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Simpson FH, Kulendran K, Yerkovich S, Beatty A, Flynn D, Mao D, Brooks T, Wood P, Chandrasegaram MD. Perioperative Blood Transfusions and Anastomotic Leak After Colorectal Surgery for Cancer in an Australian Hospital. J Gastrointest Cancer 2024; 55:219-226. [PMID: 37335436 PMCID: PMC11096243 DOI: 10.1007/s12029-023-00947-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE Peri-operative blood transfusion has been identified as a risk factor for anastomotic leak in recent studies, but little is known about which patients are at risk for blood transfusion. This study aims to assess the relationship between blood transfusion and anastomotic leak and factors predisposing to leak in patients undergoing colorectal cancer surgery. METHODS This retrospective cohort study was conducted in a tertiary hospital in Brisbane, Australia, between 2010 and 2019. A total of 522 patients underwent resection of colorectal cancer with primary anastomosis with no covering stoma and the prevalence of anastomotic leak was compared between those who had had perioperative blood transfusion(s) and those who had not. RESULTS A total of 19 of 522 patients undergoing surgery for colorectal cancer had developed an anastomotic leak (3.64%). 11.3% of patients who had had a perioperative blood transfusion developed an anastomotic leak whereas 2.2% of patients who had not had a blood transfusion developed an anastomotic leak (p = 0.0002). Patients undergoing procedure on their right colon had proportionally more blood transfusions and this approached statistical significance (p = 0.06). Patients who received a greater quantity of units of blood transfusion prior to their diagnosis of anastomotic leak were more likely to develop an anastomotic leak (p = 0.001). CONCLUSION Perioperative blood transfusions are associated with a significantly increased risk of an anastomotic leak following bowel resection with primary anastomosis for colorectal cancer.
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Affiliation(s)
- Fraser Hugh Simpson
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia.
- Northside Clinical School, School of Medicine, The University of Queensland, Brisbane, QLD, Australia.
| | - Krish Kulendran
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Stephanie Yerkovich
- School of Clinical Medicine, The University of Queensland, Brisbane, Australia
| | - Andrew Beatty
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - David Flynn
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Derek Mao
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Taylor Brooks
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Phoebe Wood
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Manju D Chandrasegaram
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
- Northside Clinical School, School of Medicine, The University of Queensland, Brisbane, QLD, Australia
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2
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Smith SA, Simpson F, Bell-Allen N, Brown N, Mudaliar S, Aftab K, Tam D, Chandrasegaram MD. Percutaneous thrombolysis via cholecystostomy catheter to dissolve biliary clots causing obstructive jaundice. J Surg Case Rep 2024; 2024:rjae055. [PMID: 38404451 PMCID: PMC10884733 DOI: 10.1093/jscr/rjae055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 01/19/2024] [Indexed: 02/27/2024] Open
Abstract
Haemobilia, or bleeding within the biliary tree, is rare. It can cause biliary obstruction secondary to blood clots. A comorbid 87-year-old was admitted to hospital with acute cholecystitis, choledocholithiasis, and an Escherichia coli bacteremia. He had a partial pancreatectomy and gastrojejunostomy 35 years prior for severe pancreatitis. He was treated with antibiotics and a percutaneous cholecystostomy. He developed atrial fibrillation and was subsequently commenced on warfarin. He re-presented 5 days after discharge with abdominal pain and fevers. Liver function tests revealed cholestasis and a supratherapeutic international normalised ratio. Imaging showed cholecystitis, biliary obstruction, and extensive biliary blood clots. He improved with antibiotics, vitamin K, and alteplase flushes through the percutaneous cholecystostomy. Repeat cholangiogram demonstrated dissolution of the biliary clots. Due to altered anatomy and comorbidities, alteplase flushes were utilized to relieve this patient's biliary obstruction. Thrombolytics may assist in treating biliary clots when first-line options are not possible or favourable.
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Affiliation(s)
- Sonya A Smith
- Department of General Surgery, The Prince Charles Hospital, 627 Rode Rd, Chermside QLD0, Queensland 4032, Australia
| | - Fraser Simpson
- Department of General Surgery, The Prince Charles Hospital, 627 Rode Rd, Chermside QLD0, Queensland 4032, Australia
| | - Nicholas Bell-Allen
- Department of General Surgery, The Prince Charles Hospital, 627 Rode Rd, Chermside QLD0, Queensland 4032, Australia
| | - Nicholas Brown
- Department of Radiology, The Prince Charles Hospital, 627 Rode Rd, Chermside, Queensland 4032, Australia
| | - Sanjivan Mudaliar
- Department of Gastroentrology, The Prince Charles Hospital, 627 Rode Rd, Chermside, Queensland 4032, Australia
| | - Khurram Aftab
- Department of Radiology, The Prince Charles Hospital, 627 Rode Rd, Chermside, Queensland 4032, Australia
| | - Diana Tam
- Department of General Surgery, The Prince Charles Hospital, 627 Rode Rd, Chermside QLD0, Queensland 4032, Australia
| | - Manju D Chandrasegaram
- Department of General Surgery, The Prince Charles Hospital, 627 Rode Rd, Chermside QLD0, Queensland 4032, Australia
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3
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Beatty AS, Kulendran K, Iswariah H, Chandrasegaram MD. Gallbladder volvulus with preoperative and intraoperative imaging. J Surg Case Rep 2023; 2023:rjad048. [PMID: 36811069 PMCID: PMC9939045 DOI: 10.1093/jscr/rjad048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/24/2023] [Indexed: 02/21/2023] Open
Abstract
Volvulus of the gallbladder is one of the rarest conditions to affect the gallbladder, however, it should remain an important differential. Typically, it is diagnosed in elderly women, but it has also been reported in children and men. The lack of unique distinguishing features make diagnosis difficult to distinguish between other gallbladder pathology such as acute cholecystitis; however, delayed recognition or non-operative management is associated with higher mortality. We present the case of a 92-year-old woman who presented with this pathology, had diagnosis established preoperatively and was successfully treated with a cholecystectomy.
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Affiliation(s)
- Andrew Stafford Beatty
- Correspondence address. Department of General Surgery, The Prince Charles Hospital, Rode Road, Chermside 4032 Queensland, Australia. Tel: +61-7-3139-4000; Fax: +61-7-3139-4000; E-mail:
| | - Krish Kulendran
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia,Northside Clinical School, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Harish Iswariah
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia,Northside Clinical School, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Manju D Chandrasegaram
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia,Northside Clinical School, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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Beatty AS, Simpson FH, Chandrasegaram MD. Massive pulmonary embolism and intra-cardiac thrombus requiring systemic thrombolysis 9-hours post emergency laparotomy. J Surg Case Rep 2022; 2022:rjac528. [DOI: 10.1093/jscr/rjac528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 10/27/2022] [Indexed: 11/29/2022] Open
Abstract
Abstract
The link between abdominal surgery and venous thromboembolism (VTE) has been well established with recent evidence exploring the optimal VTE risk reducing strategy. However, despite these strategies pulmonary embolisms (PEs) do occur, which in the immediate post-operative setting creates a dilemma; to treat the VTE with anticoagulation but balance against the risk of hemorrhage. Treatment guidelines often do not include post-operative patients leaving the decision up to the treating physician to weigh the relative risks on an individual basis. We present a 59-year-old lady who developed a life-threatening submassive PE within 9 h of an emergency laparotomy for a perforated rectal cancer. She was treated with systemic thrombolysis after alternative interventions had been excluded. She responded well to therapy with no major bleeding. She was successfully discharged home after a short period of inpatient rehabilitation.
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Affiliation(s)
- Andrew Stafford Beatty
- Department of General Surgery, The Prince Charles Hospital , Brisbane, Queensland , Australia
- Northside Clinical School, School of Medicine, The University of Queensland , Brisbane, Queensland , Australia
| | - Fraser Hugh Simpson
- Department of General Surgery, The Prince Charles Hospital , Brisbane, Queensland , Australia
- Northside Clinical School, School of Medicine, The University of Queensland , Brisbane, Queensland , Australia
| | - Manju D Chandrasegaram
- Department of General Surgery, The Prince Charles Hospital , Brisbane, Queensland , Australia
- Northside Clinical School, School of Medicine, The University of Queensland , Brisbane, Queensland , Australia
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5
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Mao D, Flynn DE, Yerkovich S, Tran K, Gurunathan U, Chandrasegaram MD. Effect of obesity on post-operative outcomes following colorectal cancer surgery. World J Gastrointest Oncol 2022; 14:1324-1336. [PMID: 36051092 PMCID: PMC9305574 DOI: 10.4251/wjgo.v14.i7.1324] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/10/2022] [Accepted: 06/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) resection is currently being undertaken in an increasing number of obese patients. Existing studies have yet to reach a consensus as to whether obesity affects post-operative outcomes following CRC surgery.
AIM To evaluate the post-operative outcomes of obese patients following CRC resection, as well as to determine the post-operative outcomes of obese patients in the subgroup undergoing laparoscopic surgery.
METHODS Six-hundred and fifteen CRC patients who underwent surgery at the Prince Charles Hospital between January 2010 and December 2020 were categorized into two groups based on body mass index (BMI): Obese [BMI ≥ 30, n = 182 (29.6%)] and non-obese [BMI < 30, n = 433 (70.4%)]. Demographics, comorbidities, surgical features, and post-operative outcomes were compared between both groups. Post-operative outcomes were also compared between both groups in the subgroup of patients undergoing laparoscopic surgery [n = 472: BMI ≥ 30, n = 136 (28.8%); BMI < 30, n = 336 (71.2%)].
RESULTS Obese patients had a higher burden of cardiac (73.1% vs 56.8%; P < 0.001) and respiratory comorbidities (37.4% vs 26.8%; P = 0.01). Obese patients were also more likely to undergo conversion to an open procedure (12.8% vs 5.1%; P = 0.002), but did not experience more post-operative complications (51.6% vs 44.1%; P = 0.06) or high-grade complications (19.2% vs 14.1%; P = 0.11). In the laparoscopic subgroup, however, obesity was associated with a higher prevalence of post-operative complications (47.8% vs 39.3%; P = 0.05) but not high-grade complications (17.6% vs 11.0%; P = 0.07).
CONCLUSION Surgical resection of CRC in obese individuals is safe. A higher prevalence of post-operative complications in obese patients appears to only be in the context of laparoscopic surgery.
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Affiliation(s)
- Derek Mao
- Faculty of Medicine and Health, The University of Sydney, Sydney 2050, New South Wales, Australia
| | - David E Flynn
- Department of General Surgery, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia
| | - Stephanie Yerkovich
- Faculty of Medicine, The University of Queensland, Brisbane 4006, Queensland, Australia
| | - Kayla Tran
- Department of Pathology, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia
| | - Usha Gurunathan
- Faculty of Medicine, The University of Queensland, Brisbane 4006, Queensland, Australia
- Department of Anaesthesia, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia
| | - Manju D Chandrasegaram
- Department of General Surgery, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane 4006, Queensland, Australia
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6
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Gurunathan U, L King J, French C, Iswariah H, R Hancock P, Holmes P, Linnane M, J Mahoney A, D Chandrasegaram M, Tronstad O. A multimodal surgical prehabilitation programme for major abdominal cancer surgery at a tertiary metropolitan institution in Australia: Our initial experience. Anaesth Intensive Care 2022; 50:258-261. [PMID: 35040346 DOI: 10.1177/0310057x211027891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Usha Gurunathan
- Department of Anaesthesia and Perfusion Services, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Jessica L King
- Physiotherapy Department, The Prince Charles Hospital, Brisbane, Australia
| | - Cameron French
- Nutrition and Dietetics, The Prince Charles Hospital, Brisbane, Australia
| | - Harish Iswariah
- Department of Surgery, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Peter R Hancock
- Preadmission Clinic & Outpatient Department, The Prince Charles Hospital, Brisbane, Australia
| | - Petrina Holmes
- Department of Social Work, The Prince Charles Hospital, Brisbane, Australia
| | - Matthew Linnane
- Physiotherapy Department, The Prince Charles Hospital, Brisbane, Australia
| | - Alison J Mahoney
- Physiotherapy Department, The Prince Charles Hospital, Brisbane, Australia
| | - Manju D Chandrasegaram
- Department of Surgery, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Oystein Tronstad
- Physiotherapy Department, The Prince Charles Hospital, Brisbane, Australia.,Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia
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Simpson FH, Auld M, Kandpal H, Tran K, Chandrasegaram MD. Double trouble: synchronous extrahepatic cholangiocarcinoma and gallbladder cancer in a Caucasian woman with no pancreaticobiliary maljunction. J Surg Case Rep 2022; 2022:rjab587. [PMID: 35079333 PMCID: PMC8784173 DOI: 10.1093/jscr/rjab587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 12/03/2021] [Indexed: 11/14/2022] Open
Abstract
Synchronous malignancies of the bile duct and the gallbladder are rare. These cases are often associated with pancreaticobiliary maljunction which is characterized by a long common shared pancreatobiliary channel leading to the Sphincter of Oddi. This predisposes the biliary epithelium to pancreatic enzyme reflux and makes the development of neoplasia more likely. We describe the case of a 64-year-old Caucasian female who presented with new jaundice and severe cholecystitis secondary to an impacted gallstone which was seen on ultrasound. Magnetic resonance cholangiopancreatography was organized with suspicion of a possible Mirizzi syndrome. This revealed a mid-distal bile duct cancer in addition to cholecystitis from an impacted gallstone. She was treated with intravenous antibiotics for her cholecystitis and underwent an urgent endoscopic retrograde cholangiopancreatography procedure for biliary decompression and stenting for her obstructive jaundice. The patient proceeded to pancreaticoduodenectomy with final histopathology revealing a synchronous primary gallbladder malignancy in addition to the known bile duct cancer.
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Affiliation(s)
- Fraser Hugh Simpson
- Correspondence address. Northside Clinical School, University of Queensland, The Prince Charles Hospital, Brisbane, Queensland, Australia. Tel: +61 439 637 851; Fax: +61 7 3139 4000; E-mail:
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8
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Simpson FH, Beatty A, Auld M, Maurice AP, Chandrasegaram MD. Stones have been known to move: Bouveret's syndrome treated with cholecystolithotomy after previous episode of gallstone ileus. ANZ J Surg 2021; 92:1560-1562. [PMID: 34719852 DOI: 10.1111/ans.17342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 10/20/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Fraser Hugh Simpson
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia.,Northside Clinical School, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Andrew Beatty
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Michael Auld
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Andrew Phillip Maurice
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Manju D Chandrasegaram
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia.,Northside Clinical School, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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9
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Flynn DE, Mao D, Yerkovich ST, Franz R, Iswariah H, Hughes A, Shaw IM, Tam DPL, Chandrasegaram MD. The impact of comorbidities on post-operative complications following colorectal cancer surgery. PLoS One 2020; 15:e0243995. [PMID: 33362234 PMCID: PMC7757883 DOI: 10.1371/journal.pone.0243995] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 12/01/2020] [Indexed: 02/05/2023] Open
Abstract
Background Colorectal cancer surgery is complex and can result in severe post-operative complications. Optimisation of surgical outcomes requires a thorough understanding of the background complexity and comorbid status of patients. Aim The aim of this study is to determine whether certain pre-existing comorbidities are associated with high grade post-operative complications following colorectal cancer surgery. The study also aims to define the prevalence of demographic, comorbid and surgical features in a population undergoing colorectal cancer resection. Method A colorectal cancer database at The Prince Charles Hospital was established to capture detailed information on patient background, comorbidities and clinicopathological features. A single-centre retrospective study was undertaken to assess the effect of comorbidities on post-operative outcomes following colorectal cancer resection. Five hundred and thirty-three patients were reviewed between 2010–2018 to assess if specific comorbidities were associated with higher grade post-operative complications. A Clavien-Dindo grade of three or higher was defined as a high grade complication. Results Fifty-eight percent of all patients had an ASA grade of ASA III or above. The average BMI of patients undergoing resection was 28 ± 6.0. Sixteen percent of all patients experienced a high grade complications. Patients with high grade complications had a higher mean average age compared to patients with low grade or no post-operative complications (74 years vs 70 years, p = 0.01). Univariate analysis revealed patients with atrial fibrillation, COPD, ischaemic heart disease and heart failure had an increased risk of high grade complications. Multivariate analysis revealed pre-existing atrial fibrillation (OR 2.70, 95% CI 1.53–4.89, p <0.01) and COPD (OR 2.02 1.07–3.80, p = 0.029) were independently associated with an increased risk of high grade complications. Conclusion Pre-existing atrial fibrillation and COPD are independent risk factors for high grade complications. Targeted perioperative management is necessary to optimise outcomes.
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Affiliation(s)
- David E. Flynn
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia
- * E-mail:
| | - Derek Mao
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Stephanie T. Yerkovich
- The Common Good Foundation, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Robert Franz
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Harish Iswariah
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Andrew Hughes
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Ian M. Shaw
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Diana P. L. Tam
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia
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Choi K, Flynn DE, Karunairajah A, Hughes A, Bhasin A, Devereaux B, Chandrasegaram MD. Management of infected pancreatic necrosis in the setting of concomitant rectal cancer: A case report and review of literature. World J Gastrointest Surg 2019; 11:237-246. [PMID: 31123561 PMCID: PMC6513786 DOI: 10.4240/wjgs.v11.i4.237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 03/26/2019] [Accepted: 04/09/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatitis with infected necrosis is a severe complication of acute pancreatitis and carries with it high rates of morbidity and mortality. The management of infected pancreatic necrosis alongside concomitant colorectal cancer has never been described in literature.
CASE SUMMARY A 77 years old gentleman presented to the Emergency Department of our hospital complaining of ongoing abdominal pain for 8 h. The patient had clinical features of pancreatitis with a raised lipase of 3810 U/L, A computed tomography (CT) abdomen confirmed pancreatitis with extensive peri-pancreatic edema. During the course of his admission, the patient had persistent high fevers and delirium thought secondary to infected necrosis, prompting the commencement of broad-spectrum antibiotic therapy with Piperacillin/Tazobactam. Subsequent CT abdomen confirmed extensive pancreatic necrosis (over 70%). Patient was managed with supportive therapy, nutritional support and gut rest initially and improved over the course of his admission and was discharged 42 d post admission. He represented 24 d following his discharge with fever and chills and a repeat CT abdomen scan noted gas bubbles within the necrotic pancreatic tissue thereby confirming infected necrotic pancreatitis. This CT scan also revealed asymmetric thickening of the rectal wall suspicious for malignancy. A rectal cancer was confirmed on flexible sigmoidoscopy. The patient underwent two endoscopic necrosectomies and was treated with intravenous antibiotics and was discharged after 28 d. Within 1 wk post discharge, the patient commenced a course of neoadjuvant radiotherapy and subsequently underwent concomitant chemotherapy prior to undergoing a successful Hartmann’s procedure for treatment of his colorectal cancer.
CONCLUSION This case highlights the efficacy of endoscopic necrosectomy, early enteral feeding and targeted antibiotic therapy for timely management of infected necrotic pancreatitis. The prompt resolution of pancreatitis permitted the patient to undergo neoadjuvant treatment and resection for his concomitant colorectal cancer.
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Affiliation(s)
- Kihoon Choi
- Department of Surgery, Gold Coast University Hospital, Southport, QLD 4215, Australia
| | - David E Flynn
- Department of General Surgery, the Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Anitha Karunairajah
- Department of General Surgery, the Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Andrew Hughes
- Department of General Surgery, the Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Ambika Bhasin
- Department of Radiology, the Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Benedict Devereaux
- Department of Gastroenterology, Royal Brisbane and Women’s Hospital, Brisbane, QLD 4029, Australia
| | - Manju D Chandrasegaram
- Department of General Surgery, the Prince Charles Hospital, Brisbane, QLD 4032, Australia
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Chandrasegaram MD, Gill AJ, Samra J, Price T, Chen J, Fawcett J, Merrett ND. Ampullary cancer of intestinal origin and duodenal cancer - A logical clinical and therapeutic subgroup in periampullary cancer. World J Gastrointest Oncol 2017; 9:407-415. [PMID: 29085567 PMCID: PMC5648984 DOI: 10.4251/wjgo.v9.i10.407] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 06/26/2017] [Accepted: 08/16/2017] [Indexed: 02/05/2023] Open
Abstract
Periampullary cancers include pancreatic, ampullary, biliary and duodenal cancers. At presentation, the majority of periampullary tumours have grown to involve the pancreas, bile duct, ampulla and duodenum. This can result in difficulty in defining the primary site of origin in all but the smallest tumors due to anatomical proximity and architectural distortion. This has led to variation in the reported proportions of resected periampullary cancers. Pancreatic cancer is the most common cancer resected with a pancreaticoduodenectomy followed by ampullary (16%-50%), bile duct (5%-39%), and duodenal cancer (3%-17%). Patients with resected duodenal and ampullary cancers have a better reported median survival (29-47 mo and 22-54 mo) compared to pancreatic cancer (13-19 mo). The poorer survival with pancreatic cancer relates to differences in tumour characteristics such as a higher incidence of nodal, neural and vascular invasion. While small ampullary cancers can present early with biliary obstruction, pancreatic cancers need to reach a certain size before biliary obstruction ensues. This larger size at presentation contributes to a higher incidence of resection margin involvement in pancreatic cancer. Ampullary cancers can be subdivided into intestinal or pancreatobiliary subtype cancers with histomolecular staining. This avoids relying on histomorphology alone, as even some poorly differentiated cancers preserve the histomolecular profile of their mucosa of origin. Histomolecular profiling is superior to anatomic location in prognosticating survival. Ampullary cancers of intestinal subtype and duodenal cancers are similar in their intestinal origin and form a logical clinical and therapeutic subgroup of periampullary cancers. They respond to 5-FU based chemotherapeutic regimens such as capecitabine-oxaliplatin. Unlike pancreatic cancers, KRAS mutation occurs in only approximately a third of ampullary and duodenal cancers. Future clinical trials should group ampullary cancers of intestinal origin and duodenal cancers together given their similarities and their response to fluoropyrimidine therapy in combination with oxaliplatin. The addition of anti-epidermal growth factor receptor therapy in this group warrants study.
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Affiliation(s)
- Manju D Chandrasegaram
- the Prince Charles Hospital, Brisbane, Queensland 4032, Australia
- School of Medicine, University of Queensland, Queensland 4006, Australia
| | - Anthony J Gill
- Sydney Medical School, University of Sydney, New South Wales 2006, Australia
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales 2065, Australia
| | - Jas Samra
- Sydney Medical School, University of Sydney, New South Wales 2006, Australia
- Department of Surgery, Royal North Shore Hospital, Sydney, New South Wales 2065, Australia
| | - Tim Price
- Queen Elizabeth Hospital, Adelaide, South Australia 5011, Australia
- University of Adelaide, South Australia 5005, Australia
| | - John Chen
- Flinders Medical Centre, Adelaide, South Australia 5042, Australia
- Royal Adelaide Hospital, Adelaide, South Australia 5000, Australia
| | - Jonathan Fawcett
- School of Medicine, University of Queensland, Queensland 4006, Australia
- Princess Alexandra Hospital, Brisbane, Queensland 4102, Australia
| | - Neil D Merrett
- Department of Upper GI Surgery, Bankstown Hospital, Sydney, New South Wales 2200, Australia
- Discipline of Surgery, Western Sydney University, Sydney, New South Wales 2560, Australia
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Chandrasegaram MD, Goldstein D, Simes J, Gebski V, Kench JG, Gill AJ, Samra JS, Merrett ND, Richardson AJ, Barbour AP. Meta-analysis of radical resection rates and margin assessment in pancreatic cancer. Br J Surg 2015; 102:1459-72. [PMID: 26350029 DOI: 10.1002/bjs.9892] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 04/28/2015] [Accepted: 06/05/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND R0 resection rates (complete tumour removal with negative resection margins) in pancreatic cancer are 70-80 per cent when a 0-mm margin is used, declining to 15-24 per cent with a 1-mm margin. This review evaluated the R0 resection rates according to different margin definitions and techniques. METHODS Three databases (MEDLINE from 1946, PubMed from 1946 and Embase from 1949) were searched to mid-October 2014. The search terms included 'pancreatectomy OR pancreaticoduodenectomy' and 'margin'. A meta-analysis was performed with studies in three groups: group 1, axial slicing technique (minimum 1-mm margin); group 2, other slicing techniques (minimum 1-mm margin); and group 3, studies with minimum 0-mm margin. RESULTS The R0 rates were 29 (95 per cent c.i. 26 to 32) per cent in group 1 (8 studies; 882 patients) and 49 (47 to 52) per cent in group 2 (6 studies; 1568 patients). The combined R0 rate (groups 1 and 2) was 41 (40 to 43) per cent. The R0 rate in group 3 (7 studies; 1926 patients) with a 0-mm margin was 72 (70 to 74) per cent The survival hazard ratios (R1 resection/R0 resection) revealed a reduction in the risk of death of at least 22 per cent in group 1, 12 per cent in group 2 and 23 per cent in group 3 with an R0 compared with an R1 resection. Local recurrence occurred more frequently with an R1 resection in most studies. CONCLUSION Margin clearance definitions affect R0 resection rates in pancreatic cancer surgery. This review collates individual studies providing an estimate of achievable R0 rates, creating a benchmark for future trials.
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Affiliation(s)
- M D Chandrasegaram
- National Health and Medical Research Clinical Trials Centre, University of Sydney, New South Wales, Australia.,Discipline of Surgery, University of Adelaide, Adelaide, South Australia, Australia.,Department of Surgery, Prince Charles Hospital, Queensland, Australia
| | - D Goldstein
- Department of Medical Oncology, Prince of Wales Hospital, Prince of Wales Clinical School University of New South Wales, New South Wales, Australia
| | - J Simes
- National Health and Medical Research Clinical Trials Centre, University of Sydney, New South Wales, Australia
| | - V Gebski
- National Health and Medical Research Clinical Trials Centre, University of Sydney, New South Wales, Australia
| | - J G Kench
- Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - A J Gill
- Cancer Diagnosis and Pathology Research Group, Kolling Institute of Medical Research, University of Sydney, New South Wales, Australia
| | - J S Samra
- Department of Surgery, Royal North Shore Hospital, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - N D Merrett
- Discipline of Surgery, School of Medicine, University of Western Sydney, New South Wales, Australia.,Department of Surgery, Prince Charles Hospital, Queensland, Australia
| | - A J Richardson
- Department of Surgery, Westmead Hospital, Westmead, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - A P Barbour
- University of Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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13
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Chandrasegaram MD, Shah A, Chen JW, Ruszkiewicz A, Astill DS, England G, Raju RS, Neo EL, Dolan PM, Tan CP, Brooke-Smith M, Wilson T, Padbury RTA, Worthley CS. Oestrogen hormone receptors in focal nodular hyperplasia. HPB (Oxford) 2015; 17:502-7. [PMID: 25728618 PMCID: PMC4430780 DOI: 10.1111/hpb.12387] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 12/13/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND The role of hormones in focal nodular hyperplasia (FNH) has been investigated with conflicting results. OBJECTIVE The aim of this study was to evaluate oestrogen and progesterone receptor immunohistochemical expression in FNH and surrounding normal liver (control material). METHODS Biopsy materials from FNH and control tissue were investigated using an immunostainer. Receptor expression was graded as the proportion score (percentage of nuclear staining) and oestrogen receptor intensity score. RESULTS Study material included tissue from 11 resected FNH lesions and two core biopsies in 13 patients (two male). Twelve samples showed oestrogen receptor expression. The percentage of nuclear oestrogen receptor staining was <33% in eight FNH biopsies, 34-66% in two FNH biopsies, and >67% in both core biopsies. The better staining in core biopsies relates to limitations of the staining technique imposed by the fibrous nature of larger resected FNH. Control samples from surrounding tissue were available for nine of the resected specimens and all showed oestrogen receptor expression. Progesterone receptor expression was negligible in FNH and control samples. CONCLUSIONS By contrast with previous studies, the majority of FNH and surrounding liver in this cohort demonstrated oestrogen receptor nuclear staining. The implications of this for continued oral contraceptive use in women of reproductive age with FNH remain uncertain given the lack of consistent reported growth response to oestrogen stimulation or withdrawal.
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Affiliation(s)
- Manju D Chandrasegaram
- Hepatobiliary Unit, Royal Adelaide HospitalAdelaide, SA, Australia,Division of Surgery, University of AdelaideAdelaide, SA, Australia,Correspondence Manju Chandrasegaram, Discipline of Surgery, School of Medicine, University of Adelaide, Adelaide, SA 5005, Australia. E-mail:
| | - Ali Shah
- Hepatobiliary Unit, Royal Adelaide HospitalAdelaide, SA, Australia
| | - John W Chen
- Hepatobiliary Unit, Royal Adelaide HospitalAdelaide, SA, Australia,Department of Surgery, Flinders Medical CentreAdelaide, SA, Australia
| | - Andrew Ruszkiewicz
- Department of Tissue Pathology, SA Pathology, Royal Adelaide Hospital SiteAdelaide, SA, Australia
| | - David S Astill
- Department of Tissue Pathology, SA Pathology, Flinders Medical Centre SiteAdelaide, SA, Australia
| | - Georgina England
- Department of Tissue Pathology, SA Pathology, Royal Adelaide Hospital SiteAdelaide, SA, Australia
| | - Ravish S Raju
- Department of Surgery, Flinders Medical CentreAdelaide, SA, Australia
| | - Eu Ling Neo
- Hepatobiliary Unit, Royal Adelaide HospitalAdelaide, SA, Australia,Department of Surgery, Flinders Medical CentreAdelaide, SA, Australia
| | - Paul M Dolan
- Hepatobiliary Unit, Royal Adelaide HospitalAdelaide, SA, Australia
| | - Chuan Ping Tan
- Hepatobiliary Unit, Royal Adelaide HospitalAdelaide, SA, Australia
| | - Mark Brooke-Smith
- Hepatobiliary Unit, Royal Adelaide HospitalAdelaide, SA, Australia,Department of Surgery, Flinders Medical CentreAdelaide, SA, Australia
| | - Tom Wilson
- Department of Surgery, Flinders Medical CentreAdelaide, SA, Australia
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14
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Barbour A, O'Rourke N, Chandrasegaram MD, Chua YJ, Kench J, Samra JS, Pavlakis N, Haghighi KS, Yip S, Fawcett J, Donoghoe M, Walker K, Burge ME, Gananadha S, Harris M, Aghmesheh M, Joubert WL, Gebski V, Simes J, Goldstein D. A multicenter, phase II trial of preoperative gemcitabine and nab-paclitaxel for resectable pancreas cancer: The AGITG GAP study. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.4115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | - James Kench
- Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, Australia
| | | | - Nick Pavlakis
- Department of Medical Oncology, Royal North Shore Hospital, The University of Sydney, Sydney, Australia
| | | | - Sonia Yip
- Sydney Catalyst Translational Cancer Research Centre, Sydney, Australia
| | | | | | - Kate Walker
- NHMRC Clinical Trials Centre, Sydney, Australia
| | | | | | | | | | | | - Val Gebski
- National Health and Medical Research Council Clinical Trials Centre, Sydney, Australia
| | - John Simes
- NHMRC Clinical Trials Centre, Sydney, Australia
| | - David Goldstein
- Prince of Wales Hospital, University of New South Wales, Cancer Survivors Centre, Sydney, Australia
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15
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Raashed S, Chandrasegaram MD, Alsaleh K, Schlaphoff G, Merrett ND. Vascular coil erosion into hepaticojejunostomy following hepatic arterial embolisation. BMC Surg 2015; 15:51. [PMID: 25925841 PMCID: PMC4423092 DOI: 10.1186/s12893-015-0039-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 04/24/2015] [Indexed: 01/22/2023] Open
Abstract
Background Right hepatic arterial injury (RHAI) is the most common vascular injury sustained during laparoscopic cholecystectomy, occurring in up to 7% of cholecystectomies. RHAI is also the most common vascular injury associated with a bile duct injury (BDI) and is reported to occur in up to 41 – 61% of cases when routine angiography is employed following a BDI. We present an unusual case of erosion of vascular coils from a previously embolised right hepatic artery into bilio-enteric anastomoses causing biliary obstruction. This is on a background of biliary reconstruction following a major BDI. Case presentation A 37-year old man underwent a bile duct reconstruction following a major BDI (Strasberg-Bismuth E4 injury) sustained at laparoscopic cholecystectomy. He had two separate bilio-enteric anastomoses of the right and left hepatic ducts and had a modified Terblanche Roux-en-Y access limb formed. Approximately three weeks later he was admitted for significant gastrointestinal bleeding and was hypotensive and anaemic. Selective computed tomography angiography revealed a 2 x 2 centimetre right hepatic artery pseudoaneurysm, which was urgently embolised with radiological coils. Two months later he developed intermittent fevers, rigors, jaundice, and right upper quadrant pain with evidence of intrahepatic biliary dilatation on magnetic resonance cholangiopancreatography. The degree of intrahepatic biliary dilatation progressively increased on subsequent imaging over several months, suggesting stricturing of the bilio-enteric anastomoses. Several attempts to traverse these strictures with a percutaneous transhepatic approach had failed. Then, approximately ten months after the initial BDI repair, choledochoscopy through the Terblanche access limb revealed multiple radiological coils within the bilio-enteric anastomoses, which had eroded from the previously embolised right hepatic artery. A laparotomy was performed to remove the coils, take down the existing obstructed bilio-enteric anastomoses and revise this. Following this the patient recovered uneventfully. Conclusion Obstructive jaundice and cholangitis secondary to erosion of angiographically placed embolisation coils is a rarely described complication. In view of the relative frequency of arterial injury and complications following major bile duct injury, we suggest that these patients be formally assessed for associated arterial injury following a major BDI.
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Affiliation(s)
- Soondoos Raashed
- Upper Gastrointestinal Unit, Bankstown Hospital, Sydney, Australia
| | - Manju D Chandrasegaram
- Upper Gastrointestinal Unit, Bankstown Hospital, Sydney, Australia.,Division of Surgery, School of Medicine, University of Western Sydney, Sydney, Australia
| | - Khaled Alsaleh
- Upper Gastrointestinal Unit, Bankstown Hospital, Sydney, Australia
| | - Glen Schlaphoff
- Interventional and Diagnostic Radiology, Liverpool Hospital, Sydney, Australia
| | - Neil D Merrett
- Upper Gastrointestinal Unit, Bankstown Hospital, Sydney, Australia. .,Division of Surgery, School of Medicine, University of Western Sydney, Sydney, Australia.
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16
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Ahn J, Chandrasegaram MD, Alsaleh K, Woodham BL, Teo A, Das A, Merrett ND, Apostolou C. Large retroperitoneal isolated fibrous cyst in absence of preceding trauma or acute pancreatitis. BMC Surg 2015; 15:25. [PMID: 25884761 PMCID: PMC4364509 DOI: 10.1186/s12893-015-0016-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 02/26/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Isolated retroperitoneal cystic masses are uncommon with an estimated incidence of 1/5750 to 1/250,000. The majority present with size related symptoms, complications, or a mass. Approximately a third of patients are asymptomatic and are diagnosed incidentally. Aetiologies of retroperitoneal cystic masses (RPC) include mesenteric, omental, splenic and enteric duplication cysts. Neoplastic RPCs can be divided into epithelial (mucinous or serous cystadenoma), mesothelial (mesothelioma), germ cell (cystic teratoma) and cystic changes in a solid neoplasm (paraganglioma, neurilemmoma, sarcoma). CASE PRESENTATION A 53 year-old man presented to us with abdominal pain related to a large mass in his left upper quadrant with associated anorexia and weight loss. He gave no history of previous trauma and denied having symptoms or a history of pancreatitis. He said he had felt this mass increasing in size over the course of several years. Clinical examination of his abdomen revealed a large firm left sided mass extending to his left upper quadrant. Imaging with computed tomography (CT) and magnetic resonance imaging cholangio-pancreatogram (MRCP) revealed a 13.7 cm × 12.2 cm × 10.9 cm cystic lesion in the retroperitoneum which was separate from the kidney, pancreas, spleen and bowel. At laparotomy, this mass was easily dissected from the surrounding viscera and was excised completely intact. Histopathological assessment found the mass to be a large fibrous pseudocyst with no epithelial lining. CONCLUSION We present a rare case of an isolated large retroperitoneal fibrous pseudocyst unrelated to previous pancreatitis which was successfully managed with surgery.
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Affiliation(s)
- Julie Ahn
- Division of Surgery, University of Western Sydney, Sydney, Australia
| | - Manju D Chandrasegaram
- Division of Surgery, University of Western Sydney, Sydney, Australia.,Upper Gastrointestinal Unit, Bankstown Hospital, Sydney, Australia
| | - Khaled Alsaleh
- Upper Gastrointestinal Unit, Bankstown Hospital, Sydney, Australia
| | - Benjamin L Woodham
- Division of Surgery, University of Western Sydney, Sydney, Australia.,Upper Gastrointestinal Unit, Bankstown Hospital, Sydney, Australia
| | - Adrian Teo
- Upper Gastrointestinal Unit, Bankstown Hospital, Sydney, Australia
| | - Amithaba Das
- Upper Gastrointestinal Unit, Bankstown Hospital, Sydney, Australia
| | - Neil D Merrett
- Division of Surgery, University of Western Sydney, Sydney, Australia. .,Upper Gastrointestinal Unit, Bankstown Hospital, Sydney, Australia.
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17
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Chandrasegaram MD, Neo EL, Nathan AD, Dolan PM, Tan CP, Chen JW, Worthley CS. Response to re: palliative bypass for small bowel carcinoid with mesenteric mass and vascular encasement. ANZ J Surg 2015; 85:197-8. [PMID: 25732392 DOI: 10.1111/ans.12979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Manju D Chandrasegaram
- Hepato-Pancreato-Biliary Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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18
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Chandrasegaram MD, Chiam SC, Chen JW, Khalid A, Mittinty ML, Neo EL, Tan CP, Dolan PM, Brooke-Smith ME, Kanhere H, Worthley CS. Distribution and pathological features of pancreatic, ampullary, biliary and duodenal cancers resected with pancreaticoduodenectomy. World J Surg Oncol 2015; 13:85. [PMID: 25890023 PMCID: PMC4348158 DOI: 10.1186/s12957-015-0498-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 02/01/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Pancreatic cancer (PC) has the worst survival of all periampullary cancers. This may relate to histopathological differences between pancreatic cancers and other periampullary cancers. Our aim was to examine the distribution and histopathologic features of pancreatic, ampullary, biliary and duodenal cancers resected with a pancreaticoduodenectomy (PD) and to examine local trends of periampullary cancers resected with a PD. METHODS A retrospective review of PD between January 2000 and December 2012 at a public metropolitan database was performed. The institutional ethics committee approved this study. RESULTS There were 142 PDs during the study period, of which 70 cases were pre-2010 and 72 post-2010, corresponding to a recent increase in the number of cases. Of the 142 cases, 116 were for periampullary cancers. There were also proportionately more PD for PC (26/60, 43% pre-2010 vs 39/56, 70% post-2010, P = 0.005). There were 65/116 (56%) pancreatic, 29/116 (25%), ampullary, 17/116 (15%) biliary and 5/116 (4%) duodenal cancers. Nodal involvement occurred more frequently in PC (78%) compared to ampullary (59%), biliary (47%) and duodenal cancers (20%), P = 0.002. Perineural invasion was also more frequent in PC (74%) compared to ampullary (34%), biliary (59%) and duodenal cancers (20%), P = 0.002. Microvascular invasion was seen in 57% pancreatic, 38% ampullary, 41% biliary and 20% duodenal cancers, P = 0.222. Overall, clear margins (R0) were achieved in fewer PC 41/65 (63%) compared to ampullary 27/29 (93%; P = 0.003) and biliary cancers 16/17 (94%; P = 0.014). CONCLUSIONS This study highlights that almost half of PD was performed for cancers other than PC, mainly ampullary and biliary cancers. The volume of PD has increased in recent years with an increased proportion being for PC. PC had higher rates of nodal and perineural invasion compared to ampullary, biliary and duodenal cancers.
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Affiliation(s)
- Manju D Chandrasegaram
- HPB Surgery Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia. .,Division of Surgery, School of Medicine, University of Adelaide, Adelaide, SA, 5005, Australia.
| | - Su C Chiam
- HPB Surgery Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia.
| | - John W Chen
- HPB Surgery Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia. .,Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia. .,Flinders University, Sturt Rd, Bedford Park, Adelaide, SA, 5042, Australia.
| | - Aisha Khalid
- Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia.
| | - Murthy L Mittinty
- School of Population Health, University of Adelaide, 178 North Terrace, Adelaide, SA, 5005, Australia.
| | - Eu L Neo
- HPB Surgery Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia. .,Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia.
| | - Chuan P Tan
- HPB Surgery Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia.
| | - Paul M Dolan
- HPB Surgery Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia.
| | - Mark E Brooke-Smith
- HPB Surgery Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia. .,Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia. .,Flinders University, Sturt Rd, Bedford Park, Adelaide, SA, 5042, Australia.
| | - Harsh Kanhere
- Division of Surgery, School of Medicine, University of Adelaide, Adelaide, SA, 5005, Australia. .,HPB Surgery Unit, Queen Elizabeth Hospital, 28 Woodville Road, Adelaide, SA, 5011, Australia.
| | - Chris S Worthley
- HPB Surgery Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia.
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19
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Chandrasegaram MD, Eslick GD, Lee W, Brooke-Smith ME, Padbury R, Worthley CS, Chen JW, Windsor JA. Anticoagulation policy after venous resection with a pancreatectomy: a systematic review. HPB (Oxford) 2014; 16:691-8. [PMID: 24344986 PMCID: PMC4113250 DOI: 10.1111/hpb.12205] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 10/30/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Portal vein (PV) resection is used increasingly in pancreatic resections. There is no agreed policy regarding anticoagulation. METHODS A systematic review was performed to compare studies with an anticoagulation policy (AC+) to no anticoagulation policy (AC-) after venous resection. RESULTS There were eight AC+ studies (n = 266) and five AC- studies (n = 95). The AC+ studies included aspirin, clopidogrel, heparin or warfarin. Only 50% of patients in the AC+ group received anticoagulation. There were more prosthetic grafts in the AC+ group (30 versus 2, Fisher's exact P < 0.001). The overall morbidity and mortality was similar in both groups. Early PV thrombosis (EPVT) was similar in the AC+ group and the AC- group (7%, versus 3%, Fisher's exact P = 0.270) and was associated with a high mortality (8/20, 40%). When prosthetic grafts were excluded there was no difference in the incidence of EPVT between both groups (1% vs 2%, Fisher's exact test P = 0.621). CONCLUSION There is significant heterogeneity in the use of anticoagulation after PV resection. Overall morbidity, mortality and EPVT in both groups were similar. EPVT has a high associated mortality. While we have been unable to demonstrate a benefit for anticoagulation, the incidence of EPVT is low in the absence of prosthetic grafts.
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Affiliation(s)
- Manju D Chandrasegaram
- HPB Department, Flinders Medical CentreAdelaide, SA, Australia,Department of Surgery, The University of Sydney, Sydney Medical SchoolNepean, Penrith, NSW, Australia
| | - Guy D Eslick
- Department of Surgery, The University of Sydney, Sydney Medical SchoolNepean, Penrith, NSW, Australia
| | - Wayne Lee
- School of Medicine, University of AdelaideAdelaide, SA, Australia
| | - Mark E Brooke-Smith
- HPB Department, Flinders Medical CentreAdelaide, SA, Australia,HPB Unit, Royal Adelaide HospitalAdelaide, SA, Australia,Flinders Clinical and Molecular Medicine, Flinders UniversityAdelaide, SA, Australia
| | - Rob Padbury
- HPB Department, Flinders Medical CentreAdelaide, SA, Australia,Flinders Clinical and Molecular Medicine, Flinders UniversityAdelaide, SA, Australia
| | | | - John W Chen
- HPB Department, Flinders Medical CentreAdelaide, SA, Australia,HPB Unit, Royal Adelaide HospitalAdelaide, SA, Australia,Flinders Clinical and Molecular Medicine, Flinders UniversityAdelaide, SA, Australia
| | - John A Windsor
- HPB/Upper GI Unit, Auckland City HospitalAuckland, New Zealand
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20
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Warren LR, Chandrasegaram MD, Neo EL, Dolan PM, Tan CP, Chen JW, Worthley CS. Large gas containing hepatic abscess following transarterial chemoembolization. ANZ J Surg 2014; 84:587-8. [DOI: 10.1111/ans.12275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Leigh R. Warren
- Hepatobiliary Unit; Royal Adelaide Hospital; Adelaide South Australia Australia
| | | | - Eu L. Neo
- Hepatobiliary Unit; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Paul M. Dolan
- Hepatobiliary Unit; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Chuan P. Tan
- Hepatobiliary Unit; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - John W. Chen
- Hepatobiliary Unit; Royal Adelaide Hospital; Adelaide South Australia Australia
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21
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Nathan AD, Chandrasegaram MD, Neo EL, Dolan PM, Tan CP, Chen JW, Worthley CS. Palliative bypass for small bowel carcinoid with mesenteric mass and vascular encasement. ANZ J Surg 2013; 84:793-4. [PMID: 24172022 DOI: 10.1111/ans.12333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Anand D Nathan
- Hepatobiliary Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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22
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Warren LR, Chandrasegaram MD, Madigan DJ, Dolan PM, Neo EL, Worthley CS. Falciform ligament abscess from left sided portal pyaemia following malignant obstructive cholangitis. World J Surg Oncol 2012; 10:278. [PMID: 23259725 PMCID: PMC3562200 DOI: 10.1186/1477-7819-10-278] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Accepted: 11/30/2012] [Indexed: 11/16/2022] Open
Abstract
Abscess formation of the falciform ligament is incredibly rare and perplexing when encountered for the first time. It is reported to occur in the setting of cholecystitis and cholangitis, but the pathophysiology is poorly understood. In this case report, we present a 73-year-old man with falciform ligament abscess following cholangitis from an obstructive ampullary carcinoma. The patient was referred to the Royal Adelaide Hospital from a country hospital, with progressive jaundice, anorexia and nausea. Prior to transfer, he deteriorated with cholangitis, dehydration and renal failure. On arrival, his abdomen was exquisitely tender along the course of the falciform ligament. His blood tests revealed an elevated white cell count of 14.9 x 103/μl, bilirubin of 291μmol/l and creatinine of 347 μmol/l. His CA 19-9 was markedly elevated at 35,000 kU/l. A non-contrast computed tomography (CT) demonstrated gross biliary dilatation and a collection tracking along the path of the falciform ligament to the umbilicus. The patient was commenced on intravenous antibiotics and underwent an urgent endoscopic retrograde cholangiopancreatogram (ERCP) with sphincterotomy and biliary stent drainage. Cholangiogram revealed a grossly dilated biliary tree, with abrupt transition at the ampulla, which on biopsy confirmed an obstructing ampullary carcinoma. Following ERCP, his jaundice and abdominal tenderness resolved. He was optimized over 4 weeks for an elective pancreaticoduodenectomy. At operation, we found abscess transformation of the falciform ligament. Copious amounts of pus and necrotic material was drained. Part of the round ligament was resected along the undersurface of the liver. Histology showed that there was prominent histiocytic inflammation with granular acellular eosinophilic components. The patient recovered slowly but uneventfully. A contrast CT scan undertaken 2 weeks post-operatively (approximately 7 weeks after the initial CT) revealed left portal venous thrombosis, which was likely to be a delayed discovery and was managed conservatively. We present this patient’s operative images and radiographic findings, which may explain the pathophysiology behind this rare complication. We hypothesize that cholangitis, with secondary portal pyaemia and tracking via the paraumbilical veins, can cause infectious seeding of the falciform ligament, with consequent abscess formation.
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Affiliation(s)
- Leigh R Warren
- Hepatobiliary Unit, Royal Adelaide Hospital, North Terrace, Adelaide 5000, South Australia
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Chandrasegaram MD, Rothwell LA, An EI, Miller RJ. Pathologies of the appendix: a 10-year review of 4670 appendicectomy specimens. ANZ J Surg 2012; 82:844-7. [PMID: 22924871 DOI: 10.1111/j.1445-2197.2012.06185.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2012] [Indexed: 01/14/2023]
Abstract
BACKGROUND Debate surrounds the management of the macroscopically normal appendix. Current literature recommends its removal given the high incidence of microscopic appendicitis, and other unusual pathologies in the normal-looking appendix. Negative appendicectomies are reported on the decline with increased use of diagnostic radiological adjuncts. METHODS This study analysed pathologies of the appendix over 10 years in the Pathology Department in Canberra. A positive appendicectomy was defined as acute appendicitis, faecoliths, worms, endometriosis or appendiceal tumours. We reviewed the positive appendicectomy rate over this time period. RESULTS There were 4670 appendicectomy specimens in 2386 males (51.1%) and 2284 (49%) females. The incidence of acute appendicitis was 71.3% and the positive appendicectomy rate was 76.3%. There were significantly fewer negative appendicectomies in males (16.8%) compared with females (31.0%). There was no appreciable change in this trend over the study period. Of the positive appendicectomies, there were 129 (3.6%) faecoliths. Of these, only 39.5% had concomitant appendicitis. There were 44 (1.2%) specimens identified with worms. Of these, 40.9% had concomitant appendicitis. There were 14 cases of endometriosis of the appendix of which 36% had concomitant appendicitis. There were 58/3562 (1.6%) appendiceal tumours within the positive appendicectomy group the majority of which were carcinoid tumours (65.5%). CONCLUSION There is a higher incidence of negative appendicectomies in women compared with men, which is similar to other published studies. Faecoliths and worms are a known cause of appendiceal colic and in our series were identified mostly in the absence of histological evidence of appendicitis.
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Chandrasegaram MD, Eslick GD, Mansfield CO, Liem H, Richardson M, Ahmed S, Cox MR. Endoscopic stenting versus operative gastrojejunostomy for malignant gastric outlet obstruction. Surg Endosc 2011; 26:323-9. [PMID: 21898024 DOI: 10.1007/s00464-011-1870-3] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2010] [Accepted: 08/01/2011] [Indexed: 02/12/2023]
Abstract
BACKGROUND Malignant gastric outlet obstruction represents a terminal stage in pancreatic cancer. Between 5% and 25% of patients with pancreatic cancer ultimately experience malignant gastric outlet obstruction. The aim in palliating patients with malignant gastric outlet obstruction is to reestablish an oral intake by restoring gastrointestinal continuity. This ultimately improves their quality of life in the advanced stages of cancer. The main drawback to operative bypass is the high incidence of delayed gastric emptying, particularly in this group of patients with symptomatic obstruction. This study aimed to compare surgical gastrojejunostomy and endoscopic stenting in palliation of malignant gastric outlet obstruction, acknowledging the diversity and heterogeneity of patients with this presentation. METHODS This retrospective study investigated patients treated for malignant gastric outlet obstruction from December 1998 to November 2008 at Nepean Hospital, Sydney, Australia. Endoscopic duodenal stenting was performed under fluoroscopic guidance for placement of the stent. The operative patients underwent open surgical gastrojejunostomy. The outcomes assessed included time to diet, hospital length of stay (LOS), biliary drainage procedures, morbidity, and mortality. RESULTS Of the 45 participants in this study, 26 underwent duodenal stenting and 19 had operative bypass. Comparing the stenting and operative patients, the median time to fluid intake was respectively 0 vs. 7 days (P < 0.001), and the time to intake of solids was 2 vs. 9 days (P = 0.004). The median total LOS was shorter in the stenting group (11 vs. 25 days; P < 0.001), as was the median postprocedure LOS (5 vs. 10 days; P = 0.07). CONCLUSIONS Endoscopic stenting is preferable to operative gastrojejunostomy in terms of shorter LOS, faster return to fluids and solids, and reduced morbidity and in-hospital mortality for patients with a limited life span.
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Affiliation(s)
- Manju D Chandrasegaram
- Department of Surgery, Upper Gastro-Intestinal Surgical Unit, Nepean Hospital, Level 5, South Block, P.O. Box 63, Penrith, NSW, 2751, Australia
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Chandrasegaram MD, Celermajer DS, Wilson MK. Apical ballooning syndrome complicated by acute severe mitral regurgitation with left ventricular outflow obstruction--case report. J Cardiothorac Surg 2007; 2:14. [PMID: 17313686 PMCID: PMC1804269 DOI: 10.1186/1749-8090-2-14] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2006] [Accepted: 02/21/2007] [Indexed: 12/12/2022] Open
Abstract
Background Apical ballooning syndrome (or Takotsubo cardiomyopathy) is a syndrome of transient left ventricular apical ballooning. Although first described in Japanese patients, it is now well reported in the Caucasian population. The syndrome mimicks an acute myocardial infarction but is characterised by the absence of obstructive coronary disease. We describe a serious and poorly understood complication of Takotsubo cardiomyopathy. Case Presentation We present the case of a 65 year-old lady referred to us from a rural hospital where she was treated with thrombolytic therapy for a presumed acute anterior myocardial infarction. Four hours after thrombolysis she developed acute pulmonary oedema and a new systolic murmur. It was presumed she had acute mitral regurgitation secondary to a ruptured papillary muscle, ischaemic dysfunction or an acute ventricular septal defect. Echocardiogram revealed severe mitral regurgitation, left ventricular apical ballooning, and systolic anterior motion of the mitral valve with significant left ventricular outflow tract gradient (60–70 mmHg). Coronary angiography revealed no obstructive coronary lesions. She had an intra-aortic balloon pump inserted with no improvement in her parlous haemodynamic state. We elected to replace her mitral valve to correct the outflow tract gradient and mitral regurgitation. Intra-operatively the mitral valve was mildly myxomatous but there were no structural abnormalities. She had a mechanical mitral valve replacement with a 29 mm St Jude valve. Post-operatively, her left ventricular outflow obstruction resolved and ventricular function returned to normal over the subsequent 10 days. She recovered well. Conclusion This case represents a serious and poorly understood association of Takotsubo cardiomyopathy with acute pulmonary oedema, severe mitral regurgitaton and systolic anterior motion of the mitral valve with significant left ventricular outflow tract obstruction. The sequence of our patient's presentation suggests that the apical ballooning caused geometric alterations in her left ventricle that in turn led to acute and severe mitral regurgitation, systolic anterior motion of the mitral valve and left ventricular outflow tract obstruction. The left ventricular outflow tract obstruction and mitral regurgitation were corrected by mechanical mitral valve replacement. We describe a variant of Takotsubo cardiomyopathy with acute mitral regurgitation, systolic anterior motion of the mitral valve leaflet and left ventricular outflow tract obstruction of a dynamic nature.
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Affiliation(s)
| | - David S Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael K Wilson
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
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Chandrasegaram MD, Plank LD, Windsor JA. The impact of parenteral nutrition on the body composition of patients with acute pancreatitis. JPEN J Parenter Enteral Nutr 2005; 29:65-73. [PMID: 15772382 DOI: 10.1177/014860710502900265] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Nutrition support by the enteral route is now the preferred modality in patients with severe acute pancreatitis. Parenteral nutrition is now required to supplement enteral nutrition when the latter is not able to provide the full nutritional requirement. We report the changes in body composition, plasma proteins, and resting energy expenditure (REE) during 14 days of parenteral nutrition (PN) in patients with acute pancreatitis. METHODS Total body protein (TBP), total body water (TBW), and total body fat (TBF) were measured by neutron activation analysis and tritium dilution before and after PN. Fat-free mass (FFM) was derived as the difference between body weight and TBF. REE was measured by indirect calorimetry. Protein index (PI) was the ratio of measured TBP to TBP, calculated from healthy volunteers. RESULTS Fifteen patients with acute pancreatitis (11 men, 4 women; median age 56, range 30-80 years) were studied. Thirteen patients had severe acute pancreatitis (Atlanta criteria), and 1 patient died. The gains in body weight (1.05 +/- 0.77 kg), TBW (0.49 +/- 0.87 kg), TBP (0.20 +/- 0.22 kg), FFM (0.73 +/- 0.92 kg), TBF (0.32 +/- 0.95 kg), and REE (146 +/- 90 kcal/d) after 14 days of PN were not significant. Plasma prealbumin increased by 46.5% (p = .020). When patients (n = 6) with intercurrent sepsis and recent surgery were excluded, there were significant increases in TBP (0.65 +/- 0.17 kg, p = .005) and PI (0.060 +/- 0.011, p = .0006). CONCLUSIONS Body composition is preserved in acute pancreatitis during 14 days of PN. In patients without sepsis or recent surgery, PN is able to significantly increase body protein stores.
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