA) is a common anomaly and its implications for patients undergoing a pancreaticoduodenectomy (PD) have not yet been previously reported. We compared the outcomes following PD in patients with and without an ARHA. A novel classification of the anatomical course of ARHA, and surgical techniques for its identification and preservation are described herein.

METHODS

All patients undergoing PD between June 1, 2002, and May 31, 2007, were divided into two groups, one with ARHA and the other without. These groups were compared to identify differences in the intraoperative variables, the oncological clearance, the postoperative complications, and the survival.

RESULTS

A total of 135 patients underwent PD of which 28 (20.8%) patients were found to have either accessory or replaced right hepatic arteries (ARHA group). There were no significant differences in the intraoperative variables (blood loss and operative time) and the incidence of postoperative complications (pancreatic leak and delayed gastric emptying). Oncological clearance (nodal yield and resection margins) and survival were also similar in the two groups.

CONCLUSIONS

The surgical and oncological outcomes of PD remain unaffected by the presence of ARHA provided that the anatomy is recognized and appropriately managed. Aberrant right hepatic artery can be classified into three types according to their anatomical relationship with the head of the pancreas.

Primary hepatic embryonal sarcoma masquerading as metastatic ovarian cancer

BACKGROUND

Hepatic embryonal sarcoma (HES) is a rare but aggressive primary tumor of the liver occurring most frequently in childhood.

CASE PRESENTATION

We report a case of a 52 year old woman having previously undergone treatment for ovarian serous papillary carcinoma who subsequently presented with a large solitary mass in the liver. Initially this was presumed to be metastasis from the ovarian primary however, on further examination it was shown to be a primary hepatic embryonal sarcoma.

CONCLUSION

Primary liver tumors should be considered in differential diagnoses in patients with ovarian cancer who subsequently present with liver tumors. This is particularly important when there is no direct evidence of recurrence of ovarian cancer.

Interposition graft with polytetrafluoroethylene for mesenteric and portal vein reconstruction after pancreaticoduodenectomy (Br J Surg 2009; 96: 247-252)

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Endoscopic Ultrasound-guided drainage of an abdominal fluid collection following Whipple’s resection

Percutaneous aspiration and drainage of post-operative abdominal fluid collections is a well established standard technique. However, some fluid collections are not amenable to percutaneous drainage either due to location or the presence of surrounding visceral structures. Endoscopic Ultrasound (EUS) has been widely used for the drainage of pancreatitis-related abdominal fluid collections. However, there are no reports on the use of this technique in the post-operative setting. We report a case where the EUS-guided technique was used to drain a percutaneously inaccessible post-operative collection which had developed after Whipple’s resection.